Tranexamic acid is not associated with decreased infection risk after primary shoulder arthroplasty: a cohort study of 9276 patients.

BACKGROUND: The use of tranexamic acid (TXA) is associated with less blood loss and reduced transfusion risk after shoulder arthroplasty surgery. Recent studies have shown lower odds of postoperative infection after hip or knee arthroplasty with its use. The purpose of this study was to determine whether TXA use reduces the risk of infection after primary elective shoulder arthroplasty. METHODS: A retrospective cohort study was conducted using data from a US integrated health care system's shoulder arthroplasty registry. Patients aged 18 years who underwent primary elective anatomic total shoulder arthroplasty for osteoarthritis or primary reverse shoulder arthroplasty for rotator cuff arthropathy were included (2013-2020). We compared patients who received preoperative intravenous TXA to those who did not receive TXA by assessing the risk for revision due to deep infection within 5 years' follow-up using multivariable Cox proportional hazard regression. Interaction between TXA and diabetes status was analyzed separately. RESULTS: The study sample included 9276 shoulder arthroplasties performed by 153 surgeons at 43 hospitals. The mean age was 70.0 years and 48% were male. The 5-year probability of revision for deep infection was 0.8% and 0.7% for patients with and without TXA, respectively. We failed to observe a difference in infection risk after adjustment for confounders and surgeon differences (hazard ratio [HR] 1.00, 95% confidence interval [CI] 0.56-1.80, P = .998). Further, no differences were observed in patients with (HR 1.64, 95% CI 0.42-6.44, P = .481) or without diabetes (HR 0.79, 95% CI 0.40-1.55, P = .488). CONCLUSION: In a multicenter cohort of more than 9000 primary shoulder arthroplasty procedures, the use of preoperative TXA was not associated with a decrease in the 5-year probability of revision for deep infection.

Procedure Cost Comparison of Outpatient and Inpatient Shoulder Arthroplasty and Lower-Extremity Arthroplasty Within a Managed-Care Organization.

Introduction The authors sought to evaluate cost differences between shoulder arthroplasties and lower-extremity joint replacements in the outpatient and inpatient setting within a large health-maintenance organization. Methods A cross-sectional study of 100 total hip arthroplasties (THA), 100 total knee arthroplasties (TKA), and 100 shoulder arthroplasties (50 anatomical total shoulder arthroplasties and 50 reverse shoulder arthroplasties [RTSA]) was performed at a single regional health care center within an integrated health care maintenance organization. A time-driven activity-based costing methodology was used to obtain total cost of each episode for outpatient (vs) inpatient surgery. Results are presented by procedure type. Results Compared to their respective inpatient procedure, outpatient surgery was less expensive by 20% for RTSA, 22% for total shoulder arthroplasties, 29% for THA, and 30% for TKA. The cost of implants was the highest proportion of cost for all joint procedures across inpatient and outpatient settings, ranging from 28% of the total cost for inpatient THA to 63% of the cost for outpatient RTSA. Discussion Although many factors influence the total cost for arthroplasty surgery, including rate of hospitalization, duration of stay, operative time, complexity of cases, patient factors, equipment, and resource utilization, the implant cost remains the most expensive factor, with hospital bed admission status being the second costliest contribution. Conclusion Outpatient total arthroplasty substantially reduced procedure expenses in a managed-care setting by 20%-30%, although savings for outpatient shoulder arthroplasty was lower than savings for THA or TKA. Implant costs remain the largest portion of shoulder arthroplasty procedure expenses.

Operative Management of Acute Triceps Tendon Ruptures: Review of 184 Cases.

BACKGROUND: Distal triceps tendon ruptures are rare. The authors present a series of 184 surgically treated, acute, traumatic triceps tendon avulsions and compare the complications between those treated with anchors (A) versus transosseous (TO) suture repair. HYPOTHESIS: No difference exists in the retear rate between TO and A repairs. Study Designed: Cohort study; Level of evidence, 3. METHODS: All patients who underwent an open primary repair of a traumatic triceps tendon avulsion within 90 days of injury, between 2007 and 2015, were retrospectively reviewed. Surgeries were performed within a multisurgeon (75 surgeons), multicenter (14 centers), community-based integrated health care system. Patient demographic information, type of repair, complications, and time from surgery to release from medical care were recorded. RESULTS: 184 triceps tears in 181 patients met the inclusion criteria. The mean age was 49 years (range, 15-83 years). There were 169 males. The most common mechanisms of injury were fall (56.5%) and weight lifting (19%). Mean time from injury to surgery was 19 days (range, 1-90 days); in 74.5% of cases, surgery was performed in 3 weeks or less. There were 105 TO and 73 A repairs. No significant difference was found between the two groups in the mean age ( P = .18), sex ( P = .51), completeness of tears ( P = .74), tourniquet time ( P = .455), and prevalence of smokers ( P = .64). Significant differences were noted between TO and A repairs in terms of reruptures (6.7% vs 0%, respectively; P = .0244), overall reoperation rate (9.5% vs 1.4%; P = .026), and release from medical care (4.3 vs 3.4 months; P = .0014), but no difference was seen in infection rate (3.8% vs 0%; P = .092). No difference was noted in release from medical care in patients who underwent surgery 3 weeks or less after injury compared with those undergoing surgery more than 3 weeks after injury (3.90 vs 4.09 months, respectively; P = .911). CONCLUSION: Primary repair of triceps ruptures with TO fixation has a significantly higher rerupture rate, higher reoperation rate, and longer release from medical care than does repair with A fixation. Implementation of suture anchors in triceps repairs offers a lower complication rate and earlier release from medical care.

Yearly Trends in Elective Shoulder Arthroplasty, 2005-2013.

OBJECTIVE: To evaluate the change in incidence rate of shoulder arthroplasty, the utilization of shoulder arthroplasty for specific indications, and the surgeon volume trends associated with these procedures between 2005 and 2013. METHODS: A population-based cohort study was conducted using the more than 7 million members of an integrated health care system in California. Cases of shoulder arthroplasties performed between 2005 and 2013 were identified using a shoulder arthroplasty registry. Annual shoulder arthroplasty incidence rates per 100,000 patients were determined, and adjusted yearly changes in rates were estimated using incidence rate ratios (IRRs). Changes in surgeon volumes by year and number of surgeons performing different procedures were also compared. RESULTS: The incidence of shoulder arthroplasty per 100,000 members increased from 6.1 (95% confidence interval [95% CI] 5.5-6.7) in 2005 to 13.4 (95% CI 12.5-14.2) in 2013. In patients with osteoarthritis, there was increasing utilization of total shoulder arthroplasty (IRR 1.12 [95% CI 1.11-1.14]) and decreasing utilization of hemiarthroplasty (IRR 0.91 [95% CI 0.89-0.94]). For patients with rotator cuff tear arthropathy, there was an increase in utilization of reverse total shoulder arthroplasty (IRR 1.33 [95% CI 1.29-1.37]) but no change in hemiarthroplasty (IRR 0.99 [95% CI 0.92-1.05]). The average surgeon yearly volume increased for total shoulder arthroplasty (P < 0.001) and for reverse total shoulder arthroplasty (P = 0.020). CONCLUSION: Shoulder arthroplasty is being used with greater frequency in this population. Surgeons are performing a greater yearly volume of total shoulder arthroplasty and reverse total shoulder arthroplasty.

The Kaiser Permanente shoulder arthroplasty registry: results from 6,336 primary shoulder arthroplasties.

BACKGROUND AND PURPOSE: Shoulder arthroplasty is being performed in the United States with increasing frequency. We describe the medium-term findings from a large integrated healthcare system shoulder arthroplasty registry. PATIENTS AND METHODS: Shoulder arthroplasty cases registered between January 2005 and June 2013 were included for analysis. The registry included patient characteristics, surgical information, implant data, attrition, and patient outcomes such as surgical site infections, venous thromboembolism, and revision procedures. RESULTS: During the study period, 6,336 primary cases were registered. Median follow-up time for all primaries was 3.3 years; 461 cases were lost to follow-up by ending of health plan membership. Primary cases were predominantly female (56%) and white (81%), with an average age of 70 years. The most common reason for surgery was osteoarthritis in 60% of cases, followed by acute fracture (17%) and rotator cuff tear arthropathy (15%). In elective shoulder arthroplasty procedures, 200 all-cause revisions (4%) were reported, with glenoid wear being the most common reason. INTERPRETATION: Most arthroplasties were elective procedures: over half performed for osteoarthritis. Glenoid wear was the most common reason for revision of primary shoulder arthroplasty in elective cases.

Patient and procedure-specific risk factors for deep infection after primary shoulder arthroplasty.

BACKGROUND: Deep infection after shoulder arthroplasty is a diagnostic and therapeutic challenge. The current literature on this topic is from single institutions or Medicare samples, lacking generalizability to the larger shoulder arthroplasty population. QUESTIONS/PURPOSES: We sought to identify (1) patient-specific risk factors for deep infection, and (2) the pathogen profile after primary shoulder arthroplasty in a large integrated healthcare system. METHODS: A retrospective cohort study was conducted. Of 4528 patients identified, 320 had died and 302 were lost to followup. The remaining 3906 patients had a mean followup of 2.7 years (1 day-7 years). The study endpoint was the diagnosis of deep infection, which was defined as revision surgery for infection supported clinically by more than one of the following criteria: purulent drainage from the deep incision, fever, localized pain or tenderness, a positive deep culture, and/or a diagnosis of deep infection made by the operating surgeon based on intraoperative findings. Risk factors evaluated included age, sex, race, BMI, diabetes status, American Society for Anesthesiologists (ASA) score, traumatic versus elective procedure, and type of surgical implant. For patients with deep infections, we reviewed the surgical notes and microbiology records for the pathogen profile. Multivariable Cox regression models were used to evaluate the association of risk factors and deep infection. Adjusted hazard ratios and 95% CI are presented. RESULTS: With every 1-year increase in age, a 5% (95% CI, 2%-8%) lower risk of infection was observed. Male patients had a risk of infection of 2.59 times (95% CI, 1.27-5.31) greater than female patients. Patients undergoing primary reverse total shoulder arthroplasty had a 6.11 times (95% CI, 2.65-14.07) greater risk of infection compared with patients having primary unconstrained total shoulder arthroplasty. Patients having traumatic arthroplasties were 2.98 times (95% CI, 1.15-7.74) more likely to have an infection develop than patients having elective arthroplasties. BMI, race, ASA score, and diabetes status were not associated with infection risk (all p > 0.05). Propionibacterium acnes was the most commonly cultured organism, accounting for 31% of isolates. CONCLUSIONS: Younger, male patients are at greater risk for deep infection after primary shoulder arthroplasty. Reverse total shoulder arthroplasty and traumatic shoulder arthroplasties also carry a greater risk for infection. Propionibacterium acnes was the most prevalent pathogen causing infection in our primary shoulder arthroplasty population. LEVEL OF EVIDENCE: Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Shoulder arthroplasty in patients 59 years of age and younger.

BACKGROUND: While shoulder arthroplasty is a well established treatment for a variety of conditions about the shoulder, the results of shoulder replacement in younger patients are not as predictable. The purpose of this study is to examine the indications for shoulder arthroplasty in patients 59 years old and younger, and to analyze revision rates between younger and older patients. METHODS: This is a retrospective cohort study of shoulder arthroplasties performed within a statewide integrated healthcare system between 2005 and 2010. Patients were stratified into 2 groups based on age at time of index replacement procedure: younger patients (≤59 years) and older patients (>59 years). RESULTS: There were 2981 primary arthroplasties followed for a median time of 2.2 years (interquartile range, 1.0-3.8), 90 (3.0%) of which required revisions. After adjusting for procedure type and diagnosis, younger patients had a two times higher risk (95% CI 1.2-3.5, P = .007) of revision than older patients. When looking at the risk of revision in younger and older patients separately, the risk of revision in hemiarthroplasty (RR = 4.5 vs RR = 1.7) and reverse total shoulder arthroplasty (RR = 33.6 vs RR = 3.0) compared to total shoulder arthroplasty were higher in younger patients compared to older patients. CONCLUSION: This study suggests patients 59 years and younger have an increased risk of revision at early follow-up. The higher risk of revision in younger patients receiving hemiarthroplasty may support the use of total shoulder arthroplasty in patients 59 years of age and younger.

Risk of thromboembolism in shoulder arthroplasty: effect of implant type and traumatic indication.

BACKGROUND: Prior research about symptomatic venous thromboembolism (VTE) after shoulder arthroplasty has not determined whether procedure type (hemiarthroplasty, total shoulder arthroplasty, or reverse shoulder arthroplasty) or surgical indication (traumatic or elective) represent risk factors for VTE after shoulder replacement. QUESTIONS/PURPOSES: We therefore asked whether the risk of symptomatic VTE events and mortality within 90 days of shoulder arthroplasty was influenced by (1) procedure type, and (2) surgical indication (traumatic or elective). METHODS: We performed a retrospective database review of symptomatic VTE events and mortality within 90 days of shoulder arthroplasty in a large (30-hospital) integrated healthcare system over a 5-year period, from January 2005 to December 2009. We compared the likelihood of VTE and death in patients undergoing reverse shoulder arthroplasties (RSAs), total shoulder arthroplasties (TSAs), and hemiarthroplasties (HAs), and we compared the likelihood of VTE and death in patients who underwent elective shoulder arthroplasties with those who underwent shoulder arthroplasty in the setting of acute trauma. RESULTS: In the 2574 eligible shoulder arthroplasties identified during the study period, VTE developed in 1.01% of patients (deep vein thrombosis 0.51% and pulmonary embolism 0.54%). With the numbers available, no differences were observed in rates of VTE or mortality by procedure type. A trend toward increased VTE occurred more frequently in patients having surgery for traumatic indications than after elective surgery (1.71% versus 0.80%; p = 0.055). A higher likelihood of 90-day mortality was observed in trauma patients compared with elective (odds ratio = 7.4; 95% CI, 2.4-25.2). CONCLUSIONS: VTE occurred infrequently in this study sample. These data support future risk and benefit assessment of routine pharmacologic VTE prophylaxis in the perioperative treatment of patients undergoing shoulder arthroplasty, especially in all RSA and traumatic HA subsets, where the risk of VTE may be higher.