Total shoulder arthroplasty in patients with dementia or mild cognitive impairment.

Background: Anatomic total shoulder arthroplasty (ATSA) and reverse total shoulder arthroplasty (RTSA) reliably alleviate pain and restore shoulder function for a variety of indications. However, these procedures are not well-studied in patients with neurocognitive impairment. Therefore, the purpose of this study was to investigate whether patients with dementia or mild cognitive impairment (MCI) have increased odds of surgical or medical complications following arthroplasty. Methods: The PearlDiver database was queried from 2010 through October 2021 to identify a cohort of patients who underwent either ATSA or RTSA and had a minimum 2-year follow-up. Current Procedural Terminology and International Classification of Diseases codes were used to stratify this cohort into three groups: (1) patients with dementia, (2) patients with MCI, and (3) patients with neither condition. Surgical and medical complication rates were compared among these three groups. Results: The overall prevalence of neurocognitive impairment among patients undergoing total shoulder arthroplasty was 3.0% in a cohort of 92,022 patients. Patients with dementia had increased odds of sustaining a periprosthetic humerus fracture (odds ratio [OR] = 1.46, P < .001), developing prosthesis instability (OR = 1.72, P < .001), and undergoing revision arthroplasty (OR = 1.55, P = .003) after RTSA compared to patients with normal cognition. ATSA patients with dementia did not have an elevated risk of surgical complications or revision. Conversely, RTSA patients with MCI did not have an elevated risk of complications or revision, although ATSA patients with MCI had greater odds of prosthesis instability (OR = 2.51, P = .008). Additionally, patients with neurocognitive impairment had elevated odds of medical complications compared to patients with normal cognition, including acute myocardial infarction and cerebrovascular accident. Conclusion: Compared to patients with normal cognition, RTSA patients with preoperative dementia and ATSA patients with preoperative MCI are at increased risk for surgical complications. Moreover, both ATSA and RTSA patients with either preoperative MCI or dementia are at increased risk for medical complications. As the mean age in the U.S. continues to rise, special attention should be directed towards patients with neurocognitive impairment to minimize postoperative complications aftertotal shoulder arthroplasty, and the risks of this surgery more carefully discussed with patients and their families and caretakers.

Increasing Hip Arthroscopy Case Volume Is Associated With Increased Risk for Revision Surgery but Not Conversion to Total Hip Arthroplasty or 90-Day Hospitalizations: A Cross-Sectional Analysis of 468 Surgeons.

PURPOSE: To analyze the effects of surgeon-specific factors, including case volume, career duration, fellowship training, practice type, and region of practice, on rates of 2-year revision surgery, conversion to total hip arthroplasty (THA), and 90-day hospitalizations following hip arthroscopy. METHODS: The PearlDiver Mariner Database was used to query patients undergoing hip arthroscopy between 2015 and 2018. Surgeons performing these procedures were identified, and surgeon-specific demographics and variables were collected from publicly available data. Patients were followed for 2 years to assess for reoperations, including revision hip arthroscopy and conversion to THA, as well as 90-day hospitalizations, including emergency department visits and hospital readmissions. International Classification of Diseases, Tenth Revision codes were used to track the laterality of revision hip procedures. Associations between surgeon-specific factors and postoperative outcomes were assessed through univariate and multivariate analyses. RESULTS: In total, 20,834 patients underwent hip arthroscopy procedures by 468 surgeons. Multivariate analysis with logistic regression adjusted for patient-related factors (age, sex, obesity, Charlson Comorbidity Index, and smoking status) identified increasing surgeon case volume to be associated with increased risk for 2-year revision hip arthroscopy (P < .001), but not 2-year conversion to THA or 90-day hospitalizations. Nonsports medicine fellowship-trained surgeons were associated with greater risk for 2-year THA conversion (P < .001) and 90-day hospital readmissions (P < .01). Surgeons practicing in an academic setting demonstrated greater risk for 90-day hospital readmissions (P < .001). Surgeons practicing in the West region of the United States were more likely to incur 2-year revision hip arthroscopy procedures compared to surgeons in the South, Midwest or Northeast (P < .001). CONCLUSIONS: Increasing surgeon hip arthroscopy case volume is associated with an increased risk for 2-year revision hip arthroscopy but not conversion to THA or 90-day hospitalizations. Further, non-sports medicine fellowship-trained surgeons were associated with higher risk for 2-year THA conversion after hip arthroscopy. LEVEL OF EVIDENCE: Level III, retrospective cohort analysis.

Incidence, risk factors, and complications of acromial stress fractures after reverse total shoulder arthroplasty.

BACKGROUND: An acromial stress fracture (ASF) is an uncommon complication after reverse total shoulder arthroplasty (RTSA) that can have severe clinical consequences on shoulder function. Although patient-specific factors have been identified to influence the risk of ASF, it is unclear whether modifying these factors can minimize risk. Moreover, there is limited information on the treatment outcomes of these fractures. Therefore, the purpose of this study was to determine modifiable risk factors for ASFs and the complication and revision rates of conservatively and operatively managed ASFs. METHODS: The PearlDiver database was queried to identify a cohort of patients who underwent RTSA with minimum 2-year follow-up. Current Procedural Terminology and International Classification of Diseases codes were used to compare the demographic characteristics, comorbidities, and medication use of patients with and without ASFs. Surgical complication and revision rates were compared between operatively and conservatively treated fractures. RESULTS: The overall incidence of ASFs was 1.4%. Patient-specific factors that were independently associated with the occurrence of an ASF included osteoporosis, rheumatologic disease, shoulder corticosteroid injection within 3 months before surgery, and chronic oral corticosteroid use. Among patients with osteoporosis, the initiation of physical therapy within 6 weeks after surgery also increased the risk of ASF. Patients who underwent surgical treatment of ASFs had a revision arthroplasty rate of 7.0% compared to a rate of 3.2% among those with conservatively managed fractures. CONCLUSION: ASFs are infrequent complications that can occur after RTSA. Preoperative factors that affect the quality of bone independently increase the fracture risk. Moreover, this risk can be minimized by avoiding shoulder corticosteroid injections 3 months before surgery and delaying physical therapy exercises among patients with osteoporosis. Surgical fixation of these fractures should be reserved for instances when conservative management has failed given high rates of infection, instability, and revision shoulder arthroplasty.

Development and Validation of a Short-Form Version of the Western Ontario Shoulder Instability Scale (Short-WOSI).

BACKGROUND: Patient-reported outcome measures (PROMs) have transitioned from primarily being used as research instruments to becoming increasingly used in the clinical setting to assess recovery and inform shared decision-making. However, there is a need to develop validated short-form PROM instruments to decrease patient burden and ease incorporation into clinical practice. PURPOSE: To assess the validity and responsiveness of a shortened version of the Western Ontario Shoulder Instability Index (Short-WOSI) when compared with the full WOSI and other shoulder-related PROM instruments. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: This study was a secondary analysis of data collected as part of an institutional review board-approved, multicenter cohort of 1160 patients undergoing surgical stabilization for shoulder instability. The following PROMs were captured preoperatively and 2 years after surgery: WOSI, American Shoulder and Elbow Surgeons (ASES) score, the Single Assessment Numeric Evaluation (SANE), and 36-Item Health Survey (RAND-36). The cohort was split into 2 data sets: a training set to be used in the development of the Short-WOSI (n = 580) and a test set to be used to assess the validity and responsiveness of the Short-WOSI relative to the full WOSI, ASES, SANE, and RAND-36. RESULTS: The Short-WOSI demonstrated excellent internal consistency before surgery (Cronbach α = .83) and excellent internal consistency at the 2-year follow-up (Cronbach α = .93). The baseline, 2-year, and pre- to postoperative changes in Short-WOSI and WOSI were closely correlated (r > 0.90), with both demonstrating large effect sizes (Short-WOSI = 1.92, WOSI = 1.81). Neither the Short-WOSI nor the WOSI correlated well with the other PROM instruments before (r = 0.21-0.33) or after (r = 0.25-0.38) surgery. The Short-WOSI, WOSI, and SANE scores were more responsive than ASES and RAND-36 scores. CONCLUSION: The 7-item Short-WOSI demonstrated excellent internal consistency and a lack of floor or ceiling effects. The Short-WOSI demonstrated excellent cross-sectional and longitudinal construct validity and was similarly responsive over time as the full WOSI. Neither the Short-WOSI nor WOSI correlated with more general shoulder PROMs, underscoring the advantage of using instability-specific instruments for this population.

Periarticular injection in addition to interscalene nerve block can decrease opioid consumption and pain following total shoulder arthroplasty: a comparison cohort study.

BACKGROUND: Interscalene nerve block (INB) is an effective technique to provide postoperative analgesia for total shoulder arthroplasty (TSA). However, the analgesic effects of the block typically resolve between 8 and 24 hours postadministration, which results in rebound pain and subsequent increased opioid use. The objective of this study was to address this issue by determining how adding an intraoperative periarticular injection (PAI) in combination with INB affects acute postoperative opioid consumption and pain scores in patients undergoing TSA. We hypothesized that compared with INB alone, INB + PAI will significantly reduce opioid consumption and pain scores for the first 24 hours postsurgery. METHODS: We reviewed 130 consecutive patients who underwent elective primary TSA at a single tertiary institution. The first 65 patients were treated with INB alone, followed by 65 patients treated with INB + PAI. The INB used was 15-20 mL of 0.5% ropivacaine. The PAI used was 50 mL of a combination of ropivacaine (123 mg), epinephrine (0.25 mg), clonidine (40 µg), and ketorolac (15 mg). The PAI was injected using a standardized protocol: 10 mL into the subcutaneous tissues prior to incision, 15 mL into the supraspinatus fossa, 15 mL at the base of the coracoid process, and 10 mL into the deltoid and pectoralis muscles-a protocol analogous with a previously described technique. For all patients, a standardized postoperative oral pain medication protocol was used. The primary outcome was acute postoperative opioid consumption represented by morphine equivalent units (MEUs), whereas the secondary outcome was visual analog scale (VAS) pain scores over the first 24 hours postsurgery, operative time, length of stay, and acute perioperative complications. RESULTS: No significant differences in demographics existed between patients who received INB alone vs. INB + PAI. Patients who received INB + PAI had a significantly lower 24-hour postoperative opioid consumption compared to the INB alone group (38.6 ± 30.5 MEU vs. 60.5 ± 37.3 MEU, P < .001). Additionally, VAS pain scores for the first 24 hours postsurgery in the INB + PAI group were significantly lower compared to those for the INB alone group (2.9 ± 1.5 vs. 4.3 ± 1.6, P ≤ .001). No differences existed between groups regarding operative time, length of inpatient stay, and acute perioperative complications. CONCLUSION: Patients undergoing TSA with INB + PAI demonstrated significantly decreased 24-hour postoperative total opioid consumption and 24-hour postoperative pain scores compared to the group treated with INB alone. No increase in acute perioperative complications related to PAI was observed. Thus, compared to an INB, the addition of an intraoperative periarticular cocktail injection appears to be a safe and effective method to reduce acute postoperative pain following TSA.

Complications and re-operations after extensor mechanism repair surgery in a large cross-sectional cohort: females and tobacco-users at highest risk for adverse outcomes.

PURPOSE: There is little information on patients most at risk for poor outcomes following surgical repair of extensor mechanism tendon injuries. The purpose of this study is to provide an epidemiological overview of patients undergoing patellar or quadriceps tendon repair and to assess the incidence of postoperative complications, readmissions, and revision repairs among this population. METHODS: Retrospective data were obtained using the PearlDiver database for patellar tendon repair and quadriceps tendon repair patients between 2010 and 2020. Baseline demographics, incidences of 90-day readmissions and postoperative complications, and reoperation rates were collected for each group. Multivariate logistic regression was performed to assess the predictive power of each demographic variable on the incidence of postoperative complications and reoperations. RESULTS: In total, 1543 patients underwent patellar tendon repair and 601 underwent quadriceps tendon repair. Complications within 90-days were observed in 33.7% of patients with patellar tendon repair and 39.2% of patients with quadriceps tendon repair. Reoperation rates were 4.2% and 4.8% for patellar tendon repair and quadriceps tendon repair, respectively. Females in both patellar tendon repair and quadriceps tendon repair groups were at significantly higher risk for post-operative complications (patellar tendon repair OR 3.0, 95% CI 2.4-3.7; quadriceps tendon repair OR 2.9, 95% CI 1.9-4.6; p < 0.001 for both). Older age (p < 0.001), female gender (p < 0.001), CCI (p < 0.001), tobacco use (p < 0.001), and obesity (p < 0.01) were all predictors of experiencing at least one complication following patellar tendon repair. For quadriceps tendon repair, female gender (p < 0.001) and CCI (p < 0.001) were the strongest predictors of experiencing at least one complication, while older age, tobacco use, and obesity (p < 0.05 for all) were also significant independent predictors. CONCLUSION: Patellar tendon repair patients are younger on average than quadriceps tendon repair patients. Although females are less likely to sustain extensor mechanism ruptures compared to males, females are significantly more likely to have at least one complication after quadriceps or patellar tendon repair. These findings may be used by surgeons, patients, and payors to understand who is most at risk for adverse outcomes following extensor mechanism repair surgery, resulting in earlier intervention and counseling to reduce the likelihood of a poor outcome following extensor mechanism repair surgery. LEVEL OF EVIDENCE: Level III.

Pre-existing Mental Health Diagnoses Are Associated With Higher Rates of Postoperative Complications, Readmissions, and Reoperations Following Arthroscopic Rotator Cuff Repair.

PURPOSE: To investigate the association between preoperative mental health disorders and postoperative complications, readmissions, and ipsilateral revision procedures among patients undergoing arthroscopic rotator cuff repair (RCR). METHODS: A retrospective cohort study from 2010 to 2020 was performed using the PearlDiver database. Current Procedural Terminology and International Classification of Diseases codes were used to compare patients with and without mental health disorders who underwent arthroscopic RCR. Mental health disorders evaluated in this study include depressive disorder, major depressive disorder, major depressive affective disorder, bipolar disorder, dysthymic disorder, adjustment disorder, separation anxiety disorder, and posttraumatic stress disorder. Patients were matched at a 1:1 ratio based on age, sex, Charlson Comorbidity Index, body mass index, and tobacco use. Rates of complications and subsequent surgeries were compared between patients with and without a preoperative diagnosis of a mental health disorder. RESULTS: The 1-year preoperative prevalence of a mental health disorder from 2010 to 2020 was 14.6%. After 1:1 matching, patients with a mental health disorder who underwent arthroscopic RCR were nearly twice as likely to undergo a revision procedure (odds ratio 1.94, 95% confidence interval 1.76-2.14, P < .001) and more than twice as likely to experience conversion to shoulder arthroplasty (odds ratio 2.29, 95% confidence interval 1.88-2.80, P < .001) within 2 years of initial arthroscopy when compared with patients without a mental disorder. Patients with a mental disorder also experienced increased risk for 90-day readmission (1.9% vs 0%, P < .001) as well as multiple postoperative medical complications. CONCLUSIONS: Patients with pre-existing mental health diagnoses experience increased rates of 90-day postoperative complications and readmissions following arthroscopic RCR. In addition, patients with mental health diagnoses are more likely to undergo revision repair and conversion to shoulder arthroplasty within 2 years of the index procedure. LEVEL OF EVIDENCE: Level III.

Reverse total shoulder arthroplasty pain and function: new perspectives from a 10-year multicenter study at the 7-year follow-up.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) can decrease shoulder pain and improve function. However, results reportedly deteriorate as patients approach mid-term follow-up and little is known about how this impacts physical health-related quality of life (PHRQOL) and mental health-related quality of life (MHRQOL). The study hypothesis was that shoulder function, pain, and medication use for pain would influence PHRQOL and MHRQOL. METHODS: This prospective cohort study involving subjects from 6 orthopedic clinics and 12 fellowship-trained surgeons evaluated the influence of RTSA on PHRQOL, MHRQOL, shoulder function, pain, instability, and medication use over the initial 7 years of a 10-year study, and device survivorship and revision rates. Clinical examination, the American Shoulder and Elbow Surgeons (ASES) score, Short Form (SF)-12 PHRQOL and MHRQOL assessments, the single assessment numeric shoulder function evaluation (SANE), visual analog scale (VAS) shoulder pain and instability scores, shoulder pain, medication use for pain, surgery satisfaction, survivorship and revision rate data were collected pre-RTSA, and at 6-week, 6-month, 1-year, 2-year, 3-year, 5-year, and 7-year follow-ups. RESULTS: Two hundred participants (108 female) of 69 ± 8.3 years of age, with gross rotator cuff deficiency (poor tissue quality or impaired dynamic stability) (n = 92), glenohumeral joint osteoarthritis (n = 88), failed primary total shoulder arthroplasty (n = 8), non-united humeral head fracture (n = 6) or 3-4 section comminuted humeral head fracture (n = 6) underwent pre-RTSA evaluation. Device survivorship was 94%. Friedman two-way ANOVA and Wilcoxon test pairwise comparisons revealed that compared to pre-RTSA, median active shoulder flexion (+ 25°) and external rotation (+ 10°) mobility improved by 6 months (p < 0.0001) and remained improved. Shoulder flexion (+ 1 grade), abduction, external rotation (+ 0.5 grade), and internal rotation strength (+ 1 grade) also improved by 6 months (p < 0.0001) and remained improved. ASES (+ 26.8), SANE (+ 17.5) and VAS pain (- 5.7) scores improved by 6 weeks (p < 0.0001) and remained improved, as medication use for shoulder pain decreased (- 24.6%) (p < 0.0001). SF-12 PHRQOL scores improved by 6 months (+ 11.5) and remained improved (p < 0.0001). Significant Spearman Rho correlations were observed between shoulder function (ASES or SANE) and SF-12 PHRQOL (r ≥ 0.52) and MHRQOL (r ≥ 0.20) scores (p < 0.0001) supporting the relationship between shoulder function and quality of life. Trend analysis revealed changing shoulder function, pain, and PHRQOL relationships between 2 and 3 years, and 5 and 7 years post-RTSA (Chi-Square, p < 0.05). CONCLUSION: Excellent device survival and good-to-excellent perceived shoulder function, and PHRQOL improvements were observed. Secondary objectives of improved shoulder mobility, strength, pain and instability were also achieved. In contrast to previous reports, subjects did not display shoulder mobility or perceived function deterioration by the 7-year follow-up. Following chronic pain relief at 6 weeks post-RTSA, subjects appear to balance PHRQOL and shoulder pain relationships at the 6-month and 1-year post-RTSA follow-ups. Careful evaluation at this time may help patients with higher pain levels and lower function expectations reverse these trends, or patients with lower pain levels and higher function expectations to optimize RTSA use and longevity.

Delayed ACL reconstruction increases rates of concomitant procedures and risk of subsequent surgery.

PURPOSE: To utilise a large cross-sectional database to analyse the effects of time duration between diagnosis of anterior cruciate ligament (ACL) tear and ACL reconstruction (ACLR) on concomitant procedures performed and subsequent surgery within 2 years. METHODS: An analysis from 2015 to 2018 was performed using the Mariner PearlDiver Patient Records Database. Current Procedural Terminology (CPT), and International Classification of Diseases (ICD-10) codes identified patients with a diagnosis of ACL tear who underwent subsequent ACLR. Patients were stratified in biweekly and bimonthly increments based on the time duration between initial diagnosis of ACL tear and surgical treatment. Chi-squared analysis was used to compare categorical variables, and trend analysis was performed with Cochran-Armitage independence testing. RESULTS: Of 11,867 patients who underwent ACLR, 76.1% underwent surgery within 2 months of injury diagnosis. Patients aged 10-19 were most likely to undergo surgery within 2 months of injury diagnosis (83.5%, P < 0.0001). As duration from injury diagnosis to ACLR increased from < 2 months to > 6 months, rates of concomitant meniscectomy increased from 9.1% to 20.5% (P < 0.0001). The overall 2-year subsequent surgery rate was 5.3%. The incidence of revision ACLR was highest for patients who underwent surgery > 6 months after diagnosis (P < 0.0001), whilst the incidence of ipsilateral lysis of adhesions and manipulation under anaesthesia (MUA) was highest for patients who underwent surgery < 2 months after diagnosis (P < 0.0001). ACLR at 6-8 weeks after diagnosis demonstrated the lowest risk for concomitant procedures as well as 2-year subsequent surgery. CONCLUSION: The majority of patients undergo ACL reconstruction within 2 months of initial ACL tear diagnosis. Delayed surgery greater than 6 months after the diagnosis of an ACL rupture leads to increased need for concomitant meniscectomy as well as higher risk for revision ACLR within 2 years, but immediate surgery may increase risk for knee arthrofibrosis. LEVEL OF EVIDENCE: IV.

Medicaid insurance is associated with treatment disparities for proximal humerus fractures in a national database analysis.

BACKGROUND: Proximal humerus fractures (PHFs) are the third most common type of fragility fracture in the elderly and are increasing in incidence. Disparities in treatment type, time to surgery (TTS), and complications based upon insurance type have been identified for other orthopedic conditions. Given the incidence and burden of PHFs, we sought to evaluate if insurance type was associated with treatment received, TTS, and complications in the treatment of PHFs. METHODS: We used PearlDiver, a national administrative claims database that consists of 122 million patient records. Patients diagnosed with an isolated PHF between 2010 and 2019 were identified by International Classification of Diseases, Ninth and Tenth Revision diagnostic codes and stratified by insurance type (Medicaid, private, or Medicare). Outcomes evaluated were rate of surgery within 3 months of diagnosis with open reduction and internal fixation, hemiarthroplasty, or reverse shoulder arthroplasty; average TTS; 90-day readmissions and medical postoperative complications (deep vein thrombosis, urinary tract infection, pneumonia, sepsis, acute respiratory failure, cerebrovascular event, and acute renal failure); and 1-year surgical postoperative complications (stiffness, noninfectious wound complications, dislocation, and infection). Multivariable logistic regressions adjusting for age, sex, and Elixhauser comorbidity index were utilized to determine the association between insurance type and surgery rate/complications. RESULTS: We included 245,396 patients for analysis. Fourteen percent of Medicaid patients (1789/12,498) underwent surgery compared to 17% (25,347/149,830) of privately insured patients and 16% (13,305/83,068) of Medicare patients (pairwise, P < .001). TTS (Medicaid: 11.7 days, private: 10.6 days [P < .001]; Medicare: 10.7 days [P = .003]) varied by insurance type. Private or Medicare-insured patients were less likely to be readmitted (adjusted odds ratio: 0.77 [95% confidence interval (CI): 0.63-0.93] for private vs. Medicaid and 0.71 [95% CI: 0.59-0.88] for Medicare vs. Medicaid) and experienced fewer 90-day postoperative complications (adjusted odds ratio: 0.73 [95% CI: 0.62-0.85] for private vs. Medicaid, 0.65 [95% CI: 0.55-0.77] for Medicare vs. Medicaid), such as acute renal failure. TTS was also associated with differing rates of readmissions and complications. CONCLUSION: There are differences in rates of surgery, TTS, and complications after PHFs based on insurance type, representing opportunities for quality improvement initiatives. Potential methods to address these disparities include implementing standardized PHF protocols and/or reimbursement models and quality metrics that reward equitable treatment. Further research and policy adaptations should be incorporated to decrease barriers that patients face and minimize health care inequities seen in the treatment of PHFs based on insurance type.

Utilization of Autologous Chondrocyte Implantation in the Knee Is Increasing While Reoperation Rates Are Decreasing Despite Increasing Preoperative Comorbidities.

PURPOSE: The primary purpose of this study was to assess the use of autologous chondrocyte implantation (ACI) procedures in the knee during last decade, and the secondary aims of the study were to determine reoperation rates after ACI and to identify associated risk factors. METHODS: A retrospective cohort study from 2010-2020 was performed using the PearlDiver database. The database was queried for the Current Procedural Terminology (CPT) code for ACI performed in any knee location, including the patellofemoral and tibiofemoral joints. Reoperation was defined as interventional knee procedures or total knee arthroplasty after ACI. Reoperations were identified using CPT and International Classification of Diseases codes. Univariate and multivariate logistic regression were used to identify risk factors for reoperation. Significance was defined as P < .05. RESULTS: Among the 2010 patients included in this study, there were 90-day and overall reoperation rates of 2.24% and 30.4%, respectively, with an average follow up of 4.8 ± 3.3 years. The most common reoperations included chondroplasty, meniscectomy, and microfracture. There was an increased rate of ACI performed from 2017-2019 (5.53/100,000) compared to 2014-2016 (4.16/100,000; P < .001). ACI surgeries performed in 2017-2019 were associated with decreased risk of reoperation within 2 years relative to 2014-2016 (odds ratio [OR] = 0.70; 95% confidence interval [CI], 0.52-0.94; P = .019). In the entire ACI cohort, older age (OR = 1.07; 95% CI, 1.05-1.09; P < .001) and tobacco use (OR = 2.13; 95% CI, 1.06-3.94; P = .022) were associated with increased risk of conversion to arthroplasty. Male sex was associated with decreased overall reoperation rates (OR = 0.73; 95% CI, 0.60-0.89; P = .002). CONCLUSIONS: There has been increasing use of ACI in the knee with decreased risk of reoperation since 2017 and the introduction of matrix-associated autologous chondrocyte implantation. Older age and tobacco use were predictors of increased risk of conversion to arthroplasty. Male sex was associated with decreased risk of reoperation. LEVEL OF EVIDENCE: Level IV, retrospective cohort design; database study.

Incidence of Venous Thromboembolism After Hip Arthroscopy Is Low With or Without Prophylaxis but Risk Factors Include Oral Contraceptive Use, Obesity, and Malignancy.

PURPOSE: To determine the incidence of and risk factors for symptomatic venous thromboembolism (VTE) after hip arthroscopy (HA) and thromboprophylaxis prescription utilization for this procedure. METHODS: The PearlDiver Mariner database was queried using Current Procedural Terminology codes to identify adult patients (aged ≥ 18 years) who underwent HA between 2010 and 2020. Patient demographic information, including age, oral contraceptive use, and medical comorbidities, as well as perioperative thromboprophylaxis utilization, was recorded using International Classification of Diseases codes and National Drug Codes. The incidence of postoperative VTE within 90 days was determined. Multivariate logistic regression was used to identify predictors of perioperative thromboprophylaxis utilization and risk factors for VTE. RESULTS: The queried records identified 60,181 patients who met the inclusion criteria. Of these patients, 367 (0.6%) experienced VTE, including deep venous thrombosis (0.5%) and/or pulmonary embolism (0.2%). Approximately 2.1% of patients used thromboprophylaxis, including aspirin (1.1%), low-molecular-weight heparin (0.9%), and oral factor Xa inhibitors (0.1%). Oral contraceptive pill use (adjusted odds ratio [aOR], 2.16; 95% confidence interval [CI], 1.34-3.46), obesity (aOR, 1.37; 95% CI, 1.05-1.79), and a history of malignancy (aOR, 1.69; 95% CI, 1.12-2.54) were associated with increased odds of experiencing VTE. Perioperative thromboprophylaxis (aOR, 0.52; 95% CI, 0.19-1.39) was not significantly associated with decreased odds of experiencing VTE. However, obesity (aOR, 1.17; 95% CI, 1.00-1.38) and hypertension (aOR, 1.17; 95% CI, 1.02-1.36) were associated with increased odds of thromboprophylaxis prescription utilization. CONCLUSIONS: Although the overall risk of symptomatic VTE after HA remains low, oral contraceptive use, obesity, and a history of malignancy are associated with increased odds of thromboembolic events within 90 days. Routine thromboprophylaxis after HA may not be indicated in all patients but can be considered based on patient-specific risk factors. LEVEL OF EVIDENCE: Level III, retrospective prognostic comparative trial.

Perioperative Thromboprophylaxis Is Associated With Lower Risk of Venous Thromboembolism After Knee Arthroscopy.

PURPOSE: To determine the rate of symptomatic venous thromboembolism (VTE) among patients undergoing arthroscopic knee procedures, risk factors associated with postoperative VTE, and current perioperative thromboprophylaxis prescription patterns associated with this population in the United States. METHODS: Medical records for patients ≥18 years of age were queried from the Mariner database using Current Procedural Terminology codes for knee arthroscopy performed in the United States from 2010 to 2020 in this cross-sectional study. Patients who received thromboprophylaxis and those diagnosed with VTE, including deep-vein thrombosis or pulmonary embolism, within 90 days of surgery were identified using International Classification of Diseases and National Drug Codes. Two multivariable logistic regression models were used to identify VTE risk factors and likelihood of perioperative thromboprophylaxis. Covariates included procedure type, age, oral contraceptive pill (OCP) use, and medical comorbidities. RESULTS: A total of 718,289 patients met inclusion criteria and 7,618 patients (1.06%) experienced VTE, including deep-vein thrombosis (n = 6,394, 0.9%) and/or pulmonary embolism (n = 2,211, 0.3%). A total of 10,769 patients (1.5%) filled perioperative thromboprophylaxis, including aspirin (n = 5,353, 0.7%), low-molecular-weight heparin (n = 4,563, 0.6%), and oral factor Xa inhibitors (n = 947, 0.1%). Perioperative thromboprophylaxis was associated with decreased odds of experiencing VTE (adjusted odds ratio [aOR] 0.65, 95% confidence interval [CI] 0.51-0.80). Procedure types categorized as moderate-to-greater risk were associated with increased odds of VTE (aOR 1.42, 95% CI 1.34-1.50). OCP use (aOR 1.63, 95% CI 1.38-1.91), obesity (aOR 1.17, 95% CI 1.11-1.24), renal disease (aOR 1.33, 95% CI 1.18-1.50) and congestive heart failure (aOR 1.30, 95% CI 1.13-1.50) were associated with increased odds of VTE. CONCLUSIONS: While the overall rate of symptomatic VTE following knee arthroscopy remains low, procedure types that are more complex and generally require restrictive rehabilitation protocols, OCP use, obesity, renal disease, and congestive heart failure are associated with increased odds of postoperative VTE. Conversely, the use of perioperative thromboprophylaxis is associated with significantly lower VTE risk. LEVEL OF EVIDENCE: III, retrospective comparative prognostic trial.

Younger Patients Are More Likely to Undergo Arthroscopic Meniscal Repair and Revision Meniscal Surgery in a Large Cross-Sectional Cohort.

PURPOSE: To evaluate recent trends in the treatment of meniscal tears with arthroscopic repair and debridement and to assess revision surgery within 2 years using a large cross-sectional database. METHODS: Patients with a diagnosis of meniscal tear from 2010 to 2017 were queried using the Mariner data set from PearlDiver. Patient demographic data were analyzed and tracked via International Classification of Diseases, Tenth Revision codes to investigate subsequent ipsilateral meniscal procedures and conversion to total knee arthroplasty within 2 years after index meniscal surgery. RESULTS: Of the 1,383,161 patients with a diagnosis of meniscal tear, 53.0% underwent surgical treatment. Surgical treatment consisted of meniscal debridement in 96.6% of patients and meniscal repair in 3.4%. The percentage of meniscal repairs increased from 2.7% to 4.4% over the 8-year period evaluated, whereas the percentage of meniscal debridement decreased from 97.3% to 95.6% (P < .0001). Younger patients were more likely to undergo meniscal repair (23% of those aged 10-19 years) than older patients (<1% of those aged ≥60 years). Among the 191,729 patients with International Classification of Diseases, Tenth Revision coding and 2-year follow-up, 10.6% of patients with index meniscal repair required a revision meniscal operation and 1.2% underwent conversion to arthroplasty. Subsequent meniscal procedures within 2 years after index meniscal repair included meniscal debridement in 81.6% of patients and revision repair in 18.4%. Patients who initially underwent meniscal debridement were less likely to undergo revision meniscal surgery (5.1%), but 4.7% required conversion to arthroplasty. Patients aged 10 to 19 years were most likely to undergo revision meniscal procedures after both index meniscal repair (12.8%) and meniscal debridement (8.8%). CONCLUSIONS: The rate of meniscal repair is increasing over time, with patients younger than 30 years most likely to undergo repair for a meniscal tear. Revision surgery for meniscal repair or debridement is more common in adolescents and patients who undergo an index meniscal repair. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

The Use of Multiple Imaging Studies Before Shoulder Stabilization Surgery Is Increasing.

Purpose: To determine the incidence of preoperative shoulder imaging, explore the prevalence of obtaining multiple advanced imaging studies, and identify patient characteristics associated with specific imaging studies before anterior versus posterior shoulder stabilization surgery. Methods: The PearlDiver database was queried for patients who underwent anterior or posterior shoulder stabilization surgery from 2010 to 2019. The incidence of imaging studies within a year of surgery was collected. Patient characteristics were compared between groups using one-way analysis of variance or χ2 test. Results: In total, 10,252 patients underwent anterior shoulder stabilization surgery, and 1,108 patients underwent posterior shoulder stabilization surgery. Imaging use before anterior and posterior shoulder stabilization surgery included plain radiographs (69%, 70%, respectively), magnetic resonance imaging (MRI; 43%, 33%), and computed tomography (CT; 22%, 22%). In total, 1,098 patients (11%) received MRI and CT before anterior stabilization surgery and 85 patients (8%) received MRI and CT before posterior stabilization surgery. Over time, the incidence of obtaining MRI and CT increased before anterior (z = 2.54, P = .011) and posterior (z = 2.36, P = .018) stabilization surgery. Conclusions: This study highlights the increasing use of multiple imaging studies before shoulder stabilization surgery over recent years, including plain radiographs, MRI, and CT imaging. In total, 45% of anterior shoulder stabilization patients and 41% of posterior shoulder stabilization patients obtained more than 1 imaging study within a year of surgery, with a recent increase in patients obtaining both MR and CT scans preoperatively. Statement of Clinical Relevance: The increasing use of multiple preoperative imaging studies observed in this study highlights an opportunity for new imaging technology to streamline and improve the preoperative workup.

Arthroscopic Treatment Yields Lower Reoperation Rates than Open Treatment for Native Knee but Not Native Shoulder Septic Arthritis.

Purpose: To compare the incidence, patient demographics, complication rates, readmission rates, and reoperation rates of open and arthroscopic surgery performed for septic arthritis in native knee and shoulder joints. Methods: Records of patients who were diagnosed with native knee or shoulder septic arthritis and underwent open or arthroscopic irrigation and debridement (I&D) between 2015 and 2018 were queried from the PearlDiver Mariner Database. International Classification of Diseases 10th (ICD-10) diagnosis and procedure codes were used to identify patients and track reoperations. Reoperation procedures, including revision open and arthroscopic I&D, were analyzed at 1 month, 1 year, and 2 years. Complications, emergency department (ED) admissions, and hospital readmissions within 30 days were analyzed and compared between the open and arthroscopic cohorts. Results: The query resulted with 1,993 patients who underwent knee I&D (75.3% arthroscopic, 24.7% open, P < .001) and 476 patients who underwent shoulder I&D (64.8% arthroscopic, 35.2% open, P < .001). One-month complication rates (11.6-22.7%) and hospital readmission rates (15.8-19.6%) were similar for arthroscopic and open treatment for knee and shoulder septic arthritis. Reoperation rates for revision I&D of the knee were higher after open compared to arthroscopic treatment at 1 month, 1 and 2 years (20.9% vs. 16.7%, 32.5% vs 27.6% and 34.1% vs. 29.4%, P < .05, respectively). For shoulder septic arthritis 1-month, 1-year, and 2-year reoperation rates were similar for open and arthroscopic treatment (16.0% vs 11.7%, 22.0% vs 19.3%, and 22.7% vs 20.0%, P = .57, respectively). Lastly, 6.7% of patients with native septic knee arthritis underwent subsequent arthroplasty by 2 years. Conclusion: Arthroscopic treatment carries a lower reoperation rate than open surgery for knee septic arthritis, but in the shoulder, the risk for revision I&D is similar after arthroscopic or open surgery.

Editorial Commentary: Anterior Cruciate Ligament Reconstruction Success Must Be Defined Including Patient-Reported Outcome, Functional and Structural Outcome, Avoidance of Early Adverse Events, and Avoidance of Graft Failure.

Successful anterior cruciate ligament (ACL) reconstruction requires definition. Some focus on return to sport or early return to sport. Others focus on reproduction of normal ACL anatomy or biomechanics. Recent focus includes restoration of secondary stabilizers. However, each new focus can have positive, but also adverse, consequences. In general, positive results in 4 categories are equally important for the success of ACL reconstruction: early adverse events, patient-reported outcomes, ACL graft failure/recurrent ligament disruption, and clinical measures of knee function and structure. We are moving the needle to achieve the "best" ACL reconstruction, but we should never change treatment based on one parameter or "fashion."

Orthopedic sleep and novel analgesia pathway: a prospective randomized controlled trial to advance recovery after shoulder arthroplasty.

BACKGROUND: Lack of sleep is associated with adverse effects on postsurgical pain and recovery. We hypothesized that a multimodal sleep pathway, including nonpharmacologic sleep hygiene interventions and the use of zolpidem and melatonin, could improve patient analgesia and sleep after total shoulder arthroplasty. METHODS: We performed a prospective randomized controlled study in which patients undergoing anatomic and reverse total shoulder arthroplasty were treated with or without an interventional multimodal sleep pathway. This pathway included nursing-directed nonpharmacologic measures that promote sleep hygiene and pharmacologic interventions with low-dose zolpidem and melatonin at bedtime. All patients underwent a standardized multimodal analgesia protocol with scheduled acetaminophen, naproxen, and gabapentin, as well as a single-shot interscalene regional nerve block. RESULTS: This study enrolled 125 patients (64 in control group and 61 in interventional group) with similar demographic characteristics. The interventional group showed less oral morphine milligram equivalent (MME) consumption on postoperative day (POD) 0 (44.8 ± 36.1 MMEs vs. 60.9 ± 42.1 MMEs, P = .01) and showed a trend toward lower POD 0 visual analog scale pain scores (2.6 ± 1.8 vs. 3.3 ± 3.0, P = .06). Visual analog scale pain scores and MME consumption were similar on POD 1. The interventional group showed a longer objective sleep duration by quantitative wrist actigraphy (5.9 ± 3.1 hours vs. 4.6 ± 2.7 hours, P = .008), with better sleep quality assessed by the Leeds Sleep Evaluation Questionnaire (0-100 scale; 50.3 ± 26.8 vs. 38.5 ± 27.8, P = .01). The 2 groups showed similar satisfaction with pain management (89.2% vs. 79.6%, P = .16) and sleep management (82.1% vs. 76.8%, P = .48). There was no difference in the length of inpatient stay (32.2 ± 14.8 hours vs. 34.1 ± 12.8 hours, P = .44). CONCLUSION: In the setting of a regional and multimodal analgesia recovery plan for shoulder arthroplasty patients undergoing inpatient observation, the use of an interventional sleep pathway appears to be safe and beneficial, with improved analgesia, reduced opioid use, increased sleep duration, and improved reported sleep quality during the postoperative recovery period.