Head and Neck Cutaneous Soft-Tissue Sarcoma Demonstrate Sex and Racial/Ethnic Disparities in Incidence and Socioeconomic Disparities in Survival.

BACKGROUND: Cutaneous soft-tissue sarcoma (CSTS) of the head and neck are rare and are known to have aggressive clinical course. The current study utilizes a population-based registry in the U.S. to characterize these malignancies and explore disparities. METHODS: National Cancer Institute's (NCI) Surveillance, Epidemiology and End Result (SEER) database from 2000 to 2018 was queried to report incidence and survival data in 4253 cases in the U.S. RESULTS: Males were 5.37 times more likely and Non-Hispanic-White people (NHW) were 4.62 times more likely than females and Non-Hispanic-Black people (NHB) to develop CSTS of the head and neck. The overall incidence was 0.27 per 100,000 persons in 2018, with a significant increase since 2000. Advanced age and stage, histologic group other than 'fibromatous sarcoma' and lower SES groups were independent factors for worse overall survival. CONCLUSIONS: CSTS of the head and neck demonstrate sex and racial/ethnic disparities in incidence and socioeconomic disparities in overall survival. LEVEL OF EVIDENCE: II.

The Use of Carbon Fiber Implants for Impending or Existing Pathologic Fractures.

OBJECTIVES: To evaluate the utility and complications of using carbon fiber implants (CFIs) compared with standard titanium alloy (TI) intramedullary implants for stabilization of impending or existing pathologic fractures. DESIGN: Retrospective comparison. PATIENTS/PARTICIPANTS: Ninety-four patients undergoing intramedullary fixation of 100 impending or existing pathologic fractures between 2014-2019 were identified for inclusion. MAIN OUTCOME MEASUREMENTS: The primary outcome was postoperative complications. Other outcomes included implant type, pathology, indication, and adjuvant therapy. RESULTS: Fifty-three percent of cases used a CFI, whereas 47% of cases used a TI. There were no differences between groups with regard to anatomic location (P = 0.218), indication for surgery (P = 0.066), histology (P = 0.306), or postoperative adjuvant therapy (P = 0.308). Nineteen percent of cases incurred a postoperative complication in each group (P = 0.530), and no differences were noted with regard to complication type including implant failure (P = 0.442) and wound complications (P = 0.322). There was a cost saving of $400 with TI implants compared with CFI. CONCLUSIONS: This is a high-risk population for postoperative complications after stabilization of pathologic fractures. Although there were no statistical differences in complications between CFI and TI, implant choice depends on patient characteristics and surgeon preference. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Impact of local treatment modality on overall- and disease-specific survival for nonmetastatic pelvic and sacral Ewing sarcoma.

PURPOSE: The ideal local treatment modality for pelvic and sacral Ewing sarcoma (EWS) is controversial. METHODS: We present the data from the American College of Surgeon's National Cancer Database (NCDB) and the National Cancer Institute's Surveillance, Epidemiology and End Result (SEER) database to investigate the impact of local treatment modalities on survival for nonmetastatic pelvic and sacral Ewing sarcoma. Local treatment includes "surgery," "radiation," and a combination of "surgery and radiation." RESULTS: A total of 235 cases from SEER and 285 cases from NCDB were analyzed. Patients with "localized" stage (intraosseous) in the SEER database did not show any statistically significant difference in the disease-specific survival (DSS) for any of the local treatment modalities. Similar findings were observed for overall survival among patients with American Joint Committee on Cancer (AJCC) stage II and III in the NCDB database. However, patients with nonmetastatic disease, particularly regional disease (extraosseous), showed improved DSS with surgery only, in the SEER. CONCLUSION: We found similar levels of efficacy for different treatment modalities for patients with intraosseous and AJCC II and III pelvic and sacral EWS. "Radiotherapy" is the most common local treatment modality employed in the United States. A prospective, randomized controlled trial with a direct head-to-head comparison is needed for a definitive conclusion.

Resident Level Involvement Affects Operative Time and Surgical Complications in Lower Extremity Fracture Care.

OBJECTIVE: The purpose of this study is to evaluate the effect of resident participation on operative time and surgical complications in isolated lower extremity fracture care. SETTING: Patients who were treated at teaching hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program database. PARTICIPANTS: A total of 2,488 patients who underwent surgical fixation of isolated hip fractures, femoral or tibial shaft fractures, and ankle fractures. DESIGN: Patients were stratified by surgical procedure and post-graduate year (PGY) of the resident involved. Total operative time and surgical complications were analyzed with respect to resident participation and seniority. Multivariable logistic regression analyses were used to adjust for potential confounders including case complexity, wound class, and patient comorbidity burden. RESULTS: As PGY level increased, operative time increased for each procedure. The odds for a deep surgical site infection decreased as resident seniority increased, but the odds for wound dehiscence increased as resident seniority increased. We found no difference in the incidences of superficial infections or return to the OR with respect to PGY level. Academic quarter within the academic year did not correlate with any of the surgical complications. Furthermore, when cases performed with residents were compared to those performed without residents, there was no increased risk of superficial infections, deep infections, or return to the OR. CONCLUSIONS: This nationally representative dataset demonstrates that operative times for lower extremity orthopedic trauma increased as resident seniority increased. Additionally, senior resident participation was associated with increased wound dehiscence, whereas junior resident participation was associated with an increased risk of deep surgical site infections. However, there was no associated "July effect" for residents at any level of training and there was no increased risk for surgical site infections or return to the OR in cases involving resident participation.

Elevated BMI increases concurrent pathology and operative time in adolescent ACL reconstruction.

PURPOSE: The purpose of this study was to (1) report on the incidence of concurrent surgical pathology at the time of adolescent ACL reconstruction, (2) evaluate patient risk factors for concurrent pathology, and (3) measure the effect of BMI on operating room (OR) time. METHODS: A retrospective analysis of the NSQIP database for the years 2005-2017 was conducted. Nine-hundred and seventeen patients 18 years of age and younger who underwent ACL reconstruction (ACLR) were identified using CPT code 29888 and patients undergoing surgery for multi-ligamentous knee injuries were excluded. The mean patient age was 17.6 years (range 14-18, standard deviation 0.52) and consisted of 546 males (59.5%) and 371 females (40.5%). Logistic regression was used to assess the relationship between BMI and additional CPT codes for internal derangement at the time of surgery. Internal derangement was defined as any procedure for the treatment of a meniscal tear, chondral lesion, or loose body removal. Linear regression analysis was then performed to evaluate the effect of BMI on operative time. RESULTS: 43.7% of patients undergoing ACLR required an associated procedure for internal derangement. Additionally, the risk of requiring additional procedures for internal derangement increased by 3.1% per BMI point. BMI was also predictive of operative time, independent of the number of additional procedures. Specifically, the operative time increased by nearly one minute for every point increase in BMI (58.0 s). CONCLUSIONS: Adolescent patients with an elevated BMI were much more likely to require additional surgical procedures for internal derangement at the time of ACL reconstruction. Additionally, BMI was a significant predictor for longer operative times. LEVEL OF EVIDENCE: Level III.

Combined Oral Contraceptive Use Increases the Risk of Venous Thromboembolism After Knee Arthroscopy and Anterior Cruciate Ligament Reconstruction: An Analysis of 64,165 Patients in the Truven Database.

PURPOSE: To use the Truven MarketScan database to (1) report the incidence of venous thromboembolism (VTE), including deep vein thromboses (DVTs) and pulmonary embolism (PE), in patients undergoing simple knee arthroscopy and anterior cruciate ligament (ACL) reconstruction, and (2) evaluate combined oral contraceptive (COCP) use as a potential risk factor for VTE in patients undergoing knee arthroscopy. METHODS: All female patients between the ages of 16 and 40 years undergoing knee arthroscopy and ACL reconstruction between 2010 and 2015 were identified in the MarketScan database. Patients were stratified by whether they had a documented pharmaceutical claim for COCP therapy, and the primary outcome was the risk of DVT and or PE within 90 postoperative days. RESULTS: In total, 64,165 patients were identified for inclusion. While the overall incidence of VTE was low, patients taking COCPs had an increased risk of a DVT or PE compared with those not on COCPs (odds ratio [OR] 2.1, P < .001). When patients were analyzed by procedural subgroup (ACL reconstruction and simple knee arthroscopy), similar results held true. Furthermore, smoking and obesity had a synergistic effect when combined with COCPs use on the risk of VTE. Specifically, 3.1% of patients with obesity on COCPs (OR 3.1, P < .001) and 4.0% of smokers on COCPs (OR 4.3, P < .001) developed a postoperative VTE. CONCLUSIONS: This study demonstrates that COCP use is associated with an increased risk for a symptomatic DVT or PE (1.70% and 0.27%, respectively) after knee arthroscopy and an increased risk for DVT, but not PE (1.80% and 0.23%, respectively), after ACL reconstruction. In addition, patients with multiple risk factors present such as tobacco use, obesity, and COCP use had odds ratios greater than the sum of the individual risk factors alone. LEVEL OF EVIDENCE: level III prognostic cohort study.

Increased Risk of Short-Term Complications and Venous Thromboembolism in Latarjet-Bristow Procedures Compared With Bankart Repairs.

PURPOSE: To (1) determine the rate of surgical complications and venous thromboembolism (VTE) in patients undergoing arthroscopic Bankart repair, open Bankart repair, or Latarjet-Bristow; and (2) assess potential risk factors for surgical complications and VTE in patients undergoing shoulder stabilization procedures. METHODS: The NSQIP database was used to identify patients undergoing isolated surgery for shoulder instability from 2005 to 2017. Demographic data were collected and compared. Logistic regression was used to assess the risk factors for developing a postoperative complication, and regression analyses were used to evaluate the odds of postoperative complications between types of surgery. RESULTS: We identified 7,233 patients for inclusion. Patients undergoing Latarjet-Bristow were more likely to be male and Black and to report current tobacco use. Overall, there was a low rate of surgical complications (0.4%) and VTE (0.2%). However, patients undergoing Latarjet-Bristow had nearly a 10-fold increase in the risk of surgical complications compared with an arthroscopic or open Bankart repair (1.9% versus 0.2%, P < .001), including deep surgical site infections, return to operating room within 30 days, and symptomatic VTE (deep venous thrombosis rate: arthroscopic Bankart repair, 0.1%; Latarjet-Bristow, 0.8%; P < .001). There were no differences in the odds of developing a surgical complication or VTE between patients undergoing arthroscopic or open Bankart repair. CONCLUSION: This study used a nationally representative, widely validated, peer-reviewed database to demonstrate that patients undergoing a Latarjet-Bristow procedure are at significantly higher risk for short-term postoperative complications, including deep surgical site infections, return to the operating room, and symptomatic VTE, than those undergoing Bankart repair. These findings should not discourage surgeons from proceeding with a coracoid transfer procedure when indicated for glenoid deficiencies, but should inform preoperative counseling and help guide perioperative care to optimize patient outcomes. LEVEL OF EVIDENCE: III, retrospective comparative trial.

Insulin-Dependence Predicts Surgical Complications and Hospital Admission following Knee Arthroscopy.

While prior studies have demonstrated that insulin-dependence is an independent risk factor for postoperative complications, morbidity, and mortality following spine and shoulder, hip, and knee arthroplasty, it has not been evaluated in the setting of knee arthroscopy. Therefore, the purpose of this study is to compare the risk of postoperative complications among patients with insulin-dependent diabetes mellitus and noninsulin-dependent diabetes mellitus (IDDM and NIDDM respectively) with the general population following knee arthroscopy. A retrospective analysis of the National Surgical Quality Improvement Program's database for the years 2005 to 2016 was conducted. Logistic regression analyses were used to assess the relationship between diabetic status and outcomes. Multivariate models were established to adjust for age, sex, body mass index, hypertension, congestive heart failure, chronic obstructive pulmonary disease, smoking status, American Society of Anesthesiology classification, and functional status. A total of 86,023 patients were identified. Patients with IDDM were at a much higher risk of surgical complications (odds ratio [OR]: 2.186, 95% confidence interval [CI]: 1.226-1.157), including deep infections (OR: 3.082, 95% CI: 1.753-5.419) and return to operating room [OR] (OR: 1.933, 95% CI: 1.280-2.919), as well as unplanned hospital admission (OR: 1.770, 95% CI: 1.289-2.431). However, NIDDM was not an independent risk factor for subsequent medical or surgical complications, unplanned hospital admission, or 30-day mortality. Patients with IDDM were much more likely to have surgical complications, including deep infection and return to OR, as well as unplanned hospital admission following knee arthroscopy. These risks diminished among those with NIDDM, with their adjusted risk profiles comparable to those without diabetes. Since diabetes occurs in a heterogenous state, more weight should be given to those with insulin-dependence when risk-stratifying patients for surgery. This is a Level III, retrospective comparison study.

Risk Factors for Infection Following Total Wrist Arthroplasty and Arthrodesis: An Analysis of 6641 Patients.

Background: Infection following wrist arthroplasty (WA) or wrist fusion (WF) is an uncommon but difficult complication often resulting in explantation and prolonged courses of antibiotics. The purposes of this study are to: (1) characterize the demographic trends of individuals undergoing WA and WF; (2) determine the incidence of postoperative infection; and (3) identify risk factors for postoperative infection. Methods: The PearlDiver database was used to query 100% Medicare Standard Analytic files from 2005 to 2014. Patients undergoing WA or radiocarpal WF were identified using Current Procedural Terminology (CPT) codes. Diagnosis for infection within 1 year of operative intervention was assessed by International Classification of Diseases, Ninth Revision codes or CPT codes related to infection. Multivariable logistic regression analyses were performed to evaluate the risk factors for postoperative infection. Results: Of the 6641 patients included, 1137 (17.1%) underwent arthroplasty and 5504 (82.9%) underwent arthrodesis. Within 1 year of the index procedure, 3.5% had a diagnosis of, or procedure for, postoperative infection (WA: n = 40 of 1137; WF: n = 192 of 5504). Risk factors for infection following WA include age >85, tobacco use, depression, diabetes mellitus, and chronic kidney disease. Risk factors following radiocarpal WF include male sex, age >85, body mass index <19 kg/m2, depression, diabetes mellitus, and chronic kidney disease. Posttraumatic origin of wrist arthritis was a risk factor for infection following both WA and WF. Conclusions: Infection following WA and WF is relatively uncommon in a nationally representative Medicare database cohort. Risk factors common to both WA and WF include age >85, depression, diabetes mellitus, chronic kidney disease, and posttraumatic arthritis.

Fungal Periprosthetic Joint Infection: A Review of Demographics and Management.

BACKGROUND: Periprosthetic joint infection (PJI) is one of the most feared complications of total joint arthroplasty (TJA). Although commonly the result of colonization by Staphylococcal species, a growing number of cases of PJI with fungal pathogens have been reported within the last decade. Although standard treatment with two-stage exchange mirrors that of bacterial PJI, the variability in virulence between fungal species makes for an unpredictable and challenging treatment course. METHODS: A review of Pubmed and Scopus from years 2009 to 2019 was conducted with the search terms fungal, infection, Candida, arthroplasty, periprosthetic, and prosthesis. Publications were reviewed and screened, yielding data for 286 patients with fungal PJI in the hip, knee, shoulder, and elbow prosthetics. RESULTS: Patient comorbidities generally included conditions impairing wound healing and immune response such as diabetes mellitus. Candida species were the most common fungal pathogens identified (85%); 30% had a concomitant bacterial infection. A two-stage exchange was most utilized, with a mean success rate of 65%. Antifungal impregnated spacers were utilized in 82 cases, with a comparatively high success rate (81%). Attempts at debridement with implant retention had substantially lower cure rates (15%). CONCLUSIONS: Two-stage exchange is the favored approach to treating fungal PJI. Debridement with implant retention does not appear adequate to control infection, and retrieval of implanted materials should be prioritized. The use of antifungal impregnated spacers is an important area of ongoing research, with uncertainty regarding the type and quantity of antifungal agent to incorporate, although recent reports support the use of these agents.

Elevated BMI is associated with intra-articular comminution, prolonged operative time, and postoperative complications in distal radius fractures.

INTRODUCTION: Obesity continues to be a problem in the United States with greater than 35% of the adult population affected. Obesity influences fracture care as it affects impact forces, alters cellular pathways of healing, and is often associated with higher complication rates. Distal radius fractures are among the most common fracture patterns in the adult population. The purpose of this study was to evaluate the effect of BMI on the degree of intra-articular fracture comminution, operative time, and return to the OR in obese patients who underwent operation for distal radius fractures. METHODS: A retrospective analysis of the American College of Surgeons National Surgical Improvement Program's (ACS-NSQIP) database was performed and logistic regressions were used to assess the relationship between BMI and open treatment of distal radius fractures. Three separate CPT codes were used to distinguish between extra-articular fractures, intra-articular split fracture, and intra-articular fracture with comminution. Percutaneous or closed treatment of distal radius fractures were excluded. RESULTS: A total of 11,228 patients (mean age 65.1 years) with open reduction and internal fixation of distal radius fractures were identified. For every increase in BMI point, there was an increased risk of intra-articular split fracture by 1.7% (OR 1.017, 95% CI 1.010-1.023, p < 0.01) and increased risk of intra-articular comminution by 3.1% (OR 3.1, 95% CI 1.025-1.037, p < 0.01). Additionally, for every increase in BMI point, the risk of a surgical complication increased by 2.3% DISCUSSION: This nationally representative, population-based study demonstrates that elevated BMI is associated with increased risk for intra-articular involvement and higher risk for post-operative complications. Our results can be useful to patients and orthopedic surgeons as prognostic information for counseling patients on expectations following open reduction and surgical fixation of distal radius fractures. LEVEL OF EVIDENCE: Case-control study. Level III.

Notable Racial and Ethnic Disparities Persist in Lower Extremity Amputations for Critical Limb Ischemia and Infection.

INTRODUCTION: The purpose of this study is to investigate the current disparities for major lower extremity amputation in patients with critical limb ischemia (CLI) and infection. METHODS: A retrospective analysis of the National Surgical Quality Improvement Program's database for the years 2011 to 2017 was conducted. Multivariate models were used to isolate the effect of race and ethnicity on the likelihood of a below-knee or above-knee amputation (BKA and AKA, respectively) for CLI secondary to type 2 diabetes mellitus, atherosclerosis, peripheral vascular disease, chronic osteomyelitis, and deep soft-tissue infections. RESULTS: For all diagnoses, blacks were 93.3%, and Hispanics were 61.9% more likely to undergo a BKA than white patients (P < 0.001). In addition, black patients had a 133.0% higher risk of an AKA than white patients (P < 0.001). Disparities were greatest with blacks undergoing surgery for CLI secondary to atherosclerosis (BKA odds ratio 2.093; AKA: odds ratio 2.625). Black patients also had an elevated risk of amputation secondary to diabetes, peripheral vascular disease, and deep soft-tissue infections (P < 0.001). DISCUSSION: This nationally representative, cohort-based study demonstrates that notable racial and ethnic disparities for lower extremity amputations persist, with a higher proportion of black and Hispanic patients undergoing amputation compared with limb salvage procedures for atraumatic CLI and infection. LEVEL OF EVIDENCE: Level III prognostic.

The 5-Factor Modified Frailty Index Predicts Complications, Hospital Admission, and Mortality Following Arthroscopic Rotator Cuff Repair.

INTRODUCTION: The purpose of this study is to evaluate the utility of the modified frailty index-5 (mFI-5) as a predictor for postoperative complications in patients undergoing arthroscopic rotator cuff repair (RCR). METHODS: The National Surgical Quality Improvement Program database was queried for patients undergoing arthroscopic RCR between 2006 and 2016. The mFI-5, a 5-factor score comprising comorbid diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functional status limiting independence, was calculated for each patient. Multivariate logistic regression models were used to evaluate the mFI-5 score as a predictor for complications including medical complications, surgical-site infections, hospital admission, discharge to a facility, and mortality. RESULTS: In total, 24,477 patients met criteria for inclusion. The mFI-5 was a strong predictor for medical complications (P < .001), hospital admission (P < .001), length of stay (P = .007), and discharge to a facility (P = .001) but not surgical-site infections (P = .153). For each point increase in mFI-5 score, the risk for a medical complication increased by 66%, readmission by 52%, and adverse discharge by 45%. However, of all the measured complications, the mFI-5 was the strongest predictor for mortality, with the risk more than doubling for each increase in mFI-5 point (odds ratio 2.66, P = .025). CONCLUSIONS: The mFI-5 is a sensitive tool for predicting life-threatening medical complications, hospital admission, increased length of stay, adverse discharge, and mortality following arthroscopic RCR. The 5 comorbidities comprising the mFI-5 are easily obtained through the patient history, making it a practical clinical tool for identifying high-risk patients, informing preoperative counseling, and improving value-based health care. LEVEL OF EVIDENCE: Level III, prognostic.

Smoking is associated with increased surgical complications following total shoulder arthroplasty: an analysis of 14,465 patients.

HYPOTHESIS: The purpose of this study was to evaluate the association between smoking and postoperative complications following total shoulder arthroplasty. We hypothesized that active smokers would have significantly greater postoperative medical and surgical complications. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent total shoulder arthroplasties from 2005 through 2016. Patients were stratified based on tobacco use within the past year. Logistic regression was used to assess the relationship between smoking status and postoperative medical and surgical complications. Multivariate logistic regression was used to adjust for demographic and comorbid factors. RESULTS: We identified 14,465 patients, of whom 10.5% were active smokers. Smokers were more likely to be younger, to be female patients, and to have a lower body mass index compared with nonsmokers (P < .001). Univariate analysis demonstrated that smoking was not associated with postoperative medical complications (P > .05) but was associated with an increased risk of overall surgical complications (odds ratio [OR], 3.259; 95% confidence interval [CI], 1.861-5.709; P < .001). Multivariate modeling showed that smoking increased the risk of wound complications (adjusted OR, 7.564; 95% CI, 2.128-26.889; P = .002) and surgical-site infections (adjusted OR, 1.927; 95% CI, 1.023-3.630; P = .042). DISCUSSION AND CONCLUSION: This study demonstrates that smoking is associated with an increased risk of surgical complications following total shoulder arthroplasty. On the basis of our available data, medical complications are not significantly increased. This information can help risk stratify patients prior to their procedures.

A propensity-score matched analysis of limb salvage vs amputation for osteosarcoma.

BACKGROUND AND OBJECTIVES: With recent advances in chemotherapy and surgical techniques, the trend in the treatment of osteosarcoma continues to progress towards limb salvage. However, studies comparing limb salvage with amputation continue to be limited by selection bias and small sample sizes. This study utilized propensity-score matching to minimize potential confounders and selection bias to compare the survival rates in patients with osteosarcoma that were treated with amputation vs limb salvage surgery. METHODS: The Surveillance, Epidemiology, and End Results Program was utilized to identify all patients with a diagnosis of extremity osteosarcoma. Patients were matched with demographics, tumor characteristics, and treatment information. These variables were then fitted in a multivariate model and hazard ratios (HR) for overall- and disease-specific mortality was calculated. RESULTS: A total of 4107 patients were identified, of which, 1538 were left after propensity-score matching. Older age, Black race, upper extremity location, and higher American joint committee on cancer (AJCC) class were associated with worse overall- and disease-specific mortality rates (P ≤ .0389). Compared with their matched counterparts, patients treated with amputation had higher overall mortality (HR 1.677; P < .0001) and higher disease-specific mortality (HR 1.678; P < .0001). CONCLUSION: Patients whose tumor characteristics preclude limb salvage have significantly higher overall- and disease-specific mortality rates.

Modified frailty index predicts medical complications, length of stay, readmission, and mortality following total shoulder arthroplasty.

HYPOTHESIS: The purpose of this study was to evaluate the 5-factor modified frailty index (mFI-5) as a predictor of postoperative complications in patients undergoing total shoulder arthroplasty (TSA). METHODS: We conducted a retrospective analysis of the National Surgical Quality Improvement Program database for patients undergoing TSA between the years 2005 and 2017. The mFI-5 score, which includes the presence of comorbid diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functional status, was calculated for each patient. Multivariate logistic regression models were used to assess the relationship between the mFI-5 and postoperative complications. RESULTS: A total of 18,957 patients undergoing TSA were identified. The mFI-5 was a strong predictor of serious medical complications (cardiac arrest, myocardial infarction, septic shock, pulmonary embolism, postoperative dialysis, reintubation, and prolonged ventilator requirement), discharge to a facility, and readmission (odds ratio ≥ 1.309, P ≤ .001). Length of stay also increased as the mFI-5 score increased (P < .001). However, among all the measured complications, the mFI-5 was the strongest predictor of mortality, with the risk more than doubling for each point increase in the mFI-5 score (odds ratio, 2.113; 95% confidence interval, 1.447-3.086; P < .001). CONCLUSION: The mFI-5 predicts serious medical complications, increased length of stay, discharge to a facility, hospital readmission, and mortality in patients undergoing TSA. All of the variables within the mFI-5 are easily obtained through the patient history, allowing for a practical clinical tool that hospitals and surgeons can use to identify high-risk surgical candidates, inform preoperative counseling, and guide perioperative care to optimize patient outcomes.

Insulin Dependence Is Associated With Increased Medical Complications and Mortality After Shoulder Arthroscopy.

PURPOSE: To compare complications after shoulder arthroscopy in patients with insulin-dependent diabetes mellitus (IDDM), patients with non-insulin-dependent diabetes mellitus (NIDDM), and nondiabetic patients. METHODS: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database for the years 2005 to 2016 was conducted. Logistic regression analyses were used to assess the relation between diabetic status (nondiabetic patients, n = 50,626; NIDDM patients, n = 5,332; and IDDM patients, n = 2,484) and outcomes. Multivariate models were established to adjust for age, sex, body mass index, hypertension, congestive heart failure, chronic obstructive pulmonary disease, smoking status, American Society of Anesthesiologists classification, and functional status. RESULTS: Patients with IDDM were at a higher risk of medical complications, with an adjusted odds ratio (AOR) of 1.524 (95% confidence interval [CI], 1.082-2.147), including pulmonary complications (AOR, 2.078; 95% CI, 1.089-3.964) and urinary tract infections (AOR, 2.129; 95% CI, 1.027-4.415). Patients with IDDM also had a higher risk of 30-day hospital admission (AOR, 1.581; 95% CI, 1.153-2.169) and 30-day mortality (AOR, 3.821; 95% CI, 1.243-11.750). Conversely, patients with NIDDM had comparable risks of medical and surgical complications, unplanned hospital admission, and death to nondiabetic patients. CONCLUSIONS: Medical complications, 30-day hospital admission, and death after shoulder arthroscopy were more likely in patients with IDDM. These risks diminished among patients with NIDDM, with their risks being comparable with those of nondiabetic patients. LEVEL OF EVIDENCE: Level III, retrospective comparison study.

Frailty Predicts Medical Complications, Length of Stay, Readmission, and Mortality in Revision Hip and Knee Arthroplasty.

BACKGROUND: The purpose of this study is to evaluate the 5-factor modified frailty index (mFI-5) as a predictor of postoperative complications, readmission, and mortality in patients undergoing revision hip and knee arthroplasty. METHODS: A retrospective analysis of the American College of Surgeon's National Surgical Quality Improvement Program's database for patients undergoing revision total hip arthroplasty (rTHA) and revision total knee arthroplasty (rTKA) between the years 2005 and 2016 was conducted. The 5-factor score, which includes presence of comorbid diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functional status, was calculated for each patient. Multivariate logistic regression models were used to assess the relationship between the mFI-5 and postoperative complications while controlling for demographic variables. RESULTS: In total, 13,948 patients undergoing rTHA and 16,304 patients undergoing rTKA were identified. The mFI-5 was a strong predictor of serious medical complications (cardiac arrest, myocardial infarction, septic shock, pulmonary embolism, postoperative dialysis, reintubation, and prolonged ventilator requirement), discharge to a facility, total length of stay, readmission, and mortality (P ≤ .007). CONCLUSION: The mFI-5 predicts serious medical complications, increased length of stay, discharge to a facility, hospital readmission, and mortality in patients undergoing rTHA and rTKA. All the variables within the mFI-5 are easily obtained through the patient history, allowing for a practical clinical tool that hospitals and physicians can use to identify at-risk patients, educate and engage patients and their families in a shared decision-making conversation, and guide perioperative care in order to optimize patient outcomes. LEVEL OF EVIDENCE: III.

Preoperative Shoulder Injections Are Associated With Increased Risk of Revision Rotator Cuff Repair.

PURPOSE: The goal of this study was to determine whether the timing of preoperative shoulder injections is associated with an increased risk of revision rotator cuff repair following primary rotator cuff repair (RCR). METHODS: A retrospective analysis of claims data of privately insured subjects from the MarketScan database for the years 2010 to 2014 was conducted. Multivariable logistic regression models were used to compare the odds of reoperation between groups. Laterality for the injection, index procedure, and subsequent surgery were verified for all subjects. RESULTS: A total of 4,959 subjects with an arthroscopic RCR were identified, 392 of whom required revision RCR within the following 3 years. Patients who had an injection within 6 months preceding the index surgery were at a much higher risk of undergoing reoperation for revision RCR: 0 to 3 months prior, adjusted odds ratio (AOR) 1.375 (95% confidence interval [CI], 1.027-1.840); 3 to 6 months prior, AOR 1.822 (95% CI, 1.290-2.573); and 6 to 12 months prior, AOR 1.237 (95% CI, 0.787-1.943). CONCLUSIONS: Patients who had received an injection within 6 months prior to RCR were much more likely to undergo a revision cuff repair within the following 3 years. The risk of reoperation significantly declines if there is more than 6 months between injection and RCR. Consideration should be given to minimizing preoperative injections in patients requiring RCR or delaying primary RCR for 6 months following injection. LEVEL OF EVIDENCE: Level III, therapeutic study.

New Five-Factor Modified Frailty Index Predicts Morbidity and Mortality in Geriatric Hip Fractures.

INTRODUCTION: Although the 11-factor modified frailty index (mFI-11) has been shown to predict adverse outcomes in elderly patients undergoing surgery for hip fractures, the newer 5-factor index has not been evaluated in this population. The goal of this study is to evaluate the mFI-5 as a predictor of morbidity and mortality in elderly patients undergoing surgical management for hip fractures. METHODS: The NSQIP database was queried for patients 60 years of age and older who underwent surgical management for hip fractures between 2005 and 2016. The 5-factor score, which comprised diabetic status, history of COPD or current pneumonia, congestive heart failure, hypertension requiring medication, and nonindependent functional status, was calculated for each patient. Multivariate logistic regression models were used to assess the relationship between the mFI-5 and 30-day postoperative complications. RESULTS: A total of 58,603 patients were identified. After adjusting for comorbidities, the mFI-5 was a strong predictor for total complications, serious medical complications (cardiac arrest, myocardial infarction, septic shock, pulmonary embolism, postoperative dialysis, reintubation, and prolonged ventilator requirement), surgical site infections, readmission, extended hospital length of stay, and mortality (P ≤ 0.008). For each point increase, the risk for any complication increased by 29.8%, serious medical complications 35.4%, surgical site infections 14.7%, readmission 24.6%, and mortality 33.7%. CONCLUSIONS: The mFI-5 is an independent predictor of postoperative morbidity and mortality in elderly patients undergoing surgery for hip fractures. This clinical tool can be used by hospitals and surgeons to identify high-risk patients, accurately council patients and families with transparency, and guide perioperative care to optimize patient outcomes. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.