Effect of Physical Therapy and Rehabilitation Timing on Rotator Cuff Repair Revisions and Capsulitis.

INTRODUCTION: One variable that could potentially affect failure of a rotator cuff repair (RCR) is the timing of beginning physical therapy (PT) after the procedure. Although many studies have demonstrated decreased stiffness with beginning PT early, studies have also demonstrated that early PT increases repair failure. The goal of this study was to identify revision surgery and capsulitis rates after RCRs from an available database and determine whether an association was present with the timing of PT post-RCR. METHODS: Medicare patients within the PearlDiver database who underwent RCR were stratified based on the timing of their first PT session postoperatively, and revision surgery and capsulitis rates were determined among the groups for both open and arthroscopic RCR. Demographics and comorbidities of the cohort were also used to formulate a multivariate analysis for revision surgery rate. RESULTS: The cohort consisted of 64,842 patients who underwent RCR and started PT within 13 weeks of surgery. Starting PT within 1 week postoperatively resulted in a significantly higher revision surgery rate compared with starting PT in weeks 2 to 5, 6 to 9, or 10 to 13 (6.9% vs. 3.6% among all other groups, P = <0.001). The multivariate analysis for revision surgery further demonstrated that starting PT within 1 week postoperatively was associated with a significantly higher rate of revision surgery compared with beginning PT after 1 week (OR = 2.086, P < 0.001). No association was found between timing of beginning PT and capsulitis rates. CONCLUSION: In the Medicare patient cohort, beginning PT within 1 week postoperatively was associated with a significantly higher revision surgery rate; however, no associated benefit was noted in capsulitis rates for beginning PT early. This calls into question the use of an early passive range of motion protocol for older patient cohort; however, further studies should be completed to conclusively determine the most efficacious time to begin rehabilitation post-RCR. LEVEL OF EVIDENCE: Level III.

Analysis of the Cost and Efficacy of Intra-Articular Knee Injections.

INTRODUCTION: Intra-articular joint injections have been used with the goal of providing patients with symptomatic relief. Recently, however, the efficacy of corticosteroid (CS) and hyaluronic acid (HA) injections in the management of knee osteoarthritis (OA) is questionable. In this analysis, we investigated the costs associated with injections by assessing overall use, conversion and average time to total knee arthroplasty (TKA), and reimbursement. METHODS: Patients aged 50 to 70 years with a knee-related diagnosis of pain, effusion, or OA were identified in the Humana insurance national data set. Patients who received intra-articular injections were stratified by the type and number of injection(s) received. The subsequent rates of TKA were compared with Kaplan-Meier curves for patients who underwent CS injections, HA injections, and a benchmarking cohort of patients with OA and no history of knee injections in the medical record. Average time to TKA was determined from index diagnosis, and total cost was compared using Wilcoxon rank sum analyses. RESULTS: A total of 778,686 patients were identified. Of these, 637,112 had no knee injection history, while 124,129 received CS and 17,445 received HA injections. The 10-year conversion to TKA was highest in HA cohort (31.6%), followed by the CS cohort (24.0%) and the noninjection cohort (7.3%) (P < 0.001). Time to TKA increased with number of injections for both injection types. For patients who underwent TKA, median cost was greater in HA ($16,687) and CS ($15,563) cohorts relative to noninjection cohort ($14,733) (P < 0.001). DISCUSSION: Compared with the noninjection cohort, both HA and CS cohorts experienced increased costs and increased time to TKA. However, while the cost incurred in HA cohort was greater than that in CS cohort, no appreciable benefit was demonstrated for conversion or time to TKA. Therefore, if intra-articular knee injections are indicated for the nonsurgical management of knee OA, the results of this study support CS over HA.

The Effects of Chronic Preoperative Opioid Use on Single-level Lumbar Fusion Outcomes.

STUDY DESIGN: A retrospective study using a national insurance claims database. OBJECTIVE: The objective of this study was to assess the relationship between chronic preoperative opioids and the outcomes of revision surgery and nonunion after single-level lumbar fusion. SUMMARY OF BACKGROUND DATA: Opioids are widely utilized for pain management before spine procedures. Studies have associated opioids with unfavorable postoperative outcomes, and animal models have also linked opioid administration with unstable bone healing. METHODS: Single-level lumbar fusion patients were identified. Patients with any fracture history within 1 year before surgery were excluded. A chronic preoperative opioid cohort was defined by opioids prescriptions within 3 months prior and within 4-6 months before surgery. The rates of revision surgery within 6 months and nonunion within 6-24 months after surgery were assessed. Univariate analyses of chronic preoperative opioid prescriptions and various comorbidities for revision and nonunion were conducted followed by multivariate analyses controlling for these factors. Individual analyses were run for each of the 3 single-level lumbar fusion procedures. RESULTS: A total of 8494 single-level lumbar fusion patients were identified. Of the 3929 (46.3%) patients filled criteria for the chronic preoperative opioid cohort, while 3250 (38.3%) patients had no opioid prescriptions within 6 months before surgery. The opioid cohort experienced significantly higher rates of both revisions (3.92% vs. 2.71%, P=0.005) and nonunion (3.84% vs. 2.89%, P=0.027) relative to the opioid-naive cohort. In the multivariate analyses, chronic preoperative opioids were identified as an independent risk factor for revision (odds ratio: 1.453, P=0.006). CONCLUSIONS: We report that chronic opioid prescriptions before lumbar fusion may increase the risk of revision. Although these prescriptions were also associated with increased nonunion, the comparisons did not achieve statistical significance in the multivariate model. Chronic preoperative opioid use may be considered a potential risk factor in arthrodesis populations.

General health measures in shoulder surgery: are we powered for success?

BACKGROUND: Surgeons, policymakers, and payers increasingly use changes in general health to guide decision-making. It is unknown how such measures are incorporated into shoulder surgery research, how strongly they are associated with changes in shoulder-specific outcomes, and whether they are appropriately powered. METHODS: PubMed was searched for articles reporting shoulder-specific and general health measures after rotator cuff repair and total shoulder arthroplasty. Study characteristics, results at the study group level, reporting of power calculations, and statistical significance were recorded. Meta-regression was employed to describe the association of changes between shoulder-specific and general health measures. RESULTS: Of 360 identified abstracts, 21 articles with 28 patient groups were included. Only 1 article was published before 2000. There was a strong association of changes between shoulder-specific and general health measures (r = 0.66; P < .001). Power calculations were mentioned in 33% of studies and based on shoulder-specific measures. Of 20 studies conducting hypothesis tests, 75% reported agreement regarding the statistical significance of shoulder-specific and general health tests. Of 5 discordant studies, 4 found the shoulder-specific measure statistically significant and not the general health measure. CONCLUSION: Shoulder surgery research increasingly reports changes in general health measures that are associated with changes in shoulder-specific measures, suggesting that improvements in shoulder symptoms increase quality of life. When disagreement exists, it usually results from the general health measure's not meeting statistical significance, which may simply reflect type II error. Research reporting general health measures should carefully report power considerations to avoid misinterpretation of findings failing to reach statistical significance.

It All Depends on Who Does What: A Survey of Patient and Family Member Comfort With Surgical Trainees Operating.

OBJECTIVE: To measure patient and family member comfort with surgical trainees of varying levels performing different portions of surgery. DESIGN, SETTING, AND PARTICIPANTS: An electronic survey dividing surgery into 6 steps (prepping and positioning, initial incision, deep dissection, critical portions, deep suturing, and closing incision), differentiating surgical trainees by 4 levels of experience (medical student, intern, resident, and fellow), and specifying whether or not an attending surgeon is in the operating room (OR) was given to 200 patients and family members in the surgical waiting area of a single academic medical center. Responses were on a 7-point Likert scale from "Not Comfortable at All" to "Completely Comfortable". RESULTS: Patient and family member comfort significantly increased as trainee experience increased. It reached a nadir for all trainees performing "critical portions" of surgery. However, their average response was "Comfortable" for residents and fellows performing any surgical step when the attending surgeon is present in the OR. The percentage of "Comfortable" responses was significantly lower for all trainee levels performing any surgical step when the attending surgeon is absent from the OR. CONCLUSIONS: Patient and family member comfort with surgical trainees operating varies based on the trainee's level of experience, the step the trainee performs, and whether or not the attending surgeon is present in the OR. Patients and family members are on average "Comfortable" with surgical residents and fellows performing any surgical step when the attending surgeon is present.

Comparison of perioperative complications after total elbow arthroplasty in patients with and without diabetes.

BACKGROUND: Few studies have analyzed the effect of diabetes on outcomes after total elbow arthroplasty (TEA). We investigated the perioperative complications after TEA in patients with and without diabetes. METHODS: We evaluated the Nationwide Inpatient Sample (NIS) database from 2005 to 2010 for patients who underwent a TEA. Our retrospective study included 3184 patients based on International Classification of Diseases-Ninth Revision, Clinical Modification codes. We compared outcomes in 488 patients with diabetes and in 2696 patients without diabetes. RESULTS: Patients with diabetes had a significantly older mean age (66.8 vs 58.5 years, P < .001). There was no statistically significant difference when comparing length of stay (4.1 vs 3.7 days, P = .056) and cost of surgery ($56,582 vs $56,092, P = .833). A significantly higher percentage of diabetic patients underwent TEA for the indication of fracture (73.4% vs 65.3%), but a lower percentage for rheumatoid arthritis (10.2% vs 19.2%). They also had significantly increased rates of pneumonia (odds ratio [OR], 2.7), urinary tract infection (OR, 2.2), blood transfusion (OR, 2.1), and nonroutine discharge (OR, 1.9). After adjusting for significantly increased rates of comorbidities in diabetic patients, our multivariate analysis showed that having diabetes was independently associated with an increased risk of pneumonia (relative risk [RR], 2.6), urinary tract infection (RR, 1.9), and cerebrovascular accident (RR, 9.1). However, diabetes was not independently associated with hospital length of stay (P = .75), after correction, hospital cost (P = .63), or proportion of routine discharges (P = .12). CONCLUSION: Patients with diabetes have higher rates of comorbidities and perioperative complications after TEA.