Total Knee Arthroplasty in Patients with Cerebral Palsy: A Large Database Analysis.

Cerebral palsy (CP) is a neurodevelopmental condition that can result in altered gait biomechanics, joint dysfunction, and imbalance. The complications associated with total knee arthroplasty (TKA) in patients with CP have not yet been well described. Therefore, our analysis sought to compare the 90-day and 2-year complications following TKA in patients with and without CP. The PearlDiver Mariner database was utilized to identify patients with CP undergoing primary TKA between 2010 and 2020. This cohort was matched 1:4 to a control cohort without neurodegenerative disorders based on age, sex, Elixhauser Comorbidity Index (ECI), tobacco use, obesity, and diabetes. A total of 3,257 patients (657 CP patients 2,600 controls) were included in our final analysis. A multivariable logistic regression analysis was utilized to determine the risk of CP on medical and surgical complications at 90 days and all-cause revision rates at 2 years. Patients with CP had an increased risk of acute kidney injury (odds ratio [OR]: 1.66; 95% confidence interval [CI]: 1.07-2.5; p = 0.019), pneumonia (OR: 5.63; 95% CI: 3.69-8.67; p < 0.001), urinary tract infection (OR: 5.01; 95% CI: 3.85-6.52; p < 0.001), and transfusion (OR: 2.21; 95% CI: 1.50-3.23; p < 0.001). CP patients additionally had a higher incidence of emergency department (ED) visits (OR: 5.24; 95% CI: 3.76-7.32; p < 0.001) and readmissions (OR: 5.24; 95% CI: 2.57-4.96; p < 0.001). There were no differences in rates of periprosthetic joint infection (PJI; OR: 1.23; 95% CI: 0.69-2.10; p = 0.463), surgical site infection (SSI; OR: 0.51; 95% CI: 0.12-1.46; p = 0.463), and reoperation (OR: 1.35; 95% CI: 0.71-2.43; p = 0.339) at 90 days postoperatively. The all-cause revision rates at 2 years were comparable (OR: 1.02; 95% CI: 0.67-1.51; p = 0.927). In this database review, we found that CP patients have a higher risk of medical complications in the acute postoperative period following TKA. The 90-day surgical complication and 2-year revision rates in CP patients were comparable to matched controls.

Is Hospital-Based Outpatient Revision Total Knee Arthroplasty Safe? An Analysis of 2,171 Outpatient Aseptic Revision Procedures.

BACKGROUND: Outpatient primary total knee arthroplasty (TKA) has been well-established as a safe and effective procedure; however, the safety of outpatient revision TKA remains unclear. Therefore, this study utilized a large database to compare outcomes between outpatient and inpatient revision TKA. METHODS: An all-payor database was queried to identify patients undergoing revision TKA from 2010 to 2022. Patients who had diagnosis codes related to periprosthetic joint infection (PJI) were excluded. Outpatient surgery was defined as a length of stay < 24 hours. Cohorts were matched by age, sex, Elixhauser Comorbidity Index, comorbidities (diabetes, obesity, tobacco use), components revised (1-versus 2-component), and revision etiology. Medical complications at 90 days and surgical complications at 1 and 2 years postoperatively were evaluated through multivariate logistic regression. A total of 4,342 aseptic revision TKAs were included. RESULTS: No differences in patient characteristics, procedure type, or revision etiologies were seen between groups. The outpatient cohort had a lower risk of PJI (odds ratio (OR): 0.547, 95% confidence interval (CI): 0.337 to 0.869; P = .012), wound dehiscence (OR: 0.393, 95% CI: 0.225 to 0.658; P < .001), transfusion (OR: 0.241, 95% CI: 0.055 to 0.750; P = .027), reoperation (OR: 0.508, 95% CI: 0.305 to 0.822; P = .007), and any complication (OR: 0.696, 95% CI: 0.584 to 0.829; P < .001) at 90 days postoperatively. At 1 year and 2 years postoperatively, outpatient revision TKA patients had a lower incidence of revision for PJI (OR: 0.332, 95% CI: 0.131 to 0.743; P = .011 and OR: 0.446, 95% CI; 0.217 to 0.859; P = .020, respectively) and all-cause revision (OR: 0.518, 95% CI: 0.377 to 0.706; P < .001 and OR: 0.548, 95% CI: 0.422 to 0.712; P < .001, respectively). CONCLUSIONS: Our findings suggest that revision TKA can be safely performed on an outpatient basis in appropriately selected patients who do not have an increased risk of adverse events relative to inpatient revision TKA. However, we could not ascertain case complexity in either cohort, and despite controlling for several potential confounders, other less tangible differences could exist between groups.

Early Prosthetic Hip Dislocation: Does the Timing of the Dislocation Matter?

BACKGROUND: Early dislocation following total hip arthroplasty (THA) is a common reason for revision. The purpose of this study was to determine if the acuity of the dislocation episode affects the risk of revision surgery. METHODS: A retrospective review of a national, all-payer administrative database comprised of claims from 2010 to 2020 was used to identify patients who had a prosthetic hip dislocation at various postoperative time intervals (0 to 7, 7 to 30, 30 to 60, and 60 to 90 days). Of the 45,352 primary unilateral THA patients who had sufficient follow-up, there were 2,878 dislocations within 90 days. Dislocators were matched 1:1 based on age, sex, and a comorbidity index with a control group (no dislocation). Demographics, surgical indications, comorbidities, ten-year revision rates, and complications were compared among cohorts. Multivariable logistic regression analysis was performed to identify risk factors for revision THA following early dislocation. RESULTS: Among matched cohorts, dislocation at any time interval was associated with significantly increased odds of subsequent 10-years revision (OR [odds ratio] = 25.60 to 33.4, P < .001). Acute dislocators within 7 days did not have an increased risk of all cause revisions at 10 years relative to other early dislocators. Revision for indication of instability decreased with time to first dislocation (<7 days: 85.7% versus 60 to 90 days: 53.9%). Primary diagnoses of posttraumatic arthritis (OR = 2.53 [1.84 to 3.49], P < .001), hip fracture (OR = 3.8 [2.53 to 5.72], P < .001), and osteonecrosis (OR = 1.75 [1.12 to 2.73], P = .010) were most commonly associated with revision surgery after an early dislocation. CONCLUSIONS: Dislocation within 90 days of THA is associated with increased odds of subsequent revision. Early dislocation within 7 days of surgery has similar all cause revision-free survivorship, but an increased risk of a subsequent revision for instability when compared to patients who dislocated within 7 to 90 days.

Late Manipulation under Anesthesia after Total Knee Arthroplasty: Improved Range of Motion and a Low Complication Rate.

The purpose of this study was to evaluate outcomes of late manipulation under anesthesia (MUA) for stiffness performed from ≥12 weeks to more than a year after primary total knee arthroplasty (TKA). A total of 152 patients receiving MUA ≥12 weeks after primary TKA from 2014 to 2021 were reviewed. The primary outcome measured was change in range of motion (ROM). We tracked intraoperative complications and the need for repeat MUA or open procedure for continued stiffness after initial MUA. Three subgroups were analyzed: Group 1 included 58 knees between 12 weeks and 6 months after TKA, Group 2 included 44 knees between 6 and 12 months after TKA, and Group 3 included 50 knees ≥12 months after TKA. Analysis included descriptive statistics and univariate analysis, with α <0.05. Groups 1 to 3 all significantly increased their overall ROM by 20.9, 19.2, and 22.0 degrees, respectively. All groups significantly increased their flexion and extension from preoperatively. Group 1 had one intraoperative supracondylar femur fracture (1.7%) requiring open reduction and internal fixation, and five patients required repeat MUA or open procedure (8.6%). Group 2 had no intraoperative fractures, and five patients required repeat MUA or open procedure (11.4%). Group 3 had one intraoperative tibial tubercle avulsion fracture managed conservatively (2.0%) and one repeat MUA (2.0%). Late MUA resulted in significantly improved ROM in all groups. ROM improved more as the time from index TKA increased, although statistically insignificant. Repeat MUA or open procedure rate decreased with MUA ≥12 months from TKA, although statistically insignificant. The overall intraoperative fracture risk was 1.3%.

Three Differing Methods of Treating Intraoperative Nondisplaced Calcar Fractures Demonstrate Similar Radiographic Stem Subsidence.

BACKGROUND: Several management strategies have been described to treat intraoperative calcar fractures during total hip arthroplasty (THA), including retaining the primary implant and utilizing cerclage cables (CCs) or switching the implant to one that bypasses the fracture and achieves diaphyseal fixation. However, the radiographic and clinical outcomes of these differing strategies have never been described and compared. METHODS: We retrospectively identified 50 patients who sustained an intraoperative calcar fracture out of 9,129 primary total hip arthroplasties (0.55%) performed by one of three surgeons between 2008 and 2022. Each of the three surgeons consistently employed a distinct strategy for the management of these fractures: retention of the primary metaphyseal-engaging implant and placement of CCs; exchange to a modular, tapered-fluted stem (MTF); or exchange to a fully-coated, diaphyseal-engaging stem (FC). Stem subsidence was then evaluated on standing anteroposterior pelvis radiographs at three months and one year postoperatively. Postoperative medical and surgical complication rates were evaluated. RESULTS: A total of fifteen patients were treated with CC, 15 with MTF, and 20 with FC. At three-month follow-up, mean stem subsidence was 0.43 ± 0.08 mm, 1.47 ± 0.36 mm, and 0.68 ± 0.39 mm for CC, MTF, and FC cohorts, respectively (P = .323). At one-year, mean stem subsidence was 0.70 ± 0.08 mm, 1.74 ± 0.69 mm, and 1.88 ± 0.90 mm for the CC, MTF, and FC cohorts, respectively (P = .485). Medical complications included 2 venous thromboembolic events (4%) within 90 days of surgery. There were 6 reoperations (12%); 3 (6%) for acute periprosthetic joint infection (all within the FC cohort); 2 (4%) for postoperative periprosthetic fractures (one fracture distal to the stem in the FC cohort and one fracture at the level of the stem in the MTF cohort), and 1 (2%) closed reduction for instability (within the CC cohort). CONCLUSIONS: The three described methods of managing intraoperative nondisplaced calcar fractures demonstrated little radiographic stem subsidence; however, the risk of reoperation was much higher than expected.

Risk of Subsequent Fusion After Isolated Decompression of Lumbar Facet Cysts.

INTRODUCTION: Lumbar facet cysts represent a potential source of nerve root compression in elderly patients. Isolated decompression without fusion has proven to be a reasonable treatment option in properly indicated patients. However, the risk of lumbar fusion after isolated decompression and facet cyst excision has yet to be elucidated. METHODS: The PearlDiver database was reviewed for patients undergoing isolated laminectomy for lumbar facet cyst from January 2015 to December 2018 using Current Procedural Terminology coding. Patients undergoing concomitant fusion or additional decompression, as well as those diagnosed with preexisting spondylolisthesis or without a minimum of 5-year follow-up, were excluded. Rates of subsequent lumbar fusion and potential risk factors for subsequent fusion were identified. Statistical analysis included descriptive statistics, chi square test, and multivariate logistic regression. Results were considered significant at P < 0.05. RESULTS: In total, 10,707 patients were ultimately included for analysis. At 5-year follow-up, 727 (6.79%) of patients underwent subsequent lumbar fusion after initial isolated decompression. Of these, 301 (2.81% of total patients, 41.4% of fusion patients) underwent fusion within the first year after decompression. Multivariate analysis identified chronic kidney disease, hypertension, and osteoarthritis as risk factors for requiring subsequent lumbar fusion at 5 years following the index decompression procedure ( P < 0.033; all). CONCLUSION: Patients undergoing isolated decompression for lumbar facet cysts undergo subsequent lumbar fusion at a 5-year rate of 6.79%. Risk factors for subsequent decompression include chronic kidney disease, hypertension, and osteoarthritis. This study will assist spine surgeons in appropriately counseling patients on expected postoperative course and potential risks of isolated decompression.

Preoperative Corticosteroid Injections Are Not Associated with Deep Infection after Unicompartmental Knee Arthroplasty.

Prior to unicompartmental knee arthroplasty (UKA), corticosteroid injections (CSI) are a common nonoperative treatment for arthritis. It is unclear whether CSI prior to UKA impacts the likelihood of postoperative infection. This study sought to determine if there is a time- and/or dose-dependent relationship between preoperative CSI and postoperative infection. An administrative claims database was queried for patients undergoing UKA with more than 1 year of pre-enrollment and follow-up. Of 31,676 patients with a UKA who met enrollment criteria, 8,628 patients had a CSI 0 to 3 months prior to surgery, 111 had a CSI 3 to 12 months prior to surgery, and 22,937 never received an injection. Overall, 246 postoperative deep infections were reported (0.8%). Time-dependent and dose-dependent relationships were modeled using multivariable logistic regressions. Postoperative deep infections occurred in 64 patients with CSI 0 to 3 months prior to surgery (0.7%), compared with 0 patients with CSI 3 to 12 months before surgery (0.0%) and 182 controls (0.8%, p = 0.58). CSI within 1 month prior to UKA was not statistically associated with postoperative infection (p = 0.66). Two or more CSI within 3 months prior to UKA were associated with a twofold elevated odds of infection, compared with receiving a single injection (odds ratio [OR]: 2.08, p = 0.03). Univariable predictors of infection included younger age, increasing Charlson Comorbidity Index, smoking, asthma, chronic obstructive pulmonary disease, chronic kidney disease, diabetes, liver disease, and obesity. Multivariable analysis controlling for these characteristics elicited no relationship between recent CSI administration and postoperative infection. CSI within 3 months of surgery (1.5%) or 3 to 12 months (1.8%) were associated with increased conversion to total knee arthroplasty (TKA) compared with those who did not receive an injection (1.1%, p = 0.01), although TKA for indication of periprosthetic joint infection was not statistically different (p = 0.72). Preoperative CSI within 3 months of UKA is not associated with postoperative infection, although significant medical comorbidity does show an association. Preoperative CSI is associated with increased conversion from UKA to TKA for noninfectious indications.

Invasive Gastrointestinal Endoscopy Following Total Joint Arthroplasty Increases the Risk for Periprosthetic Joint Infection.

BACKGROUND: The safety of postoperative colonoscopy and endoscopy following total joint arthroplasty (TJA) remains largely unknown. The objective of this study was to characterize the effect of gastrointestinal endoscopic procedures after TJA on the risk of postoperative periprosthetic joint infection (PJI). METHODS: Using a large national database, patients who underwent an endoscopic procedure (colonoscopy or esophagogastroduodenoscopy (EGD)) within 12 months after primary TJA were identified and matched in a 1:1 fashion based on procedure (primary total knee arthroplasty (TKA) versus total hip arthroplasty (THA)), age, sex, Charlson Comorbidity Index (CCI), and smoking status with patients who did not undergo endoscopy. A total of 142,055 patients who underwent endoscopy within 12 months following TJA (96,804 TKAs and 45,251 THAs) were identified and matched. The impact of timing of endoscopy relative to TJA on postoperative outcomes was assessed. Preoperative comorbidity profiles and 1-year complications were compared. Statistical analyses included Chi-squared tests and multivariate logistic regressions with outcomes considered significant at P < .05. RESULTS: Multivariate analyses revealed that endoscopy within 2 months following TKA and 1 month of THA was associated with a significantly increased odds of periprosthetic joint infection (odds ratio (OR): 1.29 [1.08-1.53]; P = .004; OR: 1.41 [1.01-1.90]; P = .033, respectively). Patients who underwent endoscopy greater than 2 months from the timing of their TKA and 1 month from THA were not at significantly greater risk of developing PJI. CONCLUSION: These data suggest that invasive endoscopic procedures should be delayed if possible by at least 2 months following TKA and 1 month following THA to minimize the risk of PJI.

Cementless Total Knee Arthroplasty is Associated With Early Aseptic Loosening in a Large National Database.

BACKGROUND: Despite excellent longevity demonstrated in institutional studies, outcomes after cementless total knee arthroplasty (TKA) on a population level remain unknown. This study compares 2-year outcomes between cemented and cementless TKA using a large national database. METHODS: A large national database was used to identify 294,485 patients undergoing primary TKA from January 2015 to December 2018. Patients who had osteoporosis or inflammatory arthritis were excluded. Cementless and cemented TKA patients were matched one-to-one based on age, Elixhauser Comorbidity Index, sex, and year yielding matched cohorts of 10,580 patients. Outcomes at 90 days, 1 year, and 2 years postoperatively were compared between groups, and Kaplan-Meier analysis was used to evaluate implant survival rates. RESULTS: At 1 year postoperatively, cementless TKA was associated with an increased rate of any reoperation (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.12-1.92, P = .005) compared to cemented TKA. At 2 years postoperatively, there was an increased risk of revision for aseptic loosening (OR 2.34, CI 1.47-3.85, P < .001) and any reoperation (OR 1.29, CI 1.04-1.59, P = .019) after cementless TKA. Two-year revision rates for infection, fracture, and patella resurfacing were similar between cohorts. CONCLUSION: In this large national database, cementless fixation is an independent risk factor for aseptic loosening requiring revision and any reoperation within 2 years after primary TKA.

Two Intramedullary and 1 Extramedullary Cortical Button, With or Without Interference Screw, Show Biomechanical Properties Superior to Native Tendon in Repair of the Distal Biceps Tendon: A Systematic Review and Network Meta-analysis of Biomechanical Performance.

PURPOSE: The aim of this study was to use a systematic review and network meta-analysis (NMA) to compare the failure strength, maximum strength, stiffness, and displacement of available constructs for distal biceps repair. METHODS: An NMA was conducted to determine the performance of 2 all-suture suture anchors (2x ASA), 2 intramedullary cortical buttons (2x IM CB), 2 suture anchors (2x SA), extramedullary cortical buttons (EM CB), extramedullary cortical button plus interference screw (EM CB+IFS), interference screw (IFS), single intramedullary cortical button (IM CB), single suture anchor (SA), transosseous suture (TOS), tension slide technique (TST), and tension slide technique plus suture tape (TST+ST). Analysis consisted of arm-based network meta-analysis under Bayesian random-effects model with Markov Chain Monte Carlo (MCMC) sampling. Biomechanical outcomes were summarized as treatment effects and their corresponding 95% confidence intervals (CI). Rank probabilities were calculated and used to generate each treatment's surface under the cumulative ranking (SUCRA) curve. Biomechanical properties were compared to native tendon. Displacement >10 mm was defined as clinical failure. RESULTS: Twenty-one studies were included. For failure strength, no construct outperformed the native tendon but 2× SA, IFS, SA, and TOS demonstrated poorer failure strength. For the maximum load to failure, EM CB+IFS outperformed the native tendon. Compared to native tendon, EM CB+IFS, EM CB, and 2×IM CB were stiffer, while 2x SA and IFS were less stiff. No construct demonstrated >10 mm of displacement, but constructs with displacement above the mean (3.5 mm) included 2× ASA, 2xIM CB, and TOS. CONCLUSIONS: The fixation constructs that consistently demonstrated comparable or better biomechanical properties (failure strength, maximum strength, and stiffness) to native tendon in distal biceps tendon repair were the extramedullary cortical button with or without interference screw and two intramedullary cortical buttons. No construct demonstrated displacement beyond standard definitions for clinical failure. CLINICAL RELEVANCE: This network meta-analysis of biomechanical studies suggests that extramedullary cortical button and two intramedullary cortical buttons may be the most stable construct for distal biceps repair fixation, with equivalent or better biomechanical properties compared to native tendon.

COVID-19 Infection After Total Joint Arthroplasty Is Associated With Increased Complications.

BACKGROUND: The impact of a postoperative diagnosis of COVID-19 in patients undergoing total joint arthroplasty (TJA) remains unknown. The objective of this study is to characterize the effect of COVID-19 infection following TJA on perioperative complication rates. METHODS: The Mariner database was queried for patients undergoing total hip and total knee arthroplasty from January 2018 to April 2020. TJA patients who were diagnosed with COVID-19 within 90 days postoperatively were matched in a 1:3 fashion based on age, gender, iron deficiency anemia, payer status, and Charlson Comorbidity Index with patients who were not diagnosed with COVID-19. Preoperative comorbidity profiles and complications within 3 months of surgery were compared. Statistical analysis included chi-squared tests and multivariate logistic regression with outcomes considered significant at P < .05. RESULTS: Of the 239 COVID-19 positive patients, 132 (55.2%) underwent total hip arthroplasty. On multivariate analysis, COVID-19 diagnosis was associated with increased odds of deep vein thrombosis (odds ratio [OR] 4.86, 95% confidence interval [CI] 2.10-11.81, P < .001), pulmonary embolism (OR 6.27, 95% CI 2.57-16.71, P < .001), and all complications (OR 3.36, 95% CI 2.47-4.59, P < .001). Incidence of deep vein thrombosis/pulmonary embolism was greater the closer in time the COVID-19 diagnosis was to the surgical procedure (10.24 times at 1 month, 7.87 times at 2 months, and 1.42 times at 3 months; P < .001). A similar relationship was observed with all complications. CONCLUSION: Postoperative COVID-19 infection is associated with higher rates of cardiopulmonary complications, thromboembolic disease, renal injury, and urinary tract infections in patients undergoing hip and knee arthroplasty. COVID-19 infection earlier in the postoperative period is associated with a higher risk of complications.

Increased Readmission Rates but No Difference in Complication Rates in Patients Undergoing Inpatient Versus Outpatient Hip Arthroscopy: A Large Matched-Cohort Insurance Database Analysis.

Purpose: To compare the early postoperative outcomes of patients undergoing inpatient versus outpatient hip arthroscopy and identify any characteristics that may serve as predictors of these complications. Methods: The PearlDiver Mariner insurance database was queried for all patients who underwent hip arthroscopy from 2010 to 2019. Patients were matched based on Charlson Comorbidity Index, age, and sex. Outcomes recorded included postoperative complications and return to care within 90 days. Predictors of complications were assessed via multivariable logistic regression controlling for age, sex, Charlson Comorbidity Index, comorbidities, surgical setting, and procedure type. Results: The final matched cohort included 832 inpatients and 1,356 matched patients. Fifty-eight patients (7.0%) who underwent inpatient surgery versus 25 patients (1.8%) who underwent outpatient surgery were readmitted (P < .01). Of the readmitted patients, 31 inpatients (3.7%) and 5 outpatients (0.4%) were readmitted for hip-related reasons (P < .01). No significant differences were observed in emergency department visits (67 inpatients [8.1%] vs 84 outpatients [6.2%], P = .11), intensive care unit admissions (3 [0.4%] vs 1 [0.1%], P = .31), or revision hip arthroscopies (43 [5.2%] vs 65 [4.8%], P = .77). A multivariable model of complications correcting for baseline differences in chronic obstructive pulmonary disease, coronary artery disease, diabetes, hypertension, ischemic heart disease, tobacco use, and inpatient status found that age (adjusted odds ratio [OR], 0.92; 95% confidence interval [CI], 0.85-0.99; P = .03), coronary artery disease (adjusted OR, 12.82; 95% CI, 1.18-140.02; P = .03), and inpatient setting (adjusted OR, 20.59; 95% CI, 3.48-401.65; P = .01) were significantly associated with complications. No procedure type was associated with complication rates. Conclusions: Compared with the outpatient setting, inpatient hip arthroscopy is associated with higher rates of readmission in a cohort matched for age, sex, and comorbidities. Complications after inpatient hip arthroscopy appear to be related to comorbidities rather than procedure-related factors. The decision to conduct an inpatient hip arthroscopy should prioritize consideration of patient comorbidities over the type of procedure. Level of Evidence: Level III, retrospective cohort study.

Corticosteroid injections 2 months before arthroscopic meniscectomy increases the rate of postoperative infections requiring surgical irrigation and debridement.

PURPOSE: Consensus guidelines recommend administering a corticosteroid injection (CSI) for patients with a symptomatic degenerative meniscus lesion prior to arthroscopic partial meniscectomy (APM). A recent study found that CSI administered within 1 month prior to meniscectomy is associated with an increased risk of postoperative infection. However, infections may range in severity from superficial infections to serious infections requiring surgical interventions. The aim of this analysis was to define the rate of infections requiring surgery after APM and determine its relationship to preoperative CSI. METHODS: The PearlDiver Mariner administrative claims database was queried for patients > 35 years old who had a CSI in the year prior to isolated APM. Rates of deep infection and infection requiring surgery within 6 months were reported between matched patients with a CSI and no injection. RESULTS: After matching, there were 16,009 patients per group with a mean age of 59.4 years (SD = 9.6), 53.5% obesity, and 40% male. Forty-four of 113 patients who developed a postoperative deep infection went on to have a reoperation for irrigation and/or debridement (0.1% of all APM). Of these 44 patients, 30 had a preoperative CSI and 14 were controls unadjusted odds ratio (unadj-OR) if given CSI = 1.95, 95% CI 1.03-3.68, P = 0.04). Having a CSI within the month before surgery conferred a 4.56-fold increase in odds of an infection warranting surgery (95% CI 1.96-10.21, P < 0.01), whilst having a CSI 4-8 weeks before surgery conferred a 2.42-fold increase in odds (95% CI 1.04-5.42, P = 0.03). Receiving multiple CSI in the year prior to APM was associated with 5.27-fold increased odds of an infection requiring surgery (95% CI 1.19-23.27, P = 0.03), compared to having a single CSI. CONCLUSIONS: Serious infections requiring a surgical intervention are rare after a meniscectomy, occurring in 0.1% of APMs in a matched cohort of patients over 35. Patients were five times more likely to return to the operating room for infection after APM if they had a CSI in the month before or had multiple CSIs in the year before surgery. The risk of infection was no longer significant if there was at least a 2-month interval between preoperative CSI and APM. LEVEL OF EVIDENCE: Level III.

Postoperative, But Not Preoperative Coronavirus Disease 2019 (COVID-19), Is Associated With an Increased Rate of Medical Adverse Events Following Arthroscopic Procedures.

Purpose: To characterize how severe acute respiratory syndrome coronavirus 2 infection in the perioperative period affects the medical adverse event (MAE) rates in arthroscopic sports medicine procedures. Methods: The Mariner coronavirus disease 2019 (COVID-19) database was queried for all shoulder, hip, or knee arthroscopies, 2010 to 2020. Patients with COVID-19 in the 3 months before to 3 months after their surgery were matched by age, sex, and Charlson Comorbidity Index to patients with an arthroscopy but no perioperative COVID-19 infection, or a COVID-19 infection but no arthroscopic procedure. MAEs in the 3 months after surgery or illness were compared between groups. Results: The final cohort consisted of 1,299 matched patients in 3 groups: COVID-19 alone, arthroscopy and perioperative COVID-19, and arthroscopy alone. There were 265 MAEs if a patient had COVID-19 alone (20.4%), 200 MAEs if a patient had arthroscopy with COVID-19 (15.4%), and 71 (5.5%) MAEs if a patient had arthroscopy alone (P < .01). If a patient had an arthroscopy, having COVID-19 was associated with 3.1-fold elevated odds (95% confidence interval [CI] 2.9-3.4, P < .01) of MAE. Among patients with an arthroscopy, MAEs were more common if a patient acquired COVID-19 in the 3 months after their surgery (pooled odds ratio 7.39, 95% CI 5.49-9.95, P < .01) but not if a patient had preoperative COVID-19 (pooled odds ratio 0.66, 95% CI 0.42-1.03, P = .07). Conclusions: Having COVID-19 during the postoperative period appears to confer a 7-fold elevated risk of MAEs after shoulder, hip, and knee arthroscopy compared with matched patients with arthroscopy and no perioperative COVID-19 but equivalent to that of patients with COVID-19 and no arthroscopy. However, there was no increase in postoperative MAEs if a patient had COVID-19 during the 3 months preceding surgery. Therefore, it appears safe to conduct an arthroscopic procedure shortly after recovery from COVID-19 without an increase in acute medical complication rates. Level of evidence: Level III, retrospective cohort study.

Return to Play and Player Performance After Meniscal Tear Among Elite-Level European Soccer Players: A Matched Cohort Analysis of Injuries From 2006 to 2016.

BACKGROUND: Meniscal injuries are extremely common in soccer athletes, and little is known about postrecovery performance. PURPOSE: To (1) identify characteristics associated with return to play (RTP) to the same league level and (2) evaluate long-term effects that injury and management approach may have on player performance. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Using publicly available records, we identified athletes who sustained meniscal tears across the 5 major European soccer leagues (English Premier League, Bundesliga, La Liga, Ligue 1, and Serie A) between 2006 and 2016. Injured athletes were matched to controls 1:2 by demographics and performance. Investigations included rate of RTP to the same league level, reinjury, player characteristics associated with RTP within 2 seasons, long-term availability, field time, and performance metrics standardized to 90 minutes of play during the next 4 seasons. RESULTS: A total of 250 players sustaining meniscal tears were included, of which 106 (42%) received surgical management. Median absence was 57.5 days (interquartile range [IQR], 35-92) or 7 games (IQR, 4-12). Rate of RTP was 70%, and the reinjury rate 5% if a player could RTP. Age greater than 30 years was a negative predictor for RTP (odds ratio [OR], 0.62; P = .002), whereas higher preinjury goals per game (OR, 2.80; P = .04) and surgical management (OR, 1.38; P = .002) were positive predictors for RTP. Surgical management was associated with higher long-term availability (P < .01). As compared with the control, there were no significant differences in field time or performance metrics after RTP, either overall or by player position. As compared with nonoperative management, defenders undergoing surgery demonstrated decreased field time. Attackers and midfielders demonstrated similar field time and performance regardless of management. CONCLUSION: RTP of elite soccer athletes sustaining meniscal tear is contingent on age, preinjury performance, and management approach. Those who RTP to the same league level can be expected to demonstrate equivalent field time, performance, and long-term availability as noninjured athletes.

Incidence and risk factors for symptomatic venous thromboembolism following anterior cruciate ligament reconstruction.

PURPOSE: To determine the incidence of symptomatic venous thromboembolism (VTE) following anterior cruciate ligament (ACL) reconstruction using a large national database and to identify corresponding independent risk factors. METHODS: The Humana administrative claims database was reviewed for patients undergoing ACL reconstruction from 2007 to 2017. Patient demographics, medical comorbidities, as well as concurrent procedures were recorded. Postoperative incidence of VTE was measured by identifying symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) at 30 days, 90 days, and 1 year postoperatively. Univariate analysis and binary logistic regression were performed to determine independent risk factors for VTE following surgery. RESULTS: A total of 11,977 patients were included in the study. The incidence of VTE was 1.01% (n = 120) and 1.22% (n = 146) at 30 and 90 days, respectively. Analysis of VTE events within the first postoperative year revealed that 69.6% and 84.3% of VTEs occurred within 30 and 90 days of surgery, respectively. Logistic regression identified age ≥ 45 (odds ratio [OR] = 1.88; 95% confidence interval [CI] 1.32-2.68; p < 0.001), inpatient surgery (OR = 2.07; 95% CI 1.01-4.24; p = 0.045), COPD (OR = 1.51; 95% CI 1.02-2.24; p = 0.041), and tobacco use (OR = 1.75; 95% CI 1.17-2.62; p = 0.007), as well as concurrent PCL reconstruction (OR = 3.85; 95% CI 1.71-8.67; p = 0.001), meniscal transplant (OR = 17.68; 95% CI 3.63-85.97; p < 0.001) or osteochondral allograft (OR = 15.73; 95% CI 1.79-138.43; p = 0.013) as independent risk factors for VTE after ACL reconstruction. CONCLUSIONS: The incidence of symptomatic postoperative VTE is low following ACL reconstruction, with the majority of cases occurring within 90 days of surgery. Risk factors include age ≥ 45, inpatient surgery, COPD, tobacco use and concurrent PCL reconstruction, meniscal transplant or osteochondral allograft. LEVEL OF EVIDENCE: III.

Duration of Care and Operative Time Are the Primary Drivers of Total Charges After Ambulatory Hip Arthroscopy: A Machine Learning Analysis.

PURPOSE: To develop a machine learning algorithm to predict total charges after ambulatory hip arthroscopy and create a risk-adjusted payment model based on patient comorbidities. METHODS: A retrospective review of the New York State Ambulatory Surgery and Services database was performed to identify patients who underwent elective hip arthroscopy between 2015 and 2016. Features included in initial models consisted of patient characteristics, medical comorbidities, and procedure-specific variables. Models were generated to predict total charges using 5 algorithms. Model performance was assessed by the root-mean-square error, root-mean-square logarithmic error, and coefficient of determination. Global variable importance and partial dependence curves were constructed to show the impact of each input feature on total charges. For performance benchmarking, the best candidate model was compared with a multivariate linear regression using the same input features. RESULTS: A total of 5,121 patients were included. The median cost after hip arthroscopy was $19,720 (interquartile range, $12,399-$26,439). The gradient-boosted ensemble model showed the best performance (root-mean-square error, $3,800 [95% confidence interval, $3,700-$3,900]; logarithmic root-mean-square error, 0.249 [95% confidence interval, 0.24-0.26]; R2 = 0.73). Major cost drivers included total hours in facility less than 12 or more than 15, longer procedure time, performance of a labral repair, age younger than 30 years, Elixhauser Comorbidity Index (ECI) of 1 or greater, African American race, residence in extreme urban and rural areas, and higher household and neighborhood income. CONCLUSIONS: The gradient-boosted ensemble model effectively predicted total charges after hip arthroscopy. Few modifiable variables were identified other than anesthesia type; nonmodifiable drivers of total charges included duration of care less than 12 hours or more than 15 hours, operating room time more than 100 minutes, age younger than 30 years, performance of a labral repair, and ECI greater than 0. Stratification of patients based on the ECI highlighted the increased financial risk borne by physicians via flat reimbursement schedules given variable degrees of comorbidities. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Two-Year Clinical Outcomes and Survivorship After Isolated Biceps Tenodesis.

PURPOSE: The purpose of this study was to evaluate clinical outcomes and survivorship of isolated biceps tenodesis (BT) at a minimum of 2 years and to identify patient-specific factors associated with these outcomes in patients undergoing BT without concomitant rotator cuff repair (RCR). We hypothesized that patient-reported outcomes would be significantly improved on American Shoulder and Elbow Surgeons Survey (ASES) and Single Assessment Numeric Evaluation (SANE), with a high rate of survivorship (>90%) at 2-year follow-up. METHODS: A retrospective review of an institutional registry was performed to identify patients who underwent BT from July 2016 to December 2017. Patients >18 years old who underwent an open or arthroscopic BT procedure using an interference screw, button, or anchor for underlying bicipital pathology, without a concomitant RCR or shoulder arthroplasty, and were a minimum of 2 years postoperative were included. Patients were administered ASES and SANE questionnaires preoperatively and at final follow-up. Survivorship was evaluated using Kaplan-Meier analysis. Failure was defined as any patient who underwent reoperation related to the index surgery. RESULTS: A total of 110 patients (mean ± standard deviation age, 48.60 ± 12.14 years) who underwent isolated BT with a follow-up of 24.90 ± 3.95 months were included in analysis. There was a significant improvement in ASES and SANE at final follow-up (P < .001), with 81% to 84% of patients achieving minimal clinically important difference (MCID), 72% to 82% achieving substantial clinical benefit (SCB), and 72% to 80% achieving patient-acceptable symptom state (PASS). Worker's Compensation (WC) patients had a decreased likelihood of achieving PASS on ASES (P = .015) and SANE (P = .012). Four cases were deemed failures (3 revision BTs and 1 capsular debridement) at 15.09 ± 9.57 months. WC did not have a significant effect on likelihood of BT failure. CONCLUSION: Biceps tenodesis provided significant clinical improvement and high rates of survivorship 2 years postoperatively. WC was associated with a decreased likelihood of achieving PASS. These results support the continued use of isolated BT for treating biceps pathology. LEVEL OF EVIDENCE: IV, case series.

PROMIS Upper Extremity underperforms psychometrically relative to American Shoulder and Elbow Surgeons score in patients undergoing primary rotator cuff repair.

BACKGROUND: A number of patient-reported outcome measure (PROM) instruments are used to assess shoulder pain, function, and postoperative satisfaction. Computer adaptive tests (CATs) have been developed in an effort to tailor question delivery, decrease time to completion and floor/ceiling effects, and increase compliance. Previous investigations have demonstrated excellent correlation between Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity CAT (UE-CAT) and American Shoulder and Elbow Surgeons (ASES) instruments, indicating that the PROMIS UE-CAT may be an acceptable alternative to the ASES. Prior to widespread adoption, however, rigorous psychometric validation must be performed. Thus, the purpose of this study was to evaluate the psychometric properties of PROMIS UE-CAT relative to the ASES score in patients undergoing primary rotator cuff repair (RCR). METHODS: A retrospective study of an institutional RCR registry was performed from July 2018 through March 2019. Preoperative PROMIS UE-CAT and ASES scores were collected. Floor and ceiling effects were determined, and convergent validity was established through Pearson correlations. Rasch partial credit modeling was used for psychometric analysis of the validity of PROMIS UE-CAT and ASES question items, a previously established methodology for assessing shoulder PROMs. Person-item maps were generated to characterize the distribution of question responses along the latent dimension of shoulder disability. RESULTS: Responses from 107 patients (107 shoulders) were included. PROMIS UE-CAT had a strong correlation to ASES (r = 0.684; P < .001), with a 3.7% floor effect and no ceiling effect; ASES had no floor or ceiling effects. PROMIS UE-CAT person-item maps revealed excellent test item coverage between floor and ceiling effects; however, all PROMIS UE-CAT items except "Difficulty putting on a jacket" demonstrated nonsequentially ordered responses, indicating poor reliability of item responses corresponding to shoulder function. Although PROMIS UE-CAT initially demonstrated superior instrument efficiency with fewer test items for overall equivalent coverage of shoulder function assessment, final models after recursive item elimination revealed the ASES instrument to have more well-fitting items over a broader range of shoulder function. CONCLUSION: Despite its overall strong correlation with ASES and equivalent coverage between floor and ceiling effects, the psychometric properties of PROMIS UE-CAT indicate a need for optimization of individual test items to correspond to shoulder function. Until further refinements in the PROMIS UE-CAT instrument are made, it should not replace the ASES instrument in patients undergoing primary RCR.

Arthroscopic distal clavicle excision is associated with fewer postoperative complications than open.

BACKGROUND: The rate of complications of open compared to arthroscopic distal clavicle excision remain poorly studied. Therefore, the purpose of this investigation was to (1) Identify most recent national trends in the usage of open vs. arthroscopic approaches for distal clavicle excision (DCE) from 2007 to 2017; (2) to identify and compare the complication rates for both approaches, and to identify patient-specific risk factors for complications; (3) to identify and compare the revision rate for both approaches; and (4) to identify and compare the reimbursement of each approach. METHODS: The PearlDiver database was reviewed for patients undergoing DCE from 2007 to 2017. Patients were stratified into 2 cohorts: those undergoing arthroscopic DCE (n = 8933) and those undergoing open DCE (n = 2295). The rate of postoperative complications within 90 days was calculated and compared. The revision rate and reimbursement of the arthroscopic and open approach were compared. Statistical analysis included chi-square testing to compare the rates of postoperative complications and multivariate logistic regression analysis to identify risk factors for complications within 90 days. Results were considered significant at P < .05. RESULTS: The percentage of DCEs performed arthroscopically has significantly increased from 53.9% in 2007 to 69.8% in 2016, with a concomitant decrease in the use of open DCE from 46.1% in 2007 to 30.2% in 2016. The open approach was associated with significantly more postoperative complications, including a significantly greater incidence of surgical site infection (1.9% vs. 0.3%; P < .001), wound disruption (0.3% vs. 0.1%; P < .001), hematoma (0.9% vs. 0.2%; P = .001), and transfusion (0.6% vs. 0.1%; P < .001), than arthroscopic DCE. Several risk factors, including open approach, diabetes, heart disease, tobacco use, chronic kidney disease, and female gender, were identified as independent risk factors for complications after DCE. There was no significant difference in revision rate between open and arthroscopic approaches (P = .126). The reimbursement of open and arthroscopic DCE procedures were comparable, with median reimbursements of $5408 and $5,447, respectively (P = .853). CONCLUSION: Both arthroscopic and open DCE techniques were found to have similar reimbursement amounts, with a low rate of complications, although the open technique had a higher rate of early complications such as surgical site infection. Over the study period, there was an increase in the utilization of arthroscopic DCE, while the incidence of the open technique remained constant.