Trends in the treatment of proximal humerus fractures from 2010 to 2020.

BACKGROUND: The incidence of proximal humerus fractures (PHF) is continuing to rise due to shifts towards a more aged population as well as advancements in surgical treatment options. The purpose of this study is to examine and compare trends in the treatment of PHFs (nonoperative vs. operative; different surgical treatments) across different age groups over the last decade (2010-2020). METHODS: The New York Statewide Planning and Research Cooperative System (SPARCS) database was queried using International Classification of Diseases and Current Procedural Terminology codes to identify all patients presenting with or undergoing surgery for PHF between 2010 and 2020. Treatment trends, demographics, and insurance information were analyzed during the study period. Comparisons were made between operative and nonoperative trends with respect to the number and type of surgeries performed among 3 age groups: ≤49 years, 50-64 years, and ≥65 years. The rate of postoperative complications and reoperations was evaluated and compared among different surgical treatments for patients with a minimum 1-year postoperative follow-up. RESULTS: A total of 92,308 patients with a mean age of 67.8 ± 16.8 years were included. Over the last decade, there was no significant increase in the percentage of PHFs treated with surgery. A total of 15,523 PHFs (16.82%) were treated operatively, and these patients, compared with the nonoperative cohort, were younger (64.9 years vs. 68.4 years, P < .001), more likely to be White (80.2% vs. 74.7%, P < .001), and more likely to have private insurance (41.4% vs. 32.0%, P < .001). For patients ≤49 years old, trends in operative treatment have remained stable with internal fixation (IF) as the most used surgical modality. For patients 50-64 years old, we observed a gradual decline in the use of hemiarthroplasty (HA), with a corresponding increase in the use of reverse total shoulder arthroplasty (rTSA), but IF continued to be the most used operative modality. In patients over 65 years, a steep decline in the use of IF and HA was noted during the first half of the decade along with a significant exponential increase in the use of rTSA, which surpassed the use of IF in 2019. Despite the increase in the use of rTSA, no differences in rate of surgical complications were noted between rTSA and IF (χ2 = 0.245, P = .621) or reoperations (χ2 = 0.112, P = .730). CONCLUSION: Nonsurgical treatment remains the mainstay treatment of PHFs. Although there is no increase in the prevalence of operative treatment in patients ≥50 years in the last decade, there is an exponential increase in the use of rTSA with a corresponding decrease in HA and IF, a trend more substantial in patients ≥65 years compared with patients between 50 and 64 years.

Graft choice and techniques used in elbow ulnar collateral ligament reconstruction over the last 20 years: a systematic review and meta-analysis.

BACKGROUND: Elbow medial ulnar collateral ligament (mUCL) injuries have become increasingly common, leading to a higher number of mUCL reconstructions (UCLR). Various techniques and graft choices have been reported. The purpose of this study was to evaluate the prevalence of each available graft choice, the surgical techniques most utilized, and the reported complications associated with each surgical method. METHODS: A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysesguidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify all articles that included UCLR between January 2002 and October 2022. We included all studies that referenced UCLR graft choice, surgical technique, and/or ulnar nerve transposition. Studies were evaluated in a narrative fashion to assess demographics and report current trends in utilization and complications of UCLR as they pertain to graft choice and surgical techniques over the past 20 years. Where possible, we stratified based on graft and technique. RESULTS: Forty-seven articles were included, reporting on 6671 elbows. The cohort was 98% male, had a weighted mean age of 21 years and follow-up of 53 months. There were 6146 UCLRs (92%) performed with an autograft and 152 (2.3%) that utilized an allograft, while 373 (5.6%) were from mixed cohorts of autograft and allograft. Palmaris longus autograft was the most utilized mUCL graft choice (64%). The most utilized surgical configuration was the figure-of-8 (68%). Specifically, the most common techniques were the modified Jobe technique (37%), followed by American Sports Medicine Institute (ASMI) (22%), and the docking (22%) technique. A concomitant ulnar nerve transposition was performed in 44% of all patients, with 1.9% of these patients experiencing persistent ulnar nerve symptoms after ulnar nerve transposition. Of the total cohort, 14% experienced postoperative ulnar neuritis with no prior preoperative ulnar nerve symptoms. Further, meta-analysis revealed a significantly greater revision rate with the use of allografts compared to autograft and mixed cohorts (2.6% vs. 1.8% and 1.9%, P = .003). CONCLUSIONS: Most surgeons performed UCLR with palmaris autograft utilizing a figure-of-8 graft configuration, specifically with the modified Jobe technique. The overall rate of allograft use was 2.3%, much lower than expected. The revision rate for UCLR with allograft appears to be greater compared to UCLR with autograft, although this may be secondary to limited allograft literature.

The Effect of Socioeconomic Status on Clinical Outcomes and Implant Survivorship After Primary Anatomic and Reverse Total Shoulder Arthroplasty.

BACKGROUND: Low socioeconomic status has been shown to contribute to poor outcomes in patients undergoing joint replacement surgery. However, there is a paucity of studies investigating shoulder arthroplasty. The purpose of this study was to evaluate the effect of socioeconomic status on baseline and postoperative outcome scores and implant survivorship after anatomic and reverse primary total shoulder arthroplasty (TSA). METHODS: A retrospective review of a prospectively-collected single-institution database was performed to identify patients who underwent primary TSA. Zip codes were collected and converted to Area Deprivation Index (ADI) scores. We performed a correlation analysis between national ADI scores and preoperative, postoperative, and pre- to postoperative improvement in range of motion, shoulder strength, and functional outcome scores in patients with minimum 2-year follow-up. Patients were additionally grouped into groups according to their national ADI. Achievement of the MCID, SCB, and PASS and revision-free survivorship were compared between groups. RESULTS: A total of 1,148 procedures including 415 anatomic and 733 reverse total shoulder arthroplasties with a mean age of 64 ± 8.2 and 69.9 ± 8.0 years, respectively, were included. The mean follow-up was 6.3 ± 3.6 years for anatomic and 4.9 ± 2.7 years for reverse TSA. We identified a weak negative correlation between national ADI and most functional outcome scores and range of motion preoperatively (R range 0.07 to 0.16), postoperatively (R range 0.09 to 0.14), and pre- to postoperative improvement (R range 0.01 to 0.17). Thus, greater area deprivation was weakly associated with poorer function preoperatively, poorer final outcomes and poorer improvement in outcomes. There was no difference in the proportion of each ADI group achieving MCID, SCB, and PASS in the anatomic TSA cohort. However, in the reverse TSA cohort, the proportion of patients achieving MCID, SCB, and PASS decreased with greater deprivation. There was no difference in survivorship between ADI groups . CONCLUSIONS: We found a negative effect of low socioeconomic status on baseline and postoperative patient outcomes and range-of-motion; however, the correlations were relatively weak. Patients that reside in socioeconomically deprived areas have poorer functional outcomes before and after TSA and achieve less improvement from surgery. We should strive to identify modifiable factors to improve the success of TSA in socioeconomically deprived areas.

The Effect of Smoking on Outcomes of Reverse Total Shoulder Arthroplasty.

BACKGROUND: The effect of smoking status on clinical outcomes in reverse total shoulder arthroplasty (rTSA) has not been thoroughly characterized. We sought to compare pain and functional outcomes, complications, and revision-free survivorship between current smokers, former smokers, and non-smokers undergoing primary rTSA. METHODS: We retrospectively reviewed a prospectively-collected shoulder arthroplasty database from 2004-2020 to identify patients who underwent primary rTSA. Three cohorts were created based on smoking status: current smokers, former smokers, and non-smokers. Outcome scores (SPADI, SST, ASES, UCLA, Constant), range of motion (ROM) (external rotation [ER], forward elevation [FE], abduction, internal rotation [IR]) and shoulder strength (ER, FE) evaluated at 2-4-year follow-up were compared between cohorts. The incidence of complication and revision-free implant survivorship were evaluated. RESULTS: We included 676 primary rTSAs, including 38 current smokers (44±47 pack-years), 84 former smokers who quit on average 20±14 years (range: 0.5-57 years) prior to surgery (38±32 pack-years), and 544 non-smokers. At 2-4-year follow-up, current smokers had less favorable SPADI, SST, ASES scores, UCLA scores, and Constant scores compared to former smokers and non-smokers. On multivariable analysis, current smokers had less favorable SPADI, SST, ASES score, UCLA score, and Constant score compared to non-smokers. There were no significant differences between cohorts in complication rate and revision-free survivorship. CONCLUSION: Our data showed that current smokers may have poorer functional outcomes after rTSA compared to former smokers and non-smokers despite the incidence of complications and revision surgery not differing significantly between cohorts.

Survivorship and Clinical Outcomes of Reverse Total Shoulder Arthroplasty in Patients with Large Glenoid Defects Using the Stilting Technique and a Baseplate with Central Ingrowth Cage and Peripheral Locking Screws.

BACKGROUND: Stilting is a novel technique used in reverse shoulder arthroplasty (RSA) in patients with significant glenoid bone loss. This technique utilizes peripheral locking screws placed behind an unseated portion of the baseplate, to transmit forces from the baseplate to the cortical surface of the glenoid, without the need for bone grafting. The stilted screw, once locked, provides a fixed angle point of support for an unseated aspect of a baseplate. The primary advantages of this technique are reduced cost compared to a custom implant and reduced operative time compared to bone grafting. METHODS: We conducted a retrospective, non-randomized, comparative cohort study of 41 patients underwent primary Reverse Shoulder Arthroplasty (RSA) using the Stilting Technique with the Exactech Equinoxe Reverse System (Gainesville, FL, USA) at a single, academic center from the years 2004-2021. Exclusion criteria included age under 18 or over 100, and oncologic or acute fracture RSA indications. Operative data was documented, including implant records, percent baseplate seating, and operative duration. Survivorship was compared among primary stilted-RSA (n=41), bone graft-RSA (n=42), and non-stilted/non-bone grafted RSA (n=1,032) within our institutional shoulder arthroplasty database. A radiographic examination of baseplate failure was also conducted across the study groups. Postoperative functional outcomes were compared in a matched analysis involving patients with a minimum 2-year follow-up between stilted patients and a non-stilted/non-bone grafted control group for primary RSA. RESULTS: All Stilted-RSA cases utilized metal augments and demonstrated a mean baseplate seating of 61% (range 45-75%). For stilted RSAs, survivorship was 100% and 92.6% at 2- and 5-years, compared to 98.3% and 94.6% for non-stilted/non-bone grafted and 96.3% and 79.5% for bone-grafted RSAs (p=0.042). At 5-years, the baseplate-related failure rates were greater in the stilted (7.4%) and the bone-grafted (9.3%) cohorts compared with the non-stilted/non-bone grafted cohort (1.1%, p<0.001). The mean time to baseplate failure was 30 months for stilted RSA. Functional outcomes for primary RSA were statistically similar between stilted and non-stilted patients, including range of motion, Constant, ASES, SST, UCLA, and SPADI scores. CONCLUSION: The stilted-RSA cohort exhibited noninferior revision and baseplate failure rates to that of bone-grafted RSA. This suggests that stilting may be a viable technique for patients undergoing primary RSA with significant glenoid deformity.

Inpatient charges, complication, and revision rates for shoulder arthroplasty in Parkinson disease: a regional database study.

BACKGROUND: Parkinson disease (PD) is an established risk factor for higher rates of complications and revision surgery following shoulder arthroplasty, yet the economic burden of PD remains to be elucidated. The purpose of this study is to compare rates of complication and revisions as well as inpatient charges for shoulder arthroplasty procedures between PD and non-PD patients using an all-payer statewide database. METHODS: Patients undergoing primary shoulder arthroplasty from 2010 to 2020 were identified from the New York (NY) Statewide Planning and Research Cooperative System (SPARCS) database. Study groups were assigned based on concomitant diagnosis of PD at the time of index procedure. Baseline demographics, inpatient data, and medical comorbidities were collected. Primary outcomes measured were accommodation, ancillary, and total inpatient charges. Secondary outcomes included postoperative complication and reoperation rates. Logistic regression was performed to evaluate effect of PD on shoulder arthroplasty revision and complication rates. All statistical analysis was performed using R. RESULTS: A total of 39,011 patients (429 PD vs. 38,582 non-PD) underwent 43,432 primary shoulder arthroplasties (477 PD vs. 42,955 non-PD) with mean follow-up duration of 2.9 ± 2.8 years. The PD cohort was older (72.3 ± 8.0 vs. 68.6 ± 10.4 years, P < .001), with greater male composition (50.8% vs. 43.0%, P = .001), and higher mean Elixhauser scores (1.0 ± 4.6 vs. 7.2 ± 4.3, P < .001). The PD cohort had significantly greater accommodation charges ($10,967 vs. $7,661, P < .001) and total inpatient charges ($62,000 vs. $56,000, P < .001). PD patients had significantly higher rates of revision surgery (7.7% vs. 4.2%, P = .002) and complications (14.1% vs. 10.5%, P = .040), as well as significantly higher incidences of readmission at 3 and 12 months postoperatively. After controlling for age and baseline comorbidities, PD patients had 1.64 times greater odds of reoperation compared to non-PD patients (95% CI 1.10, 2.37; P = .012) and a hazard ratio of 1.54 for reoperation when evaluating revision-free survival following primary shoulder arthroplasty (95% CI 1.07, 2.20; P = .019). CONCLUSIONS: PD confers a longer length of stay, higher rates of postoperative complications and revisions, and greater inpatient charges in patients undergoing TSA. Knowledge of the associated risks and resource requirements of this population will aid surgeons in their decision making as they continue to provide care to a growing number of patients affected by PD.

Does Surgical Approach to the Hip Play a Role in Same-Day Discharge Outcomes?

BACKGROUND: Different approaches for total hip arthroplasty (THA) may offer advantages in regard to achieving same-day-discharge (SDD) success. METHODS: We retrospectively identified patients aged ≥ 18 years who underwent elective primary THA from 2015 to 2020 who were formally enrolled in a single institution's SDD program. A total of 1,127 and 207 patients underwent THA via direct anterior approach and posterior approach, respectively, were included. Cohorts were assigned based on approach. The primary outcome was failure-to-launch, defined as hospital stay extending past 1 midnight. Secondary outcomes included Forgotten Joint Score-12, Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, 90-day readmission and revision rate, and surgical time. Patient-reported outcomes were collected at 3 and 12 months. RESULTS: After controlling for demographic differences, posterior approach patients had higher rates of failure-to-launch (12.1% versus 5.9%, P = .002) and longer surgical times (99 versus 80 minutes; P < .001) compared to direct anterior approach patients. The cohorts had similar readmission (1.7% versus 1.4%; P = .64) and revision rates (1% versus 1%; P = .88). The magnitude of improvement in Hip Disability and Osteoarthritis Outcome Score for Joint Replacement scores from preoperative to 12 months was similar between cohorts (35.3 versus 34.5; P = .42). The differences in outcome scores between cohorts at each time point were not considered clinically significant. CONCLUSION: Our analysis suggests that patient selection and surgical approach may be important for achieving SDD. Surgical approach did not significantly impact readmission or revision rates nor did it have a meaningful impact on patient-reported outcomes in the first year after surgery.

Selective Use of Dual-Mobility Did Not Significantly Reduce 90-Day Readmissions or Reoperations After Total Hip Arthroplasty.

BACKGROUND: Selective use of dual mobility (DM) implants in total hip arthroplasty (THA) patients at high dislocation risk has been proposed. However, evidence-based utilization thresholds have not been defined. We explored whether surgeon-specific rates of DM utilization correlate with rates of readmission and reoperation for dislocation. METHODS: We retrospectively reviewed 14,818 primary THA procedures performed at a single institution between 2011 and 2021, including 14,310 fixed-bearing (FB) and 508 DM implant constructs. Outcomes including 90-day readmissions and reoperations were compared between patients who had FB and DM implants. Cases were then stratified into 3 groups based on the attending surgeon's rate of DM utilization (≤ 1, 1 to 10, or > 10%) and outcomes were compared. RESULTS: There were no differences in 90-day outcomes between FB and DM implant groups. Surgeon frequency of DM utilization ranged from 0% to 43%. There were 48 surgeons (73%) who used DM in ≤ 1% of cases, 11 (17%) in 1% to 10% of cases, and 7 (10%) in > 10% of cases. The 90-day rates of readmission (7.3% versus 7.6% versus 7.2%, P = .7) and reoperation (3.4% versus 3.9% versus 3.8%, P = .3), as well as readmission for instability (0.5% versus 0.6% versus 0.8%, P = .2) and reoperation for instability (0.5% versus 0.5% versus 0.8%, P = .6), did not statistically differ between cohorts. CONCLUSION: Selective DM utilization did not reduce 90-day readmissions or reoperations following primary THA. Other dislocation-mitigation strategies (ie, surgical approach, computer navigation, robotic assistance, and large diameter FBs) may have masked any benefits of selective DM use.

A Formal Same-Day Discharge Total Joint Arthroplasty Program May Not Be Necessary: A Propensity-Matched Cohort Study.

BACKGROUND: Same-day discharge (SDD) total joint arthroplasty (TJA) programs often have stringent selection criteria. Some patients deemed ineligible may nonetheless be discharged on the day of surgery. This study compares the outcomes between patients enrolled in our SDD TJA program who were SDD to those who did not participate in the program but were also SDD. METHODS: We retrospectively reviewed all patients who were SDD following TJA from 2015 to 2020. Patients were stratified into two cohorts based on whether they were formally enrolled in our institution's SDD TJA program. Propensity-score matching was performed to limit confounding and independent sample t-tests or Pearson's chi-squared tests were used to compare outcomes of interest between the matched groups. RESULTS: Of the 1778 patients included, 1384 (78%) completed the SDD TJA program and 394 (22%) were SDD but did not participate in the SDD TJA program. Upon 1:1 propensity-score matching, a total of 550 patients were matched for comparison. The surgical time was significantly longer for patients who did not participate in the SDD TJA program compared to those who participated in the program (109.39 vs 87.29 minutes; P < .001). Discharge disposition (P = .999), 90-day emergency department visits (P = .476), 90-day all-cause readmissions (P = .999), 90-day all-cause revisions (P = .563), and Hip disability and Osteoarthritis Outcome Scores for Joint Replacement (HOOS, JR) and Knee Injury and Osteoarthritis Outcome Scores for Joint Replacement at all time points did not significantly differ. CONCLUSION: Enrollment in a formal SDD TJA program may not be a necessary precursor to achieving similar outcomes following TJA for patients who are SDD without formally enrolling. Therefore, a formal program may no longer be needed at an institution with well-established evidence-based protocols with strong success and an experience with value-based care. LEVEL III EVIDENCE: Retrospective Cohort Study.

The influence of obesity on achievement of a 'forgotten joint' following total knee arthroplasty.

INTRODUCTION: Obesity has been associated with poorer outcomes following total knee arthroplasty (TKA); however, data remain sparse on its impact on patients' joint awareness following surgery. This study aims to investigate the impact of body mass index (BMI) on improvement in outcomes following TKA as assessed by the Forgotten Joint Score-12 (FJS-12). MATERIALS AND METHODS: We retrospectively reviewed 1075 patients who underwent primary TKA from 2017 to 2020 with available postoperative FJS-12 scores. Patients were stratified based on their BMI (kg/m2): < 30, 30.0-34.9 (obese class I), 35.0-39.9 (obese class II), and ≥ 40 (obese class III). FJS-12 and KOOS, JR scores were collected at various time points. Demographic differences were assessed with Chi-square and ANOVA tests. Mean scores between BMI groups were compared using univariate ANCOVA, controlling for observed demographic differences. RESULTS: Of the 1075 patients included, there were 457 with a BMI < 30, 331 who were obese class I, 162 obese class II, and 125 obese class III. There were no statistical differences in FJS-12 scores between the BMI groups at 3 months (27.24 vs. 25.33 vs. 23.57 vs. 22.48; p = 0.99), 1 year (45.07 vs. 41.86 vs. 40.51 vs. 36.22; p = 0.92) and 2 years (51.31 vs. 52.86 vs. 46.17 vs. 44.97; p = 0.94). Preoperative KOOS, JR scores significantly differed between the various BMI categories (49.33 vs. 46.63 vs. 44.24 vs. 39.33; p < 0.01); however, 3-month (p = 0.20) and 1-year (p = 0.13) scores were not statistically significant. Mean improvement in FJS-12 scores from 3 months to 2 years was statistically greatest for obese class I patients and lowest for obese class III patients (24.07 vs. 27.53 vs. 22.60 vs. 22.49; p = 0.01). KOOS, JR score improvement from baseline to 1 year was statistically greatest for obese class III patients and lowest for non-obese patients (22.34 vs. 25.49 vs. 23.77 vs. 27.58; p < 0.01). CONCLUSION: While all groups demonstrated postoperative improvement, those with higher BMI reported lower mean FJS-12 scores but these differences were not found to be significant. Our study showed no significant impact of BMI on postoperative joint awareness, which implies that obese patients, in all obesity classes, experience similar functional improvement following TKA. LEVEL III EVIDENCE: Retrospective Cohort Study.

Does the Use of Intraoperative Technology Yield Superior Patient Outcomes Following Total Knee Arthroplasty?

INTRODUCTION: There is debate regarding whether the use of computer-assisted technology, such as navigation and robotics, has any benefit on outcomes or patient-reported outcome measures (PROMs) following total knee arthroplasty (TKA). This study aims to report on the association between intraoperative use of technology and outcomes in patients who underwent primary TKA. METHODS: We retrospectively reviewed 7096 patients who underwent primary TKA from 2016-2020. Patients were stratified depending on the technology utilized: navigation, robotics, or no technology. Patient demographics, clinical data, Forgotten Joint Score-12 (FJS), and Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) were collected at various time points up to 1-year follow-up. Demographic differences were assessed with chi-square and ANOVA. Clinical data and PROMs were compared using univariate ANCOVA, controlling for demographic differences. RESULTS: A total of 287(4%) navigation, 367(5%) robotics, and 6442(91%) manual cases were included. Surgical-time significantly differed between the three groups (113.33 vs 117.44 vs 102.11; P < .001). Discharge disposition significantly differed between the three groups (P < .001), with more manual TKA patients discharged to a skilled nursing facility (12% vs 8% vs 15%; P < .001) than those who had technology utilized. FJS scores did not statistically differ at three-months (P = .067) and one-year (P = .221). We found significant statistical differences in three-month KOOS, JR scores (59.48 vs 60.10 vs 63.64; P = .001); however, one-year scores did not statistically differ between all groups (P = .320). CONCLUSION: This study demonstrates shorter operative-time in cases with no utilization of technology and clinically similar PROMs associated with TKAs performed between all modalities. While the use of technology may aid surgeons, it has not currently translated to better short-term outcomes. LEVEL III EVIDENCE: Retrospective Cohort.

Robotics Versus Navigation Versus Conventional Total Hip Arthroplasty: Does the Use of Technology Yield Superior Outcomes?

BACKGROUND: The use of technology such as navigation and robotic systems may improve the accuracy of component positioning in total hip arthroplasty (THA), but its impact on patient-reported outcome measures (PROMs) remains unclear. This study aims to elucidate the association between the use of intraoperative technology and PROMs in patients who underwent primary THA. METHODS: We retrospectively reviewed a consecutive series of patients who underwent primary THA between 2016 and 2020 and answered PROM questionnaires. Patients were separated into 3 groups depending on intraoperative technology utilization: computer-assisted navigation, robotic-assisted, or no technology (conventional) THA. Forgotten Joint Score-12 and Hip disability and Osteoarthritis Outcome Score, Joint Replacemen scores were collected at various time points. Demographic differences were assessed with chi-square and analysis of variance. Mean scores between groups were compared using univariate analysis of covariance, controlling for all significant demographic differences. RESULTS: Of the 1960 cases identified, 896 used navigation, 135 used robotics, and 929 used no technology. There were significant statistical differences in one-year Hip disability and Osteoarthritis Outcome Score, Joint Replacement scores (85.23 vs 85.95 vs 86.76, respectively; P = .014) and two-year Forgotten Joint Score-12 scores (64.72 vs 73.35 vs 74.63, respectively; P = .004) between the 3 groups. However, these differences did not exceed the mean clinically important differences. Length of stay was statistically longest for patients who underwent conventionally performed THA versus navigation and robotics (2.22 vs 1.46 vs 1.91, respectively; P < .001). Surgical time was significantly longer for cases performed using robotics versus navigation and conventionally (119.61 vs 90.35 vs 95.35, respectively; P < .001). CONCLUSION: Statistical differences observed between all modalities are not likely to be clinically meaningful with regard to early patient-reported outcomes. Although intraoperative use of technology may improve the accuracy of implant placement, these modalities have not yet translated into improved early reported functional outcomes. LEVEL III EVIDENCE: Retrospective cohort.

Vascular surgery: An essential hospital resource in modern health care.

OBJECTIVE: In modern health care, vascular surgeons frequently serve as a unique resource to other surgical specialties for vascular exposure, repair, reconstruction, or control. These services occur both in planned and unplanned clinical settings. We analyzed the frequency, outcomes, and value of vascular services in this setting to other surgical specialties and the hospital. METHODS: Intraoperative planned and unplanned vascular surgery operative consultations were reviewed over a 3-year period (2013-2016). Patient demographics, requesting surgical specialty, indication and type of vascular intervention, and work relative value units generated were recorded. Univariate and multivariate analysis of factors affecting a composite outcome of in-hospital and 30-day mortality or morbidity, or both, was performed. RESULTS: Seventy-six vascular surgery intraoperative consultations were performed, of which 56% of the consultations were unplanned. The most common unplanned consultation was for bleeding (33%). The aorta and lower extremity were the most common vascular beds requiring vascular services. The mean work relative value units generated per vascular surgery intervention was 23.8. In-hospital and 30-day mortality was 9.2%. No difference in mortality and morbidity was found between planned and unplanned consultations. Factors associated with the composite mortality/morbidity outcome were coronary artery disease (P = .002), heart failure (P = .02), total operative blood loss (P = .009), consultation for limb ischemia (P = .013), and vascular consultation for the lower extremity (P = .01). On multivariate analysis, high operative blood loss (>5000 mL) remained significant (P = .04), and coronary artery disease approached significance (P = .06). CONCLUSIONS: The need for vascular surgery services is frequent, involves diverse vascular beds, and occurs commonly in an unplanned setting. When requested, vascular surgery services effectively facilitate the completion of the nonvascular procedure, even those associated with significant intraoperative blood loss. Vascular surgery services are essential to other surgical specialties and the hospital in today's modern health care environment.

Surgical Management of Perforated Inferior Vena Cava Filters.

BACKGROUND: Management of complicated indwelling inferior vena cava (IVC) filters has increased due to low retrieval rates. Filter migration and perforation are infrequent complications and require explantation of the filter. We report our recent experience with endovascular retrieval and surgical explantation of IVC filters after caval perforation. METHODS: This is a retrospective review of patients who had IVC filter explantation between 2014 and 2015. Patient demographics, indication for filter placement, clinical presentation, surgical indication and technique, and outcomes were noted. RESULTS: Five cases of IVC filter removal due to caval perforation were identified. Four patients were female, and the median age was 50. Four IVC filters were of the retrievable type and had an average indwelling time of 4 years. One filter was permanent with an indwelling time of 9 years. The most common presentation was abdominal pain. Four patients had an open operation: 2 performed via laparotomy and 2 with retroperitoneal exposure of the IVC. One patient required median sternotomy and explantation of device fragments that migrated to the right ventricle. One patient had endovascular retrieval, with filter indwelling time of 0.8 years. No mortality occurred related to device removal. All patients had resolution of pain at their postoperative visit. CONCLUSIONS: Patients presenting with abdominal pain and history of IVC filter placement should cause concern for possible caval strut perforation. Endovascular retrieval or surgical explantation are required for removal and can be accomplished with minimal risk to the patient.

Are Orthopedic Hand Surgeons Undercompensated for Time Spent in the Operating Room? A Study of Relative Value Units.

BACKGROUND: This study aims to investigate whether compensation is equitable among the most commonly performed orthopedic hand surgeries and when compared with general orthopedic procedures. METHODS: The National Surgical Quality Improvement Program database was queried for all orthopedic procedures, from 2016 to 2018, performed more than 150 times using Current Procedural Terminology (CPT) codes. Physician work relative value unit (wRVU) data were obtained from the 2020 US Centers for Medicare and Medicaid Services fee schedule. Linear regressions were used to determine whether there was an association among wRVU, operative time, and wRVU per hour (wRVU/h). Reimbursement for hand surgery CPT codes was compared with that of nonhand orthopedic CPT codes. The CPT codes were stratified into quartile cohorts based on mean operative time, major complication rate, mortality rate, American Society of Anesthesiologists class, reoperation rate, and readmission rate. Student t tests were used to compare wRVU/h between cohorts. RESULTS: Forty-two hand CPT codes were identified from 214 orthopedic CPT codes, accounting for 32 333 hand procedures. The median wRVU/h was significantly lower for procedures in the longest operative time quartile compared with the shortest operative time quartile (P < .001). Compared with hand procedures, nonhand procedures were found to have significantly higher mean operative time (P < .001), mean complication rate (P < .001), mean wRVU (P = .001), and mean wRVU/h (P = .007). CONCLUSIONS: The 2020 Physician wRVU scale does not allocate proportional wRVUs to orthopedic hand procedures with longer mean operative times. There is a decrease in mean reimbursement rate for hand procedures with longer mean operative time. When compared with general orthopedic procedures, hand procedures have a lower mean wRVU/h and complication rate.

Effects of increased body mass index on one year outcomes following soft tissue arthroscopic shoulder instability repair.

Background: The purpose of this study was to investigate the impact of high body mass index on the 1-year minimal outcome following arthroscopic shoulder stabilization. Methods: Patients who underwent arthroscopic Bankart repair (ABR) between 2017 and 2021 were identified and assigned to 1 of 3 cohorts based on their preoperative body mass index: normal (18-25), overweight (25-30), and obese (>30). The primary outcomes assessed were postoperative shoulder instability and revision rates. The 3 groups were compared using the Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity, pain interference, pain intensity, Clinical Global Impression scores, visual analog scale pain scores, and shoulder range of motion at 1 year postoperatively. Results: During the study period, 142 patients underwent ABR and had an average age of 35 ± 10 years. Obese patients had a higher percentage of partial rotator cuff tears (60% vs. 27%, odds ratio: 3.2 [1.1, 9.2]; P = .009), longer mean operative time (99.8 ± 40.0 vs. 75.7 ± 28.5 minutes; P < .001), and shorter time to complication (0.5 ± 0 vs. 7.0 ± 0 months; P = .038). After controlling for confounding factors, obesity was associated with a lesser improvement in upper extremity function scores (obese vs. normal: -4.9 [-9.4, -0.5]; P = .029); although this difference exists, found future studies are needed to determine the clinical significance. There were no differences in patient reported outcome measures, recurrence rate, or revision surgery rates between cohorts at any time point (P > .05). Conclusion: Obesity is an independent risk factor for longer operative times but does not confer a higher risk of recurrent instability, revision surgery, or lower outcome scores 1 year following ABR.

Comparison of trends of inpatient charges among primary and revision shoulder arthroplasty over a decade: a regional database study.

Background: This study examined trends in inpatient charges for primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA), hemiarthroplasty (HA), and revision total shoulder arthroplasty (revTSA) over the past decade. Methods: The New York Statewide Planning and Research Cooperative System was queried for patients undergoing primary aTSA, rTSA, HA, and revTSA from 2010 to 2020 using International Classification of Diseases procedure codes. The primary outcome measured was total charges per encounter. Secondary outcomes included accommodation and ancillary charges, charges covered by insurance, and facility volume. Ancillary charges were defined as fees for diagnostic and therapeutic services and accommodation charges were defined as fees associated with room and board. Subgroup analysis was performed to assess differences between high- and low-volume centers. Results: During the study period, 46,044 shoulder arthroplasty cases were performed: 18,653 aTSA, 4002 HA, 19,253 rTSA, and 4136 revTSA. An exponential increase in rTSA (2428%) and considerable decrease in HA (83.9%) volumes were observed during this period. Total charges were the highest for rTSA and revTSA and the lowest for aTSA. Subgroup analysis of revTSA by indication revealed that total charges were the highest for periprosthetic fractures. For aTSA, rTSA, and HA, high-volume centers achieved significantly lower total charges compared to low-volume centers. Over the study period, total inpatient charges increased by 57.2%, 38.4%, 102.4%, and 68.4% for aTSA, rTSA, HA, and revTSA, outpacing the inflation rate of 18.7%. Conclusion: Total inpatient charges for all arthroplasty types increased dramatically from 2010 to 2020, outpacing inflation rates, but high-volume centers demonstrated greater success at mitigating charge increases compared to low-volume centers.

Is fantasy baseball score a viable outcome measure for professional baseball pitchers after undergoing Tommy John surgery?

Hypothesis and Background: Although on-field performance metrics are useful in measuring overall success of ulnar collateral ligament (UCL) reconstruction (UCLR) in professional baseball pitchers, they may not comprehensively quantify athletic performance after returning to playing in the league. To utilize fantasy baseball score (FBS) as a novel and objective outcome to assess the quality of return to play in major league baseball (MLB) pitchers who went back to professional pitching after UCLR. Methods: This is a retrospective observational cohort study of 216 established MLB pitchers who underwent UCLR while in the MLB between the years 1974 and 2018. Pitchers who either started in at least 45 games or pitched 90 relief games in the 3 years leading up to injury were included. FBS was calculated using 3 different scoring methods: ESPN (Entertainment and Sports Programming Network) (FBS-ESPN), Yahoo (FBS-Yahoo), and CBS (Columbia Broadcasting System) (FBS-CBS). Return to play, games played, innings pitched, earned runs, strikeouts, walks, hits allowed, hit batsman, and quality starts were also collected. Performance records were compiled for 3 years prior to and after the return to MLB. Players' pre-injury performance was used as a historic control group. Multivariate linear regression analysis was used to detect trends between seasons, controlling for year of surgery, and number of games. Results: The mean age of the cohort at the time of surgery was 30.0 ± 3.5 years. One hundred seventy-nine of 216 players (83%) returned to MLB play, taking an average of 16.6 ± 5.8 months. One hundred thirty-six of 179 (76%) remained in the league for 3 seasons. After adjusting for year of surgery, pitchers earned significantly fewer points for FBS-CBS (616.45 ± 332.42 vs. 389.12 ± 341.06; P < .001), FBS-Yahoo (801.90 ± 416.88 vs. 492.57 ± 428.40; P < .001), and FBS-ESPN (552.76 ± 275.77 vs. 344.19 ± 300.45; P < .001) after their injury. Also pitchers played in fewer games, pitched fewer innings, and had a decline in all measured on-field performance statistics. Conclusion: FBS may represent a useful outcome measure to objectively assess the quality of return to play in a professional baseball pitcher who returned to play in MLB after UCLR.

A comparison of utilization and short-term complications of technology-assisted versus conventional total knee arthroplasty.

BACKGROUND: While technology-assisted total knee arthroplasty (TA-TKA) improves implant positioning, whether it confers improved clinical outcomes remains inconclusive. We sought to examine national TA-TKA utilization trends and to compare outcomes between TA-TKA and unassisted TKA (U-TKA). METHODS: Patients who underwent primary, elective TKA from 2010 to 2018 were identified using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Demographic, perioperative, and 30-day outcomes were collected. Patients were stratified on the basis of whether they underwent TA-TKA, which included computer navigation and robotics, or U-TKA. The proportion of patients undergoing TKA using TA-TKA was calculated. One-to-one propensity-score matching paired patients undergoing TA-TKA or U-TKA. Independent samples t-tests and Mann-Whitney U tests were used to compare continuous variables, and chi-squared tests were used to compare categorical variables. RESULTS: Of the 402,284 TKA patients, 10,429 (2.6%) cases were performed using TA-TKA. Comparing the unmatched TA-TKA and U-TKA groups, race (p < 0.001), smoking status (p = 0.050), baseline functional status (p < 0.001), and body mass index (BMI) (p < 0.001) significantly differed. Propensity-score matching yielded 8633 TA-TKA and U-TKA pairs. The TA-TKA cohort had shorter hospital length of stay (LOS) (2.7 ± 2.5 versus 2.8 ± 1.9 days, p = 0.017) but similar operative times (92.4 ± 33.4 versus 92.6 ± 39.8 min, p = 0.670). Compared with the U-TKA group, the TA-TKA group had lower major complication (7.6% versus 9.4%, p < 0.001) and transfusion (3.9% versus 5.1%, p < 0.001) rates and higher rates of discharge to home (73.9% versus 70.4%, p < 0.001). Reoperation and readmission rates did not significantly differ between groups. CONCLUSIONS: TA-TKA utilization remains low among orthopedic surgeons. Compared with U-TKA, TA-TKA yielded improved perioperative and 30-day outcomes. Nonetheless, surgeons must consider the benefits and drawbacks of TA-TKA when determining the proper surgical technique and technology for each patient. LEVEL III EVIDENCE: Retrospective cohort study.