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.

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.

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.

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.

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.

Albumin, Prealbumin, and Transferrin May Be Predictive of Wound Complications following Total Knee Arthroplasty.

Nutritional status has become increasingly important in optimizing surgical outcomes and preventing postoperative infection and wound complications. However, currently, there is a paucity in the orthopaedics literature investigating the relationship between nutritional status and wound complications following total knee arthroplasty (TKA). Therefore, the purpose of this study was to determine the prevalence of (1) postoperative infections, (2) wound complications, (3) concomitant infection with wound (CoIW) complication, and (4) infection followed by wound complication by using (1) albumin, (2) prealbumin, and (3) transferrin levels as indicators of nutritional status. These four different outcome measures were chosen as they are encountered commonly in daily clinical practice. A retrospective review of a national private payer database for patients who underwent TKA with postoperative infections and wound complications stratified by preoperative serum albumin (normal: 3.5-5 g/dL), prealbumin (normal: 16-35 mg/dL), and transferrin levels (normal: 200-360 mg/dL) between 2007 and 2015 was conducted. Patients were identified by Current Procedural Terminology (CPT), International Classification of Disease, ninth revision (ICD-9) codes, and Logical Observation Identifiers Names and Codes (LOINC). Linear regression was performed to evaluate changes over times. Yearly rates of infection, as well as a correlation and odds ratio analysis of nutritional laboratory values to postoperative complications, were also performed. Our query returned a total of 161,625 TKAs, of which 11,047 (7%) had postoperative wound complications, 18,403 (11%) had infections, 6,296 (34%) had CoIW, and 4,877 (4%) patients with infection developed wound complications. Albumin was the most commonly ordered laboratory test when assessing complications (96%). Wound complications, infections, CoIW, and infection with wound complications after were higher in those below the normal range: albumin <3.5 g/dL (9, 14, 6, and 5%), prealbumin <15 mg/dL (20, 23, 13, and 12%), and transferrin <200 mg/dL (12, 17, 6, and 6%). Preoperative albumin, prealbumin, and transferrin values falling below the normal range represented an increased risk for postoperative complications. Those patients who were in the normal range, however, did not have an increased risk. Therefore, our results suggest that preoperative nutritional optimization can play an important role in reducing the risk for postoperative complications.

CANNABIS USE INCREASES RISK FOR REVISION AFTER TOTAL KNEE ARTHROPLASTY.

As an increasing number of states begin to legalize marijuana for either medical or recreational use, it is important to determine its effects on joint arthroplasty. The purpose of this study is to determine the impact of cannabis use on total knee arthroplasty (TKA) revision incidence, revision causes, and time to revision by analyzing the Medicare database between 2005 and 2014. A retrospective review of the Medicare database for TKA, revision TKA, and causes was performed utilizing Current Procedural Terminology (CPT) and International Classification of Disease ninth revision codes (ICD-9). Patients who underwent TKA were cross-referenced for a history of cannabis use by querying ICD-9 codes 304.30-32 and 305.20-22. The resulting group was then longitudinally tracked postoperatively for revision TKA. Cause for revision, time to revision, and gender were also investigated. Our analysis returned 2,718,023 TKAs and 247,112 (9.1%) revisions between 2005 and 2014. Cannabis use was prevalent in 18,875 (0.7%) of TKA patients with 2,419 (12.8%) revisions within the cannabis cohort. Revision incidence was significantly greater in patients who use cannabis (p < 0.001). Time to revision was also significantly decreased in patients who used cannabis, with increased 30- and 90-day revision incidence compared to the noncannabis group (P < 0.001). Infection was the most common cause of revision in both groups (33.5% nonusers versus 36.6% cannabis users).Cannabis use may result in decreasing implant survivorship and increasing the risk for revision within the 90-day global period compared to noncannabis users following primary TKA.

Comparative Outcomes Between the First and Second Operated Shoulders in Bilateral Shoulder Arthroplasty.

INTRODUCTION: Studies that report outcomes after staged bilateral shoulder arthroplasty (BSA) are limited. This study compared the overall improvement between the first and second operated shoulders after BSA. METHODS: Preoperative and postoperative motion and patient-reported outcomes for function, pain, and general health were assessed for patients who underwent BSA with a 2-year follow-up. Ultimate outcomes and the efficacy of treatment were compared between the first and second operated shoulders. RESULTS: Seventy-three patients met the inclusion criteria (mean follow-up, 51.4 months). There were no notable differences between the first and second operated shoulders for all preoperative and postoperative variables except for the preoperative 12-item Short-Form Physical Component Score, which was greater in the second shoulder (P = 0.005). The efficacy of treatment was not markedly different except for the Physical Component Score (P = 0.001) and forward elevation (P = 0.01), which were greater after the first surgery. DISCUSSION: Improvements in function, pain, and motion were not markedly different between the first and second shoulder arthroplasty surgeries.

Incidence of Drug Abuse in Revision Total Knee Arthroplasty Population.

Substance abuse can have strong negative impacts on surgical outcomes. Therefore, this study assessed the effects of drug abuse in total knee arthroplasty (TKA) patients. Specifically, we identified revision TKA (RTKA): (1) incidence, (2) causes, (3) time to revision, and (4) patient demographics in patients with a history of drug abuse. The Medicare database within the PearlDiver Supercomputer (Warsaw, IN) was queried to identify 2,159,221 TKAs performed between 2005 and 2012. Drug abuse was subdivided into cocaine, cannabis, opioids, sedatives/hypnotics/anxiolytics (SHA), amphetamines, and alcohol abusers. The effect of drug use on the incidence and cause for RTKA, time to revision, as well as patient demographics were correlated using multivariate, analysis of variance, and regression analyses. There was a significant increase in the number of primary TKAs in cocaine (p = 0.011), cannabis (p < 0.001), opioid (p < 0.001), SHA (p < 0.001), amphetamine (p < 0.001), and alcohol (p < 0.001) users. Amphetamine users had the fastest mean time to revision (691 days, standard deviation: 679 days). At 30-, 90-day, and 6-month postoperative, cocaine had the highest proportion of patients requiring RTKA (7, 12, and 20%, respectively), and at 1-year alcohol abusers (38%, p < 0.001). Infection was the most common cause of revision in all drug abuse/dependent cohorts. Age distributions varied significantly by group for primary TKA (p < 0.001). Comorbidity status was similar in all RTKA patients as determined by comparison of the mean Charlson comorbidity index scores (p = 0.091). Based on these results, drug abuse patients are at increased risk for RTKA. These high-risk patients should, therefore, be appropriately risk stratified and receive comprehensive postoperative pain management.

Loss of Functional Internal Rotation Following Various Combinations of Bilateral Shoulder Arthroplasty.

BACKGROUND: Limited internal rotation (IR) remains a concern for activities of daily living (ADLs) following bilateral shoulder arthroplasty (BSA). The purpose of this study was to evaluate the loss of the ability to perform functional IR tasks following BSA using various combinations of anatomic (TSA) and reverse (RSA) shoulder arthroplasty. METHODS: A retrospective review of an institutional shoulder-surgery database was conducted for patients who underwent BSA with any combination of TSA or RSA with at least a 2-year follow-up. IR range of motion (ROM) and individual American Shoulder and Elbow Surgeons (ASES) score and Simple Shoulder Test (SST) questions specific to IR were used to assess a patient's ability to perform IR tasks with at least one of their shoulders. RESULTS: Seventy-three patients met the inclusion criteria (47 TSA/TSA, 17 RSA/RSA, and 9 TSA/RSA). Average age at surgery was 72.1 years. Average follow-up was 51.4 months. Loss of ability to wash one's back was observed in 30.4% TSA/TSA, 33.3% TSA/RSA, and 52.9% RSA/RSA. Loss of ability to tuck in a shirt was observed in 10.6% TSA/TSA, 11.1% TSA/RSA, and 29.4% RSA/RSA. Loss of ability to manage toileting was observed in no TSA/TSA or TSA/RSA, but in 11.8% RSA/RSA. For each of the tasks, there were no significant differences in the ability to perform the task among the groups (p>0.05). Post-operative IR ROM for TSA/TSA was superior to those for TSA/RSA and RSA/RSA (p<0.01). IR ROM efficacies for both RSA/RSA and TSA/RSA were inferior to that for TSA/TSA (p<0.05). CONCLUSION: Bilateral RSA patients can perform most IR tasks, and their ability to complete these tasks does not differ significantly from those in patients with other BSA.

Participation in Work and Sport Following Reverse and Total Shoulder Arthroplasty.

Both anatomical total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) are routinely performed for patients who desire to continuously work or participate in sports. This study analyzes and compares the ability of patients to work and partake in sports following shoulder arthroplasty based on responses to clinical outcome surveys. A retrospective review of the shoulder surgery repository was performed for all patients treated with TSA and RSA and who completed questions 9 and 10 on the activity patient self-evaluation portion of the American Shoulder and Elbow Surgeons (ASES) Assessment Form. Patients with a minimum of 1-year follow-up were included if a sport or work was identified. The analysis included 162 patients with TSA and 114 patients with RSA. Comparisons were made between TSA and RSA in terms of the specific ASES scores (rated 0-3) reported for ability to work and participate in sports and total ASES scores, and scores based on specific sports or line of work reported. Comparisons were also made between sports predominantly using shoulder function and those that do not. TSA patients had a 27% higher ability to participate in sports (average specific ASES score: 2.5 vs 1.9, P < .001) than RSA patients and presented significantly higher scores for swimming and golf. Compared with RSA patients, TSA patients demonstrated more ability to participate in sports requiring shoulder function without difficulty, as 63% reported maximal scores (P = .003). Total shoulder arthroplasty patients also demonstrated a 21% higher ability to work than RSA patients (average specific ASES scores: 2.6 vs 2.1, P < .001), yielding significantly higher scores for housework and gardening. Both TSA and RSA allow for participation in work and sports, with TSA patients reporting better overall ability to participate. For sports involving shoulder function, TSA patients more commonly report maximal ability to participate than RSA patients.

Impact of Perioperative HbA1c on Reimbursements in Diabetes Mellitus Patients Undergoing Total Hip Arthroplasty: A Nationwide Analysis.

BACKGROUND: Patients who have diabetes mellitus (DM) are at an increased risk of postoperative complications following total hip arthroplasty (THA). Therefore, much interest has been paid to perioperative glycemic control. However, no prior studies have evaluated the patient variation of HbA1c levels on costs. Therefore, the purpose of this study was to evaluate the impact of obtaining preoperative HbA1c levels on (1) day of surgery (DOS) cost; (2) subsequent 89-day costs; and (3) global 90-day cost. METHODS: A retrospective query of the Humana insurance claims database was performed from 2007 to 2015 for all DM patients undergoing THA. Only patients with HbA1c (%) levels within 3 months before or after the THA were included. Patients were stratified into 6 groups based on HbA1c starting at 5.5% and increasing by 1% increments to 11.5%; one additional group (11.5%-20%) for extreme cases was analyzed. Correlations between HbA1c level and reimbursements for DOS, subsequent 89-day, and global 90-day period were performed. RESULTS: HbA1c level demonstrated a significant correlation to DOS (correlation coefficient = 0.664), subsequent 89-day (correlation coefficient = 0.789), and global 90-day period (correlation coefficient = 0.747) costs. DOS, 89-day, and global 90-day costs significantly increased with increasing HbA1c levels (P < .0001). CONCLUSION: Higher perioperative HbA1c levels increase the DOS, subsequent 89-day, and global 90-day costs of THA. This was expected as these patients require multidisciplinary care, have longer LOS, and develop more complications. Further investigation into postoperative complications based on glycemic control is warranted.

External snapping hip: a systematic review of outcomes following surgical intervention: External snapping hip systematic review.

PURPOSE: To evaluate the outcomes of surgical management for external snapping hip in terms of: (1) recurrence; (2) complications; and (3) return to pre-injury activities. METHODS: A thorough review of 4 electronic databases- EMBASE, CINAHL Plus, PubMed, and Scopus was performed to find all relevant studies for this review that were published between January 2000 and January 2017 that addressed surgical treatment for external snapping hip. The following reports were excluded: (1) non-English manuscripts; (2) n ⩽ 5; (3) clinical reviews; (4) surgical technique notes; (5) studies only analysing diagnosis; and (6) nonoperative management studies. After cross-referencing, a total of 7 reports were included. Each of these studies was analysed for the incidence of recurrence, revision surgery, complications, and return to pre-injury activity level. RESULTS: There was a recurrence rate of 7% ( n = 8 of 113 hips) with only 1 requiring revision surgery (1%). The cumulative complication rate was 9% ( n = 10 of 113) with all complications being residual weakness. Additionally, we found 98% ( n = 58 of 59) of the patients returned to their pre-injury level of activity. CONCLUSIONS: We found operative treatment for external snapping hip to be both safe and efficacious for returning patients to their pre-injury activities. When recurrence does occur, it often is painless and does not require revision surgery. Future studies should be larger and evaluate different surgical techniques to further elucidate the safety and efficacy of surgical treatment for external snapping hip.

Use of a Total Shoulder Arthroplasty in a Patient with Minimally Painful Severe Glenohumeral Arthritis and a Progressive Plexopathy: A Case Report.

CASE: A 70-year-old woman presented with severe but minimally painful right glenohumeral osteoarthritis (OA), with progressive weakness and numbness radiating to the right hand. Imaging revealed a large fluid collection extending from the joint to the subcoracoid space, with a mass effect on the brachial plexus. A total shoulder arthroplasty (TSA) and decompression of a ganglion cyst were performed. Follow-up with serial electromyography demonstrated resolution of the brachial plexopathy and restoration of function. CONCLUSION: Ganglion cysts may arise secondary to severe glenohumeral OA and may compress the surrounding structures, producing a progressive plexopathy. Treatment of the underlying pathology with a TSA may be effective.