Can images crowdsourced from the internet be used to train generalizable joint dislocation deep learning algorithms?

OBJECTIVE: Deep learning has the potential to automatically triage orthopedic emergencies, such as joint dislocations. However, due to the rarity of these injuries, collecting large numbers of images to train algorithms may be infeasible for many centers. We evaluated if the Internet could be used as a source of images to train convolutional neural networks (CNNs) for joint dislocations that would generalize well to real-world clinical cases. METHODS: We collected datasets from online radiology repositories of 100 radiographs each (50 dislocated, 50 located) for four joints: native shoulder, elbow, hip, and total hip arthroplasty (THA). We trained a variety of CNN binary classifiers using both on-the-fly and static data augmentation to identify the various joint dislocations. The best-performing classifier for each joint was evaluated on an external test set of 100 corresponding radiographs (50 dislocations) from three hospitals. CNN performance was evaluated using area under the ROC curve (AUROC). To determine areas emphasized by the CNN for decision-making, class activation map (CAM) heatmaps were generated for test images. RESULTS: The best-performing CNNs for elbow, hip, shoulder, and THA dislocation achieved high AUROCs on both internal and external test sets (internal/external AUC): elbow (1.0/0.998), hip (0.993/0.880), shoulder (1.0/0.993), THA (1.0/0.950). Heatmaps demonstrated appropriate emphasis of joints for both located and dislocated joints. CONCLUSION: With modest numbers of images, radiographs from the Internet can be used to train clinically-generalizable CNNs for joint dislocations. Given the rarity of joint dislocations at many centers, online repositories may be a viable source for CNN-training data.

Detecting total hip arthroplasty dislocations using deep learning: clinical and Internet validation.

OBJECTIVE: Periprosthetic dislocations of total hip arthroplasty (THA) are time-sensitive injuries, as the longer diagnosis and treatment are delayed, the more difficult they are to reduce. Automated triage of radiographs with dislocations could help reduce these delays. We trained convolutional neural networks (CNNs) for the detection of THA dislocations, and evaluated their generalizability by evaluating them on external datasets. METHODS: We used 357 THA radiographs from a single hospital (185 with dislocation [51.8%]) to develop and internally test a variety of CNNs to identify THA dislocation. We performed external testing of these CNNs on two datasets to evaluate generalizability. CNN performance was evaluated using area under the receiving operating characteristic curve (AUROC). Class activation mapping (CAM) was used to create heatmaps of test images for visualization of regions emphasized by the CNNs. RESULTS: Multiple CNNs achieved AUCs of 1 for both internal and external test sets, indicating good generalizability. Heatmaps showed that CNNs consistently emphasized the THA for both dislocated and located THAs. CONCLUSION: CNNs can be trained to recognize THA dislocation with high diagnostic performance, which supports their potential use for triage in the emergency department. Importantly, our CNNs generalized well to external data from two sources, further supporting their potential clinical utility.

Peripheral Nerve Blocks Associated With Shorter Length of Stay Without Increasing Readmission Rate for Ankle Open Reduction Internal Fixation in the Outpatient Setting: A Propensity-Matched Analysis.

Peripheral nerve blocks (PNB) have become an important modality for pain management in ankle fracture surgery. Previous studies have reported their efficacy, but concerns with rebound pain and readmissions have been cited as possible deterrents. The purpose of this study was to evaluate the effects of PNB on hospital length of stay (LOS), narcotic intake, visual analog scale (VAS) for pain, and associated complications in patients undergoing outpatient ankle open reduction internal fixation (ORIF). Adult patients undergoing ankle ORIF were matched 2:1 (no block:block) using propensity-score matching. Preoperative patient characteristics and postoperative outcomes were compared between cohorts. VAS and total narcotic intake were evaluated for each of the first 3 postoperative 8-hour shifts. Narcotic medication was converted to morphine milligram equivalents (MME). Thirty-two patients who received PNB were matched to 64 patients who did not. The PNB group had lower VAS and MME during each of the 8-hour shifts after surgery: 0 to 8 hours (VAS 1.8 vs 6.3; MME 10.6 vs 77.9; p < .001), 8 to 16 hours (VAS 1.2 vs 5.9; MME 9.2 vs 28.2; p < .001), 16 to 24 hours (VAS 3.7 vs 6.2; MME 13.2 vs 24.2; p = .006 and 0.019). PNB had a shorter LOS (average 16.7 hours vs 26.8 hours; p < .001). There were no differences in rates of ED presentations after discharge, hospital readmissions, or complications between cohorts. Peripheral nerve blocks after ankle ORIF are associated with shorter hospital LOS, lower VAS, and reduced narcotic intake without increasing rates of ED visits, hospital readmissions, or complications.

Gender Trends in Authorship of Foot and Ankle Academic Literature Over 24 Years.

Underrepresentation of females in surgery is reflected in research productivity across academic medicine, with male faculty being more likely to publish research than their female counterparts. In this study, we aimed to describe the representation and longevity of female investigators among the authors of articles in 3 foot and ankle research journals from 1993 to 2017. In this retrospective bibliometric analysis, authors from 3 prominent foot and ankle research journals (Foot and Ankle International, The Journal of Foot and Ankle Surgery, and Foot and Ankle Clinics) were identified. The proportion of female authors who were first, middle, and senior authors and the total publication count per author were determined. From 1993 to 2017, 8132 original articles were published and a total of 6597 (81.1%) had an accessible author list. This allowed us to identify 25,329 total authors, of whom 22,961 (90.7%) were successfully matched to a gender. A total of 9273 unique authors were identified (females, 19.2%). Female representation increased for first and senior authors over the years from 6.5% and 5.9% (1993 to 1997) to 16.9% and 13.1% (2013 to 2017, p < .001), respectively. However, compared with male authors, female authors published fewer articles (mean: 1.7 versus 2.4, p < .001). Of the 2691 authors who first published during 2006 to 2011, 369 authors (13%), consisting of 8.1% females and 15% males (p < .001), continued to publish 5 years after their initial publication. Female representation in academic foot and ankle research has increased >2-fold over the past 2 decades. But despite these advances, compared to male authors, female authors are less likely to continue publishing 5 years after initial publication, and on average publish fewer articles.

Does Intrathecal Morphine in Spinal Anesthesia Have a Role in Modern Multimodal Analgesia for Primary Total Joint Arthroplasty?

BACKGROUND: Intrathecal morphine (ITM) combined with bupivacaine spinal anesthesia can improve postoperative pain, but has potential side effects of postoperative nausea/vomiting (PONV) and pruritus. With the use of multimodal analgesia and regional anesthetic techniques, postoperative pain control has improved significantly to a point where ITM may be avoided in total joint arthroplasty (TJA). METHODS: We performed a retrospective study of primary TJA patients who underwent a standardized multimodal recovery pathway and received bupivacaine neuraxial anesthesia with ITM vs bupivacaine neuraxial anesthesia alone (control). RESULTS: In total, 598 patients were identified (131 controls, 467 ITMs) with similar demographics. On postoperative day 0 (POD 0), ITM patients had significantly lower mean visual analog scale scores (1.5 ± 1.6 vs 2.5 ± 1.9, P < .001) and consumed less oral morphine equivalents (10.5 ± 25.4 vs 16.8 ± 27.2, P = .013). ITM patients walked further compared to controls by POD 1 (133.6 ± 159.6 vs 97.3 ± 141 m, P = .028) and were less likely to develop PONV during their entire hospital stay (38.5% vs 48.6%, P = .043). No significant differences were seen for total morphine equivalents consumption, rate of discharge to care facility, length of stay, and 90-day readmission rates. CONCLUSION: ITM was associated with improved POD 0 pain scores and less initial oral/intravenous opioid consumption, which likely contributes to the subsequent improved mobilization and lower rates of PONV. In the setting of a modern regional anesthesia and multimodal analgesia recovery plan for TJA, ITM can still be considered for its benefits.

ISSLS PRIZE IN BASIC SCIENCE 2017: Intervertebral disc/bone marrow cross-talk with Modic changes.

STUDY DESIGN: Cross-sectional cohort analysis of patients with Modic Changes (MC). OBJECTIVE: Our goal was to characterize the molecular and cellular features of MC bone marrow and adjacent discs. We hypothesized that MC associate with biologic cross-talk between discs and bone marrow, the presence of which may have both diagnostic and therapeutic implications. BACKGROUND DATA: MC are vertebral bone marrow lesions that can be a diagnostic indicator for discogenic low back pain. Yet, the pathobiology of MC is largely unknown. METHODS: Patients with Modic type 1 or 2 changes (MC1, MC2) undergoing at least 2-level lumbar interbody fusion with one surgical level having MC and one without MC (control level). Two discs (MC, control) and two bone marrow aspirates (MC, control) were collected per patient. Marrow cellularity was analyzed using flow cytometry. Myelopoietic differentiation potential of bone marrow cells was quantified to gauge marrow function, as was the relative gene expression profiles of the marrow and disc cells. Disc/bone marrow cross-talk was assessed by comparing MC disc/bone marrow features relative to unaffected levels. RESULTS: Thirteen MC1 and eleven MC2 patients were included. We observed pro-osteoclastic changes in MC2 discs, an inflammatory dysmyelopoiesis with fibrogenic changes in MC1 and MC2 marrow, and up-regulation of neurotrophic receptors in MC1 and MC2 bone marrow and discs. CONCLUSION: Our data reveal a fibrogenic and pro-inflammatory cross-talk between MC bone marrow and adjacent discs. This provides insight into the pain generator at MC levels and informs novel therapeutic targets for treatment of MC-associated LBP.

Length of Endoprosthetic Reconstruction in Revision Knee Arthroplasty Is Associated With Complications and Reoperations.

BACKGROUND: Complex revision total knee arthroplasty (TKA) often calls for endoprosthetic reconstruction to address bone loss, poor bone quality, and soft tissue insufficiency. Larger amounts of segmental bone loss in the setting of joint replacement may be associated with greater areas of devascularized tissue, which could increase the risk of complications and worsen functional results. QUESTIONS/PURPOSES: Are longer endoprosthetic reconstructions associated with (1) higher risk of deep infection; (2) increased risk of reoperation and decreased implant survivorship; or (3) poorer ambulatory status? METHODS: This is a single-institution retrospective case series of nononcologic femoral endoprosthetic reconstructions for revision TKA from 1995 to 2013 (n = 32). Cases were categorized as distal (n = 17) or diaphyseal (n = 15) femoral reconstructions based on extension to or above the supracondylar metaphyseal-diaphyseal junction, respectively. Five patients from each group were lost to followup before 2 years (distal mean 4 years [range, 2-8 years]; diaphyseal mean = 6 years [range, 2-16 years]), and one of the 12 distal reconstructions and two of the 10 diaphyseal reconstructions had not been evaluated within the past 5 years. Clinical outcomes and ambulatory status (able to walk or not) were assessed through chart review by authors not involved in any cases. Prior incidence of periprosthetic joint infection was high in both groups (distal = seven of 12 versus diaphyseal = four of 10; p = 0.670). RESULTS: Patients with diaphyseal femoral replacements were more likely to develop postoperative deep infections than patients with distal femoral replacements (distal = three of 12 versus diaphyseal = nine of 10; p = 0.004). Implant survivorship (revision-free) for diaphyseal reconstructions was worse at 2 years (distal = 100%, 95% confidence interval [CI], 100%-100% versus diaphyseal = 40%, 95% CI, 19%-86%; p = 0.001) and 5 years (distal = 90%, 95% CI, 75%-100% versus diaphyseal = 30%, 95% CI, 12%-73%; p = 0.001). Infection-free, revision-free survival (retention AND no infection) was worse for diaphyseal femoral replacing reconstructions than for distal femoral replacements at 2 years (distal = 70%, 95% CI, 48%-100% versus diaphyseal = 20%, 95% CI, 6%-69%; p = 0.037) and 5 years (distal = 70%, 95% CI, 48%-100% versus diaphyseal = 10%, 95% CI, 2%-64%; p = 0.012). There was no difference with the small numbers available in proportion of patients able to walk (distal reconstruction = eight of 11 versus diaphyseal = seven of 10; p = 1.000), although all but one patient in each group required walking aids. CONCLUSIONS: Endoprosthetic femoral reconstruction is a viable salvage alternative to amputation for treatment of failed TKA with segmental distal femoral bone loss. In our small series even with substantial loss to followup and likely best-case estimates of success, extension proximal to the supracondylar metaphyseal-diaphyseal junction results in higher infection and revision risk. In infection, limb salvage remains possible with chronic antibiotic suppression, which we now use routinely for all femoral replacement extending into the diaphysis. LEVEL OF EVIDENCE: Level III, therapeutic study.

The perioperative effects of chronic preoperative opioid use on shoulder arthroplasty outcomes.

HYPOTHESIS AND BACKGROUND: Chronic opioid therapy is an increasingly used modality for the treatment of osteoarthritis-associated pain. We hypothesized that chronic opioid use would be associated with adverse outcomes in shoulder arthroplasty. METHODS: A retrospective analysis of patients undergoing elective anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (rTSA) at a single institution from 2012-2015 was performed. Patients were stratified by preoperative opioid use (nonusers, short-acting opioid users, and long-acting opioid users), and their postoperative clinical outcomes were assessed. RESULTS: We identified 262 patients (170 rTSA and 92 anatomic TSA), of whom 138 were using opioids preoperatively (82% short acting and 18% long acting). When non-opioid users, short-acting opioid users, and long-acting opioid users were compared, mean total milligrams of morphine equivalents administered during postoperative hospitalization was significantly higher for those with preoperative opioid use (66.9 mg, 111.4 mg, and 208.3 mg, respectively; P < .001). In addition, postoperative visual analog scale pain scores were higher on postoperative day 0 (2.6, 3.2, and 3.9, respectively; P = .007), day 1 (4.0, 4.9, and 6.0, respectively; P < .001), and day 2 (3.0, 3.9, and 5.1, respectively; P < .001). Opioid use was not associated with a significantly increased hospital length of stay, complications, or readmission rates. For patients who completed 2-year follow-up, both the opioid user and non-opioid user groups demonstrated similarly improved postoperative American Shoulder and Elbow Surgeons shoulder scores. CONCLUSION: A preoperative history of opioid use before shoulder arthroplasty was associated with significantly higher perioperative opioid consumption and visual analog scale scores. However, unlike in patients undergoing total knee or hip arthroplasty, preoperative opioid use was not associated with increased hospital length of stay, perioperative complications, or 90-day readmission rates for shoulder arthroplasty.

Preoperative Anemia Independently Predicts 30-Day Complications After Aseptic and Septic Revision Total Joint Arthroplasty.

BACKGROUND: Preoperative anemia is a common, important risk factor for adverse events after joint arthroplasty surgery. It affects 21%-35% patients undergoing total joint arthroplasty. To date, few studies have investigated the effect of preoperative anemia, specifically in revision total joint arthroplasty surgery. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients who underwent revision total joint arthroplasty from 2006 to 2014. We matched 6830 patients undergoing aseptic revision (3415 anemic vs 3415 not anemic) and 2650 patients undergoing septic revision (1325 anemic vs 1325 not anemic). In each cohort, patients were propensity score-matched 1:1 by the presence of preoperative anemia. The inpatient hospitalization data, postoperative complications, as well as demographics and comorbidities were compared between patients with or without anemia who underwent revision total joint arthroplasty. RESULTS: After adjusting for comorbidities via multivariate regression, anemia was associated with an increased risk of overall complications (aseptic: odds ratio [OR], 1.45; 95% confidence interval [CI], 1.24-1.70; P < .001; septic: OR, 2.16; 95% CI, 1.83-2.56; P < .001), deep infection (aseptic: OR, 1.68; 95% CI, 1.19-2.38; P = .003; septic: OR, 1.44; 95% CI, 1.06-1.94; P = .018), mortality (aseptic: OR, 2.18; 95% CI, 1.09-4.36; P = .028; septic: OR, 3.16; 95% CI, 1.03-9.74; P = .045), and increased hospital length of stay (aseptic: adjusted coefficient, 1.02 days; 95% CI, 0.73-1.31; P < .001; septic: adjusted coefficient, 2.04 days; 95% CI, 1.53-2.55; P < .001). CONCLUSION: Preoperative anemia is independently associated with postoperative complications, mortality, and increased length of stay in revision total joint arthroplasty. Further studies are needed to evaluate if preoperative treatment of anemia may modify this risk.

Early Outcomes of Primary Total Hip Arthroplasty After Prior Lumbar Spinal Fusion.

BACKGROUND: The coexistence of degenerative hip disease and spinal pathology is not uncommon with the number of surgical treatments performed for each condition increasing annually. The limited research available suggests spinal pathology portends less pain relief and worse outcomes after total hip arthroplasty (THA). We hypothesize that primary THA patients with preexisting lumbar spinal fusions (LSF) experience worse early postoperative outcomes. METHODS: This study is a retrospective matched cohort study. Primary THA patients at 1 institution who had undergone prior LSF (spine arthrodesis-hip arthroplasty [SAHA]) were identified and matched to controls of primary THA without LSF. Early outcomes (<90 days) were compared. RESULTS: From 2012 to 2014, 35 SAHA patients were compared to 70 matched controls. Patients were similar in age, sex, American Society of Anesthesiologist score, body mass index, and Charlson Comorbidity Index. SAHA patients had higher rates of complications (31.4% vs 8.6%, P = .008), reoperation (14.3% vs 2.9%, P = .040), and general anesthesia (54.3% vs 5.7%, P = .0001). Bivariate analysis demonstrated SAHA to predict reoperation (odds ratio, 5.67; P = .045) and complications (odds ratio, 4.89; P = .005). With the numbers available, dislocations (0% vs 2.8%), infections (0% vs 8.6%), readmissions, postoperative walking distance, and disposition only trended to favor controls (P > .05). Comparing controls to SAHA patients with <3 or ≥3 levels fused, longer fusions had increased cumulative postoperative narcotic consumption (mean morphine equivalents, 44.3 vs 46.9 vs 169.4; P = .001). CONCLUSION: Patients with preexisting LSF experience worse early outcomes after primary THA including higher rates of complications and reoperation. Lower rates of neuraxial anesthesia and increased narcotic usage represent potential contributors. The complex interplay between the lumbar spine and hip warrants attention and further investigation.

Is Obesity a Risk Factor for Adverse Events After Knee Arthroscopy?

PURPOSE: To evaluate how body mass index (BMI) affects rates of 30-day complication, hospital readmissions, and mortality in patients undergoing knee arthroscopy. METHODS: Patients undergoing knee arthroscopy procedures between 2006 and 2013 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patient demographics and preoperative risk factors including BMI were analyzed for postoperative complications within 30 days. Cochran-Armitage testing was performed to detect differences in complication rates across BMI categories according to World Health Organization classification. The independent risk of BMI was assessed using multivariate regression analysis. RESULTS: Of 41,919 patients with mean age 48 years undergoing knee arthroscopy, 20% were classified as normal weight (BMI 18.5 to 24), 35% overweight (BMI 25 to 29), 24% obese class I (BMI 30 to 34), 12% class II (BMI 35 to 40), and 9% class III (BMI ≥40). Risk of complication increased significantly with increasing BMI (normal: 1.5%, overweight: 1.6%, obese class I: 1.7%, obese class II: 1.8%, obese class III: 1.9%, P = .043). On multivariate analysis, there was no increased risk of postoperative complication directly attributed to patient BMI. Independent risk factors for medical and surgical complications after knee arthroscopy included American Society of Anesthesiologists (ASA) rating (class 4 v class 1 odds ratio [OR]: 5.39 [95% confidence interval: 3.11-9.33], P < .001), functional status for activities of daily living (dependent v independent OR: 2.13 [1.42, 3.31], P < .001), history of renal comorbidity (presence v absence OR: 5.10 [2.30, 11.29], P < .001), and previously experienced history of wound infection prior to current surgery (presence v absence OR: 4.91 [2.88, 8.39], P < .001). CONCLUSIONS: More than 40% of knee arthroscopy patients qualify as obese. Although univariate analysis suggests that obesity is associated with increased postoperative complications within 30 days of surgery, BMI alone does not predict complications. Independent predictors of complications include patients with high ASA classification, dependent functional status, renal comorbidities, and a recent history of wound infection. LEVEL OF EVIDENCE: Level IV, prognostic case series.

The Effects of Patient Obesity on Early Postoperative Complications After Shoulder Arthroscopy.

PURPOSE: To report the prevalence of obesity in shoulder arthroscopy, determine a body mass index (BMI) threshold most predictive of complication within 30 days, and evaluate obesity as an independent risk factor for medical and surgical complications. METHODS: Using the National Surgical Quality Improvement Program database, we reviewed all patients who underwent shoulder arthroscopy during 2011 to 2013. Receiver operating characteristic and Youden coefficient were calculated to find an optimal BMI cutoff to predict complications within 30 days of surgery. A case-control matched analysis was then performed by stratifying patient BMI by this cutoff and matching patients one to one according to age, sex, type of shoulder arthroscopy, American Society of Anesthesiology rating, surgical setting, and 8 comorbidities. Operating time, complications, and readmissions were also compared. RESULTS: Of the 15,589 patients who underwent shoulder arthroscopy, 6,684 (43%) were classified as obese when using the optimal cutoff point of BMI = 30 according to the Youden coefficient. Obese patients had a higher risk of superficial site infection than nonobese patients (0.3% vs 0.0%; odds ratio [OR]: 6.00; 95% confidence interval [CI], 1.3 to 26.8; P = .015). Obese patients did not have significantly increased risk for overall early postoperative complication (1.2% compared with nonobese 0.8%; OR: 1.54; 95% CI, 1.0 to 2.4), readmissions (OR: 0.85; 95% CI, 0.5 to 1.5), or increased operating time (P = .068). CONCLUSIONS: Up to 43% of patients undergoing shoulder arthroscopy can be classified as obese, but early perioperative complications are uncommon. Higher patient BMI is associated with increased risk of superficial site infection but not an overall risk for complication, readmission, or increased operating time. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Proximal humerus fragility fractures: recent trends in nonoperative and operative treatment in the Medicare population.

BACKGROUND: With an aging population, fragility fractures including injuries to the proximal humerus continue to rise in the United States. The purpose of this study was to investigate recent trends in the incidence and treatment of proximal humerus fractures (PHFs) in a cross-sectional elderly population. METHODS: Medicare data from 2005 to 2012 were queried to identify patients treated for PHF. Associated patient demographics, hospitalization data, treatment, and revision status were obtained. Statistical analyses were performed to identify significant trends in treatment. RESULTS: There were 259,506 PHFs recorded, with 79% occurring in female patients. In all age groups, nonoperative treatment of PHF was the most common method (67%). Within the surgical group, open reduction with internal fixation was most frequently used, and total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA) was the least common (11%). However, although the overall rate of surgical intervention remained constant, there was a significant increase in treatment with TSA from 3% in 2005 to 17% in 2012. In particular, RTSA represented 89% of all TSAs for PHF in 2011. All surgical treatment options demonstrated high 2-year survival rates without revision surgery (97%). CONCLUSION: Recent trends show that in the elderly population, nonoperative management remains the most common treatment for PHFs. Within the surgically treated cohort, there has been an increase in treatment with arthroplasty including RTSA, with a low rate of early revisions. There are excellent survival rates in all surgically treated PHFs, but long-term data will be required to fully evaluate the viability of these surgical options.

Plate fixation of midshaft clavicular fractures: patient-reported outcomes and hardware-related complications.

BACKGROUND: Recent studies report high hardware removal rates after plate fixation of midshaft clavicular fractures. Precontoured clavicle plates may decrease hardware-related complications while improving healing rates and patient-reported outcomes (PROs). METHODS: Using a private-payer national database, we identified 7826 patients who underwent clavicle open reduction and internal fixation (ORIF) in 2007 to 2011. Database patients were tracked for 2 years to assess hardware removal and revision fixation. In addition, we retrospectively identified 73 patients who underwent plate fixation of midshaft clavicular fractures at our institution. These patients completed the Disabilities of Arm, Shoulder and Hand (DASH) assessment, the EQ-5D (EuroQol, Rotterdam, The Netherlands) quality of life assessment, and a hardware-related outcomes survey. RESULTS: Among 7826 database patients, 994 (12.7%) underwent hardware removal and 78 (1%) required revision ORIF. The annual incidence of clavicle ORIF increased 61.5% between 2007 and 2011. In our institutional cohort, 56 patients (77%) were fixed with precontoured plates and 17 (23%) with standard plates. At a mean follow-up of 4.2 years, 11 patients (15%) underwent hardware removal and 1 patient (1.4%) experienced nonunion. Patients reported excellent outcomes, with average DASH of 4.0 ± 8.9 and EQ-5D of 0.89 ± 0.19. There were no differences in PROs, hardware removal, or union rate between plate types, although our study was underpowered for these outcomes. Patients who underwent hardware removal reported lower DASH, EQ-5D, satisfaction, and shoulder function compared with patients with hardware retained. Women were more likely to undergo hardware removal in the institutional (P = .009) and the database (P < .001) cohorts. CONCLUSION: Displaced midshaft clavicle fractures have high union rates with precontoured plate fixation. Women are 4 times more likely than men to have hardware removed. Patients undergoing clavicle hardware removal report worse long-term outcomes than patients with hardware retained.

Preoperative Reduction of Opioid Use Before Total Joint Arthroplasty.

BACKGROUND: The purpose of this study was to assess whether weaning of opioid use in the preoperative period improved total joint arthroplasty (TJA) outcomes. METHODS: Forty-one patients who regularly used opioids and successfully weaned (defined as a 50% reduction in morphine-equivalent dose) before a primary total knee or hip arthroplasty were matched with a group of TJA patients who did not wean and a matched control group of TJA patients who did not use opioids preoperatively. The difference between preoperative and postoperative (at 6-12 months follow-up) patient-reported outcomes were assessed using the change in University of California, Los Angeles (UCLA) activity score, SF12v2, and The Western Ontario and McMaster Universities Arthritis Index (WOMAC). Paired t tests and 1-way repeated measures analysis of variance were performed to assess differences in TJA outcomes between groups. RESULTS: Patients using opioids who successfully weaned had greater improvements in both disease-specific and generic measures of health outcomes than patients who did not wean (WOMAC 43.7 vs 17.8, P < .001; SF12v2 Physical Component Score 10.5 vs 1.85, P = .003; UCLA activity score 1.49 vs 0, P < .001). There was no statistical difference between the 2 groups on SF12v2 Mental Component Score 2.48 vs 4.21, P = .409. Patients who successfully weaned from opioids had similar outcomes to control patients who did not use opioids: WOMAC 39.0 vs 43.7, P = .31; SF12v2 Physical Component Score 12.5 vs 10.5, P = .35; SF12v2 Mental Component Score 3.08 vs 2.48, P = .82; UCLA activity 1.90 vs 1.49, P = .23. CONCLUSION: Patients with a history of chronic opioid use who successfully decreased their use of opioids before surgery had substantially improved clinical outcomes that were comparable to patients who did not use opioids at all.

Long-Acting Opioid Use Independently Predicts Perioperative Complication in Total Joint Arthroplasty.

BACKGROUND: Opioid therapy is an increasingly used modality for treatment of musculoskeletal pain despite multiple associated risks. The purpose of this study was to evaluate how preoperative opioid use affects early outcomes after total joint arthroplasty. METHODS: A total of 174 patients undergoing total joint arthroplasty were matched by age, gender, and procedure into 3 groups stratified by preoperative opioid use (nonuser, short acting [eg, Vicodin], long acting [eg, Oxycontin]). RESULTS: Compared to nonusers, preoperative long-acting use was associated with increased postoperative mean opioid consumption (46 mg vs 366 mg mean morphine equivalents, P < .001) and independently predicted complications within 90 days (odds ratio: 6.15, confidence interval: [1.46, 25.95], P = .013). CONCLUSION: Preoperative opioid use should be disclosed as a risk factor for complication to patients and taken into consideration by physicians before initiating opioid management.

Prior Lumbar Spinal Arthrodesis Increases Risk of Prosthetic-Related Complication in Total Hip Arthroplasty.

BACKGROUND: Degenerative hip disorders often coexist with degenerative changes of the lumbar spine. Limited data on this patient population suggest inferior functional improvement and pain relief after surgical management. The purpose of this study is to compare the rates of prosthetic-related complication after primary total hip arthroplasty (THA) in patients with and without prior lumbar spine arthrodesis (SA). METHODS: Medicare patients (n = 811,601) undergoing primary THA were identified and grouped by length of prior SA (no fusion, 1-2 levels fused [S-SAHA], and ≥3 levels fused [L-SAHA]). RESULTS: Compared with controls, patients with prior SA had significantly higher rates of complications including dislocation (control: 2.36%; S-SAHA: 4.26%; and L-SAHA: 7.51%), revision (control: 3.43%, S-SAHA: 5.55%, and L-SAHA: 7.77%), loosening (control: 1.33%, S-SAHA: 2.10%, and L-SAHA: 3.04%), and any prosthetic-related complication (control: 7.33%, S-SAHA: 11.15% [relative risk: 1.52], and L-SAHA: 14.16% [relative risk: 1.93]) within 24 months (P < .001). CONCLUSION: The interplay of coexisting degenerative hip and spine disease deserves further attention of both arthroplasty and spine surgeons.

Age-Related Trends in Hip Arthroscopy: A Large Cross-Sectional Analysis.

PURPOSE: To analyze a large national private payer population in the United States for trends over time in hip arthroscopy by age groups and to determine the rate of conversion to total hip arthroplasty (THA) after hip arthroscopy. METHODS: We performed a retrospective analysis using the PearlDiver private insurance patient record database from 2007 through 2011. Hip arthroscopy procedures including newly introduced codes such as osteochondroplasty of cam and pincer lesions and labral repair were queried. Hip arthroscopy incidence and conversion rates to THA were stratified by age. Chi-squared analysis was used for statistical comparison. Conversion to THA was evaluated using Kaplan-Meier analysis. RESULTS: From 2007 through 2011, 20,484,172 orthopaedic patients were analyzed. Hip arthroscopy was performed in 8,227 cases (mean annual incidence, 2.7 cases per 10,000 orthopaedic patients). The incidence of hip arthroscopies increased over 250% from 1.6 cases per 10,000 in 2007 to 4.0 cases per 10,000 in 2011 (P < .0001). Patients in the 40 to 49 age group made up 28% of cases, followed by patients ages 30 to 39 (22%) and 50 to 59 (19%). Patients under 30 years old showed the greatest increase in incidence from 2007 to 2011 (335%), but patients over 60 still had over a 200% increase. Labral debridement was the most common procedure (6,031 cases), and approximately 1.6 procedural codes were billed for every case performed. Labral repair was more common in patients under 30, while labral debridement was more common in older age groups (P = .046). Within 24 months of hip arthroscopy, 17% of patients older than 50 required conversion to THA, compared with <1% of patients under 30 (P < .0001). CONCLUSIONS: Hip arthroscopy procedures are increasing in popularity across all age groups, with patients ages 40 to 49 having the highest incidence in this large cross-sectional population, despite a high rate of early conversion to THA within 2 years in patients over 50. LEVEL OF EVIDENCE: IV, cross-sectional study.

Causes and frequency of unplanned hospital readmission after total hip arthroplasty.

BACKGROUND: Total hip arthroplasty (THA) is a beneficial and cost-effective procedure for patients with osteoarthritis. Recent initiatives to improve hospital quality of care include assessing unplanned hospital readmission rates. Patients presenting for THA have different indications and medical comorbidities that may impact rates of readmission. QUESTIONS/PURPOSES: This study measured (1) the unplanned hospital readmission rate in primary THA, revision THA, and antibiotic-spacer staged revision THA to treat infection. Additionally, we determined (2) the medical and surgical causes of readmission; and (3) the risk factors associated with unplanned readmission. METHODS: A total of 1415 patients (988 primary THA, 344 revision THA, 82 antibiotic-spacer staged revision THA to treat infection) from a single institution were included. All hospital readmissions within 90 days of discharge were reviewed. Patient demographics and medical comorbidities were included in a Cox proportional hazards model to assess risk of readmission. RESULTS: The overall unplanned readmission rate was 4% at 30 days and 7% at 90 days. At 90 days, primary THA (5%) had a lower unplanned readmission rate than revision THA (10%, p < 0.001) and antibiotic-spacer staged revision THA (18%, p < 0.001). Medical diagnoses were responsible for almost one-fourth of unplanned readmissions, whereas over half of surgical readmissions were the result of dislocation, surgical site infection, and postoperative hematoma. Type of procedure, hospital stay greater than 5 days, cardiac valvular disease, diabetes with end-organ complications, and substance abuse were each associated with increased risk of unplanned readmission. CONCLUSIONS: Higher rates of unplanned hospital readmissions in revision THA rather than primary THA suggest that healthcare quality measures that incorporate readmission rates as a proxy for quality of care should distinguish between primary and revision procedures. Failure to do so may negatively impact tertiary referral hospitals that often care for patients requiring complex revision procedures.

Higher-Than-Expected Rates of Distal Radioulnar Joint Fixation in Radial Shaft Fractures: Location of Fracture Matters.

BACKGROUND: The purpose of this study was to evaluate rates of distal radioulnar joint (DRUJ) fixation based on location of the radial shaft fracture and risk factors associated with postoperative complications following radial shaft open reduction internal fixation (ORIF). METHODS: Adult patients who underwent isolated radial shaft ORIF from 2014 to 2018 were identified from American College of Surgeons National Surgical Quality Improvement Program database and stratified by fracture location and by the presence or absence of DRUJ fixation. Preoperative patient characteristics and postoperative complications were compared to determine risk factors associated with DRUJ fixation. RESULTS: We identified 1517 patients who underwent isolated radial shaft ORIF, of which 396 (26.1%) underwent DRUJ fixation. Preoperative patient characteristics and postoperative complications were similar between cohorts. Distal radioulnar joint fixation was performed in 50 (30.7%) of 163 distal radial shaft fractures, 191 (21.8%) of 875 midshaft fractures, and 3 (13.0%) of 23 proximal shaft fractures (P = .025). Risk factors for patients readmitted include male sex (odds ratio [OR] = 12.76, P = .009) and older age (OR = 4.99, P = .035). Risk factors for patients with any postoperative complication include dependent functional status (OR = 6.78, P = .02), older age (50-69 vs <50) (OR = 2.73, P = .05), and American Society of Anesthesiologists (ASA) ≥3 (OR = 2.45, P = .047). CONCLUSIONS: The rate of DRUJ fixation in radial shaft ORIF exceeded previously reported rates of concomitant DRUJ injury, especially among distal radial shaft fractures. More distally located radial shaft fractures are significantly associated with higher rates of DRUJ fixation. Male sex is a risk factor for readmission, whereas dependent functional status, older age, and ASA ≥3 are risk factors for postoperative complications.