Is Hospital-Based Outpatient Revision Total Knee Arthroplasty Safe? An Analysis of 2,171 Outpatient Aseptic Revision Procedures.

BACKGROUND: Outpatient primary total knee arthroplasty (TKA) has been well-established as a safe and effective procedure; however, the safety of outpatient revision TKA remains unclear. Therefore, this study utilized a large database to compare outcomes between outpatient and inpatient revision TKA. METHODS: An all-payor database was queried to identify patients undergoing revision TKA from 2010 to 2022. Patients who had diagnosis codes related to periprosthetic joint infection (PJI) were excluded. Outpatient surgery was defined as a length of stay < 24 hours. Cohorts were matched by age, sex, Elixhauser Comorbidity Index, comorbidities (diabetes, obesity, tobacco use), components revised (1-versus 2-component), and revision etiology. Medical complications at 90 days and surgical complications at 1 and 2 years postoperatively were evaluated through multivariate logistic regression. A total of 4,342 aseptic revision TKAs were included. RESULTS: No differences in patient characteristics, procedure type, or revision etiologies were seen between groups. The outpatient cohort had a lower risk of PJI (odds ratio (OR): 0.547, 95% confidence interval (CI): 0.337 to 0.869; P = .012), wound dehiscence (OR: 0.393, 95% CI: 0.225 to 0.658; P < .001), transfusion (OR: 0.241, 95% CI: 0.055 to 0.750; P = .027), reoperation (OR: 0.508, 95% CI: 0.305 to 0.822; P = .007), and any complication (OR: 0.696, 95% CI: 0.584 to 0.829; P < .001) at 90 days postoperatively. At 1 year and 2 years postoperatively, outpatient revision TKA patients had a lower incidence of revision for PJI (OR: 0.332, 95% CI: 0.131 to 0.743; P = .011 and OR: 0.446, 95% CI; 0.217 to 0.859; P = .020, respectively) and all-cause revision (OR: 0.518, 95% CI: 0.377 to 0.706; P < .001 and OR: 0.548, 95% CI: 0.422 to 0.712; P < .001, respectively). CONCLUSIONS: Our findings suggest that revision TKA can be safely performed on an outpatient basis in appropriately selected patients who do not have an increased risk of adverse events relative to inpatient revision TKA. However, we could not ascertain case complexity in either cohort, and despite controlling for several potential confounders, other less tangible differences could exist between groups.

Early Prosthetic Hip Dislocation: Does the Timing of the Dislocation Matter?

BACKGROUND: Early dislocation following total hip arthroplasty (THA) is a common reason for revision. The purpose of this study was to determine if the acuity of the dislocation episode affects the risk of revision surgery. METHODS: A retrospective review of a national, all-payer administrative database comprised of claims from 2010 to 2020 was used to identify patients who had a prosthetic hip dislocation at various postoperative time intervals (0 to 7, 7 to 30, 30 to 60, and 60 to 90 days). Of the 45,352 primary unilateral THA patients who had sufficient follow-up, there were 2,878 dislocations within 90 days. Dislocators were matched 1:1 based on age, sex, and a comorbidity index with a control group (no dislocation). Demographics, surgical indications, comorbidities, ten-year revision rates, and complications were compared among cohorts. Multivariable logistic regression analysis was performed to identify risk factors for revision THA following early dislocation. RESULTS: Among matched cohorts, dislocation at any time interval was associated with significantly increased odds of subsequent 10-years revision (OR [odds ratio] = 25.60 to 33.4, P < .001). Acute dislocators within 7 days did not have an increased risk of all cause revisions at 10 years relative to other early dislocators. Revision for indication of instability decreased with time to first dislocation (<7 days: 85.7% versus 60 to 90 days: 53.9%). Primary diagnoses of posttraumatic arthritis (OR = 2.53 [1.84 to 3.49], P < .001), hip fracture (OR = 3.8 [2.53 to 5.72], P < .001), and osteonecrosis (OR = 1.75 [1.12 to 2.73], P = .010) were most commonly associated with revision surgery after an early dislocation. CONCLUSIONS: Dislocation within 90 days of THA is associated with increased odds of subsequent revision. Early dislocation within 7 days of surgery has similar all cause revision-free survivorship, but an increased risk of a subsequent revision for instability when compared to patients who dislocated within 7 to 90 days.

Body Mass Index Does Not Drive the Risk for Early Postoperative Instability After Total Hip Arthroplasty: A Matched Cohort Analysis.

BACKGROUND: Instability remains the leading cause of revision following total hip arthroplasty (THA). The objective of the present investigation was to determine whether an elevated body mass index (BMI) is associated with an increased risk of instability after primary THA. METHODS: An administrative claims database was queried for patients undergoing elective, primary THA for osteoarthritis between 2010 and 2022. Patients who underwent THA for a femoral neck fracture were excluded. Patients who had an elevated BMI were grouped into the following cohorts: 25 to 29.9 (n = 2,313), 30 to 34.9 (n = 2,230), 35 to 39.9 (n = 1,852), 40 to 44.9 (n = 1,450), 45 to 49.9 (n = 752), and 50 to 59.9 (n = 334). Patients were matched 1:1 based on age, sex, and Elixhauser Comorbidity Index, as well as a history of spinal fusion, neurodegenerative disorders, and alcohol abuse, to controls with a normal BMI (20 to 24.9). A multivariate logistic regression controlling for age, sex, Elixhauser Comorbidity Index, and additional risk factors for dislocation was used to evaluate dislocation rates at 30 days, 90 days, 6 months, 1 year, and 2 years. Rates of revision for instability were similarly compared at 1 year and 2 years postoperatively. RESULTS: No significant differences in dislocation rate were observed between control patients and each of the evaluated BMI classes at all evaluated postoperative intervals (all P values > .05). Similarly, the risk of revision for instability was comparable between the normal weight cohort and each evaluated BMI class at 1 year and 2 years postoperatively (all P values > .05). CONCLUSIONS: Controlling for comorbidities and known risk factors for instability, the present analysis demonstrated no difference in rates of dislocation or revision for instability between normal-weight patients and those in higher BMI classes.

Three Differing Methods of Treating Intraoperative Nondisplaced Calcar Fractures Demonstrate Similar Radiographic Stem Subsidence.

BACKGROUND: Several management strategies have been described to treat intraoperative calcar fractures during total hip arthroplasty (THA), including retaining the primary implant and utilizing cerclage cables (CCs) or switching the implant to one that bypasses the fracture and achieves diaphyseal fixation. However, the radiographic and clinical outcomes of these differing strategies have never been described and compared. METHODS: We retrospectively identified 50 patients who sustained an intraoperative calcar fracture out of 9,129 primary total hip arthroplasties (0.55%) performed by one of three surgeons between 2008 and 2022. Each of the three surgeons consistently employed a distinct strategy for the management of these fractures: retention of the primary metaphyseal-engaging implant and placement of CCs; exchange to a modular, tapered-fluted stem (MTF); or exchange to a fully-coated, diaphyseal-engaging stem (FC). Stem subsidence was then evaluated on standing anteroposterior pelvis radiographs at three months and one year postoperatively. Postoperative medical and surgical complication rates were evaluated. RESULTS: A total of fifteen patients were treated with CC, 15 with MTF, and 20 with FC. At three-month follow-up, mean stem subsidence was 0.43 ± 0.08 mm, 1.47 ± 0.36 mm, and 0.68 ± 0.39 mm for CC, MTF, and FC cohorts, respectively (P = .323). At one-year, mean stem subsidence was 0.70 ± 0.08 mm, 1.74 ± 0.69 mm, and 1.88 ± 0.90 mm for the CC, MTF, and FC cohorts, respectively (P = .485). Medical complications included 2 venous thromboembolic events (4%) within 90 days of surgery. There were 6 reoperations (12%); 3 (6%) for acute periprosthetic joint infection (all within the FC cohort); 2 (4%) for postoperative periprosthetic fractures (one fracture distal to the stem in the FC cohort and one fracture at the level of the stem in the MTF cohort), and 1 (2%) closed reduction for instability (within the CC cohort). CONCLUSIONS: The three described methods of managing intraoperative nondisplaced calcar fractures demonstrated little radiographic stem subsidence; however, the risk of reoperation was much higher than expected.

Two Intramedullary and 1 Extramedullary Cortical Button, With or Without Interference Screw, Show Biomechanical Properties Superior to Native Tendon in Repair of the Distal Biceps Tendon: A Systematic Review and Network Meta-analysis of Biomechanical Performance.

PURPOSE: The aim of this study was to use a systematic review and network meta-analysis (NMA) to compare the failure strength, maximum strength, stiffness, and displacement of available constructs for distal biceps repair. METHODS: An NMA was conducted to determine the performance of 2 all-suture suture anchors (2x ASA), 2 intramedullary cortical buttons (2x IM CB), 2 suture anchors (2x SA), extramedullary cortical buttons (EM CB), extramedullary cortical button plus interference screw (EM CB+IFS), interference screw (IFS), single intramedullary cortical button (IM CB), single suture anchor (SA), transosseous suture (TOS), tension slide technique (TST), and tension slide technique plus suture tape (TST+ST). Analysis consisted of arm-based network meta-analysis under Bayesian random-effects model with Markov Chain Monte Carlo (MCMC) sampling. Biomechanical outcomes were summarized as treatment effects and their corresponding 95% confidence intervals (CI). Rank probabilities were calculated and used to generate each treatment's surface under the cumulative ranking (SUCRA) curve. Biomechanical properties were compared to native tendon. Displacement >10 mm was defined as clinical failure. RESULTS: Twenty-one studies were included. For failure strength, no construct outperformed the native tendon but 2× SA, IFS, SA, and TOS demonstrated poorer failure strength. For the maximum load to failure, EM CB+IFS outperformed the native tendon. Compared to native tendon, EM CB+IFS, EM CB, and 2×IM CB were stiffer, while 2x SA and IFS were less stiff. No construct demonstrated >10 mm of displacement, but constructs with displacement above the mean (3.5 mm) included 2× ASA, 2xIM CB, and TOS. CONCLUSIONS: The fixation constructs that consistently demonstrated comparable or better biomechanical properties (failure strength, maximum strength, and stiffness) to native tendon in distal biceps tendon repair were the extramedullary cortical button with or without interference screw and two intramedullary cortical buttons. No construct demonstrated displacement beyond standard definitions for clinical failure. CLINICAL RELEVANCE: This network meta-analysis of biomechanical studies suggests that extramedullary cortical button and two intramedullary cortical buttons may be the most stable construct for distal biceps repair fixation, with equivalent or better biomechanical properties compared to native tendon.

Elective Joint Arthroplasty Should be Delayed by One Month After COVID-19 Infection to Prevent Postoperative Complications.

BACKGROUND: It remains unclear whether a history of recent COVID-19 infection affects the outcomes and risks of complications of total joint arthroplasty (TJA). The purpose of this study was to compare the outcomes of TJA in patients who have and have not had a recent COVID-19 infection. METHODS: A large national database was queried for patients undergoing total hip and total knee arthroplasty. Patients who had a diagnosis of COVID-19 within 90-days preoperatively were matched to patients who did not have a history of COVID-19 based on age, sex, Charlson Comorbidity Index, and procedure. A total of 31,453 patients undergoing TJA were identified, of which 616 (2.0%) had a preoperative diagnosis of COVID-19. Of these, 281 COVID-19 positive patients were matched with 281 patients who did not have COVID-19. The 90-day complications were compared between patients who did and did not have a diagnosis of COVID-19 at 1, 2, and 3 months preoperatively. Multivariate analyses were used to further control for potential confounders. RESULTS: Multivariate analysis of the matched cohorts showed that COVID-19 infection within 1 month prior to TJA was associated with an increased rate of postoperative deep vein thrombosis (odds ratio [OR]: 6.50, 95% confidence interval: 1.48-28.45, P = .010) and venous thromboembolic events (odds ratio: 8.32, confidence interval: 2.12-34.84, P = .002). COVID-19 infection within 2 and 3 months prior to TJA did not significantly affect outcomes. CONCLUSION: COVID-19 infection within 1 month prior to TJA significantly increases the risk of postoperative thromboembolic events; however, complication rates returned to baseline after that time point. Surgeons should consider delaying elective total hip arthroplasty and total knee arthroplasty until 1 month after a COVID-19 infection.

Cementless Total Knee Arthroplasty is Associated With Early Aseptic Loosening in a Large National Database.

BACKGROUND: Despite excellent longevity demonstrated in institutional studies, outcomes after cementless total knee arthroplasty (TKA) on a population level remain unknown. This study compares 2-year outcomes between cemented and cementless TKA using a large national database. METHODS: A large national database was used to identify 294,485 patients undergoing primary TKA from January 2015 to December 2018. Patients who had osteoporosis or inflammatory arthritis were excluded. Cementless and cemented TKA patients were matched one-to-one based on age, Elixhauser Comorbidity Index, sex, and year yielding matched cohorts of 10,580 patients. Outcomes at 90 days, 1 year, and 2 years postoperatively were compared between groups, and Kaplan-Meier analysis was used to evaluate implant survival rates. RESULTS: At 1 year postoperatively, cementless TKA was associated with an increased rate of any reoperation (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.12-1.92, P = .005) compared to cemented TKA. At 2 years postoperatively, there was an increased risk of revision for aseptic loosening (OR 2.34, CI 1.47-3.85, P < .001) and any reoperation (OR 1.29, CI 1.04-1.59, P = .019) after cementless TKA. Two-year revision rates for infection, fracture, and patella resurfacing were similar between cohorts. CONCLUSION: In this large national database, cementless fixation is an independent risk factor for aseptic loosening requiring revision and any reoperation within 2 years after primary TKA.

Invasive Gastrointestinal Endoscopy Following Total Joint Arthroplasty Increases the Risk for Periprosthetic Joint Infection.

BACKGROUND: The safety of postoperative colonoscopy and endoscopy following total joint arthroplasty (TJA) remains largely unknown. The objective of this study was to characterize the effect of gastrointestinal endoscopic procedures after TJA on the risk of postoperative periprosthetic joint infection (PJI). METHODS: Using a large national database, patients who underwent an endoscopic procedure (colonoscopy or esophagogastroduodenoscopy (EGD)) within 12 months after primary TJA were identified and matched in a 1:1 fashion based on procedure (primary total knee arthroplasty (TKA) versus total hip arthroplasty (THA)), age, sex, Charlson Comorbidity Index (CCI), and smoking status with patients who did not undergo endoscopy. A total of 142,055 patients who underwent endoscopy within 12 months following TJA (96,804 TKAs and 45,251 THAs) were identified and matched. The impact of timing of endoscopy relative to TJA on postoperative outcomes was assessed. Preoperative comorbidity profiles and 1-year complications were compared. Statistical analyses included Chi-squared tests and multivariate logistic regressions with outcomes considered significant at P < .05. RESULTS: Multivariate analyses revealed that endoscopy within 2 months following TKA and 1 month of THA was associated with a significantly increased odds of periprosthetic joint infection (odds ratio (OR): 1.29 [1.08-1.53]; P = .004; OR: 1.41 [1.01-1.90]; P = .033, respectively). Patients who underwent endoscopy greater than 2 months from the timing of their TKA and 1 month from THA were not at significantly greater risk of developing PJI. CONCLUSION: These data suggest that invasive endoscopic procedures should be delayed if possible by at least 2 months following TKA and 1 month following THA to minimize the risk of PJI.

Duration of Care and Operative Time Are the Primary Drivers of Total Charges After Ambulatory Hip Arthroscopy: A Machine Learning Analysis.

PURPOSE: To develop a machine learning algorithm to predict total charges after ambulatory hip arthroscopy and create a risk-adjusted payment model based on patient comorbidities. METHODS: A retrospective review of the New York State Ambulatory Surgery and Services database was performed to identify patients who underwent elective hip arthroscopy between 2015 and 2016. Features included in initial models consisted of patient characteristics, medical comorbidities, and procedure-specific variables. Models were generated to predict total charges using 5 algorithms. Model performance was assessed by the root-mean-square error, root-mean-square logarithmic error, and coefficient of determination. Global variable importance and partial dependence curves were constructed to show the impact of each input feature on total charges. For performance benchmarking, the best candidate model was compared with a multivariate linear regression using the same input features. RESULTS: A total of 5,121 patients were included. The median cost after hip arthroscopy was $19,720 (interquartile range, $12,399-$26,439). The gradient-boosted ensemble model showed the best performance (root-mean-square error, $3,800 [95% confidence interval, $3,700-$3,900]; logarithmic root-mean-square error, 0.249 [95% confidence interval, 0.24-0.26]; R2 = 0.73). Major cost drivers included total hours in facility less than 12 or more than 15, longer procedure time, performance of a labral repair, age younger than 30 years, Elixhauser Comorbidity Index (ECI) of 1 or greater, African American race, residence in extreme urban and rural areas, and higher household and neighborhood income. CONCLUSIONS: The gradient-boosted ensemble model effectively predicted total charges after hip arthroscopy. Few modifiable variables were identified other than anesthesia type; nonmodifiable drivers of total charges included duration of care less than 12 hours or more than 15 hours, operating room time more than 100 minutes, age younger than 30 years, performance of a labral repair, and ECI greater than 0. Stratification of patients based on the ECI highlighted the increased financial risk borne by physicians via flat reimbursement schedules given variable degrees of comorbidities. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Two-Year Clinical Outcomes and Survivorship After Isolated Biceps Tenodesis.

PURPOSE: The purpose of this study was to evaluate clinical outcomes and survivorship of isolated biceps tenodesis (BT) at a minimum of 2 years and to identify patient-specific factors associated with these outcomes in patients undergoing BT without concomitant rotator cuff repair (RCR). We hypothesized that patient-reported outcomes would be significantly improved on American Shoulder and Elbow Surgeons Survey (ASES) and Single Assessment Numeric Evaluation (SANE), with a high rate of survivorship (>90%) at 2-year follow-up. METHODS: A retrospective review of an institutional registry was performed to identify patients who underwent BT from July 2016 to December 2017. Patients >18 years old who underwent an open or arthroscopic BT procedure using an interference screw, button, or anchor for underlying bicipital pathology, without a concomitant RCR or shoulder arthroplasty, and were a minimum of 2 years postoperative were included. Patients were administered ASES and SANE questionnaires preoperatively and at final follow-up. Survivorship was evaluated using Kaplan-Meier analysis. Failure was defined as any patient who underwent reoperation related to the index surgery. RESULTS: A total of 110 patients (mean ± standard deviation age, 48.60 ± 12.14 years) who underwent isolated BT with a follow-up of 24.90 ± 3.95 months were included in analysis. There was a significant improvement in ASES and SANE at final follow-up (P < .001), with 81% to 84% of patients achieving minimal clinically important difference (MCID), 72% to 82% achieving substantial clinical benefit (SCB), and 72% to 80% achieving patient-acceptable symptom state (PASS). Worker's Compensation (WC) patients had a decreased likelihood of achieving PASS on ASES (P = .015) and SANE (P = .012). Four cases were deemed failures (3 revision BTs and 1 capsular debridement) at 15.09 ± 9.57 months. WC did not have a significant effect on likelihood of BT failure. CONCLUSION: Biceps tenodesis provided significant clinical improvement and high rates of survivorship 2 years postoperatively. WC was associated with a decreased likelihood of achieving PASS. These results support the continued use of isolated BT for treating biceps pathology. LEVEL OF EVIDENCE: IV, case series.

Corticosteroid injections 2 months before arthroscopic meniscectomy increases the rate of postoperative infections requiring surgical irrigation and debridement.

PURPOSE: Consensus guidelines recommend administering a corticosteroid injection (CSI) for patients with a symptomatic degenerative meniscus lesion prior to arthroscopic partial meniscectomy (APM). A recent study found that CSI administered within 1 month prior to meniscectomy is associated with an increased risk of postoperative infection. However, infections may range in severity from superficial infections to serious infections requiring surgical interventions. The aim of this analysis was to define the rate of infections requiring surgery after APM and determine its relationship to preoperative CSI. METHODS: The PearlDiver Mariner administrative claims database was queried for patients > 35 years old who had a CSI in the year prior to isolated APM. Rates of deep infection and infection requiring surgery within 6 months were reported between matched patients with a CSI and no injection. RESULTS: After matching, there were 16,009 patients per group with a mean age of 59.4 years (SD = 9.6), 53.5% obesity, and 40% male. Forty-four of 113 patients who developed a postoperative deep infection went on to have a reoperation for irrigation and/or debridement (0.1% of all APM). Of these 44 patients, 30 had a preoperative CSI and 14 were controls unadjusted odds ratio (unadj-OR) if given CSI = 1.95, 95% CI 1.03-3.68, P = 0.04). Having a CSI within the month before surgery conferred a 4.56-fold increase in odds of an infection warranting surgery (95% CI 1.96-10.21, P < 0.01), whilst having a CSI 4-8 weeks before surgery conferred a 2.42-fold increase in odds (95% CI 1.04-5.42, P = 0.03). Receiving multiple CSI in the year prior to APM was associated with 5.27-fold increased odds of an infection requiring surgery (95% CI 1.19-23.27, P = 0.03), compared to having a single CSI. CONCLUSIONS: Serious infections requiring a surgical intervention are rare after a meniscectomy, occurring in 0.1% of APMs in a matched cohort of patients over 35. Patients were five times more likely to return to the operating room for infection after APM if they had a CSI in the month before or had multiple CSIs in the year before surgery. The risk of infection was no longer significant if there was at least a 2-month interval between preoperative CSI and APM. LEVEL OF EVIDENCE: Level III.

Incidence and risk factors for symptomatic venous thromboembolism following anterior cruciate ligament reconstruction.

PURPOSE: To determine the incidence of symptomatic venous thromboembolism (VTE) following anterior cruciate ligament (ACL) reconstruction using a large national database and to identify corresponding independent risk factors. METHODS: The Humana administrative claims database was reviewed for patients undergoing ACL reconstruction from 2007 to 2017. Patient demographics, medical comorbidities, as well as concurrent procedures were recorded. Postoperative incidence of VTE was measured by identifying symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) at 30 days, 90 days, and 1 year postoperatively. Univariate analysis and binary logistic regression were performed to determine independent risk factors for VTE following surgery. RESULTS: A total of 11,977 patients were included in the study. The incidence of VTE was 1.01% (n = 120) and 1.22% (n = 146) at 30 and 90 days, respectively. Analysis of VTE events within the first postoperative year revealed that 69.6% and 84.3% of VTEs occurred within 30 and 90 days of surgery, respectively. Logistic regression identified age ≥ 45 (odds ratio [OR] = 1.88; 95% confidence interval [CI] 1.32-2.68; p < 0.001), inpatient surgery (OR = 2.07; 95% CI 1.01-4.24; p = 0.045), COPD (OR = 1.51; 95% CI 1.02-2.24; p = 0.041), and tobacco use (OR = 1.75; 95% CI 1.17-2.62; p = 0.007), as well as concurrent PCL reconstruction (OR = 3.85; 95% CI 1.71-8.67; p = 0.001), meniscal transplant (OR = 17.68; 95% CI 3.63-85.97; p < 0.001) or osteochondral allograft (OR = 15.73; 95% CI 1.79-138.43; p = 0.013) as independent risk factors for VTE after ACL reconstruction. CONCLUSIONS: The incidence of symptomatic postoperative VTE is low following ACL reconstruction, with the majority of cases occurring within 90 days of surgery. Risk factors include age ≥ 45, inpatient surgery, COPD, tobacco use and concurrent PCL reconstruction, meniscal transplant or osteochondral allograft. LEVEL OF EVIDENCE: III.

PROMIS Upper Extremity underperforms psychometrically relative to American Shoulder and Elbow Surgeons score in patients undergoing primary rotator cuff repair.

BACKGROUND: A number of patient-reported outcome measure (PROM) instruments are used to assess shoulder pain, function, and postoperative satisfaction. Computer adaptive tests (CATs) have been developed in an effort to tailor question delivery, decrease time to completion and floor/ceiling effects, and increase compliance. Previous investigations have demonstrated excellent correlation between Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity CAT (UE-CAT) and American Shoulder and Elbow Surgeons (ASES) instruments, indicating that the PROMIS UE-CAT may be an acceptable alternative to the ASES. Prior to widespread adoption, however, rigorous psychometric validation must be performed. Thus, the purpose of this study was to evaluate the psychometric properties of PROMIS UE-CAT relative to the ASES score in patients undergoing primary rotator cuff repair (RCR). METHODS: A retrospective study of an institutional RCR registry was performed from July 2018 through March 2019. Preoperative PROMIS UE-CAT and ASES scores were collected. Floor and ceiling effects were determined, and convergent validity was established through Pearson correlations. Rasch partial credit modeling was used for psychometric analysis of the validity of PROMIS UE-CAT and ASES question items, a previously established methodology for assessing shoulder PROMs. Person-item maps were generated to characterize the distribution of question responses along the latent dimension of shoulder disability. RESULTS: Responses from 107 patients (107 shoulders) were included. PROMIS UE-CAT had a strong correlation to ASES (r = 0.684; P < .001), with a 3.7% floor effect and no ceiling effect; ASES had no floor or ceiling effects. PROMIS UE-CAT person-item maps revealed excellent test item coverage between floor and ceiling effects; however, all PROMIS UE-CAT items except "Difficulty putting on a jacket" demonstrated nonsequentially ordered responses, indicating poor reliability of item responses corresponding to shoulder function. Although PROMIS UE-CAT initially demonstrated superior instrument efficiency with fewer test items for overall equivalent coverage of shoulder function assessment, final models after recursive item elimination revealed the ASES instrument to have more well-fitting items over a broader range of shoulder function. CONCLUSION: Despite its overall strong correlation with ASES and equivalent coverage between floor and ceiling effects, the psychometric properties of PROMIS UE-CAT indicate a need for optimization of individual test items to correspond to shoulder function. Until further refinements in the PROMIS UE-CAT instrument are made, it should not replace the ASES instrument in patients undergoing primary RCR.

COVID-19 Infection After Total Joint Arthroplasty Is Associated With Increased Complications.

BACKGROUND: The impact of a postoperative diagnosis of COVID-19 in patients undergoing total joint arthroplasty (TJA) remains unknown. The objective of this study is to characterize the effect of COVID-19 infection following TJA on perioperative complication rates. METHODS: The Mariner database was queried for patients undergoing total hip and total knee arthroplasty from January 2018 to April 2020. TJA patients who were diagnosed with COVID-19 within 90 days postoperatively were matched in a 1:3 fashion based on age, gender, iron deficiency anemia, payer status, and Charlson Comorbidity Index with patients who were not diagnosed with COVID-19. Preoperative comorbidity profiles and complications within 3 months of surgery were compared. Statistical analysis included chi-squared tests and multivariate logistic regression with outcomes considered significant at P < .05. RESULTS: Of the 239 COVID-19 positive patients, 132 (55.2%) underwent total hip arthroplasty. On multivariate analysis, COVID-19 diagnosis was associated with increased odds of deep vein thrombosis (odds ratio [OR] 4.86, 95% confidence interval [CI] 2.10-11.81, P < .001), pulmonary embolism (OR 6.27, 95% CI 2.57-16.71, P < .001), and all complications (OR 3.36, 95% CI 2.47-4.59, P < .001). Incidence of deep vein thrombosis/pulmonary embolism was greater the closer in time the COVID-19 diagnosis was to the surgical procedure (10.24 times at 1 month, 7.87 times at 2 months, and 1.42 times at 3 months; P < .001). A similar relationship was observed with all complications. CONCLUSION: Postoperative COVID-19 infection is associated with higher rates of cardiopulmonary complications, thromboembolic disease, renal injury, and urinary tract infections in patients undergoing hip and knee arthroplasty. COVID-19 infection earlier in the postoperative period is associated with a higher risk of complications.

Corticosteroid Injections 1 Month Before Arthroscopic Meniscectomy Increase the Risk of Surgical-Site Infection.

PURPOSE: To define the incidence of postoperative infections in patients who receive corticosteroid injections prior to arthroscopic meniscectomy, to determine whether there is a temporal relation between injections and the risk of surgical-site infections, and to identify corresponding risk factors. METHODS: The Humana administrative claims database was reviewed for patients undergoing arthroscopic meniscectomy within 1 year of injection and those undergoing arthroscopic meniscectomy without prior injection. Patients with preoperative injections were further stratified by the duration in months between the injection and the surgical procedure. Surgical-site infection within 6 months of surgery was recorded. Univariate analysis and binary logistic regression were performed to determine independent risk factors for surgical-site infection. Statistical significance was defined as P < .05. RESULTS: We identified patients with (n = 11,652) and without (n = 37,261) a history of a knee corticosteroid injection within 1 year of arthroscopic meniscectomy with at least 6 months of database activity from 2007 to 2017. In patients who received knee injections within 1 month prior to surgery, the rate of development of postoperative infections was twice that in patients who did not receive an injection (1.28% vs 0.63%; odds ratio [OR], 1.84; 95% confidence interval [CI], 1.24-2.62; P = .001). Multivariate logistic regression identified male sex (OR, 1.39; 95% CI, 1.14-1.71; P = .001), diabetes (OR, 1.48; 95% CI, 1.19-1.85; P < .001), chronic obstructive pulmonary disease (OR, 1.57; 95% CI, 1.27-1.94; P < .001), obesity (OR, 1.32; 95% CI, 1.07-1.63; P = .010), tobacco use (OR, 1.61; 95% CI, 1.30-1.98; P < .001), and preoperative injections within 1 month of surgery (OR, 1.78; 95% CI, 1.21-2.54; P = .002) as significant predictors, whereas injections administered more than 1 month before surgery were not significantly associated with postoperative surgical-site infection after arthroscopic meniscectomy. CONCLUSIONS: Injections 1 month before arthroscopic meniscectomy significantly increase the risk of surgical-site infection. However, injections can be safely administered more than 1 month prior to surgery because there is no increased risk of postoperative infection at this time point. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Establishing Clinically Significant Outcomes for Patient-Reported Outcomes Measurement Information System After Biceps Tenodesis.

PURPOSE: To establish thresholds for improvement in patient-reported outcome scores that correspond with clinically significant outcomes (CSOs) including the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) for Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) computer adaptive testing (CAT) and pain interference (PIF) CAT after biceps tenodesis (BT) and to assess patient variables that are associated with achieving these outcomes. METHODS: After institutional review board approval was obtained, a prospectively maintained institutional database was queried for patients undergoing BT between December 2017 and August 2019. Patients undergoing BT in isolation or BT in conjunction with rotator cuff debridement, SLAP repair, subacromial decompression, or distal clavicle excision were included in the analysis. Anchor- and distribution-based methods were used to calculate the MCID whereas an anchor-based method was used to calculate SCB and the PASS for PROMIS UE CAT and PIF CAT. RESULTS: A total of 112 patients (86.8% follow-up) who underwent BT were included for analysis. The MCID, net SCB, absolute SCB, and PASS for PROMIS UE CAT were 4.02, 9.25, 43.4, and 41.1, respectively. The MCID, net SCB, absolute SCB, and PASS for PROMIS PIF CAT were -4.12, -10.7, 52.4, and 52.4, respectively. Higher preoperative UE CAT and PIF CAT scores, preoperative opioid use, depression, and living alone were negative predictors of CSO achievement. Male sex and regular participation in exercise were positive predictors of CSO achievement. CONCLUSIONS: Patients with higher preoperative UE scores were less likely to achieve the MCID (odds ratio [OR], 0.84), whereas patients with higher preoperative PIF scores were less likely to achieve absolute SCB and the PASS (OR, 0.83-0.89). Most patients achieved the MCID for PIF CAT (70.5%) and UE CAT (62.5%) at final follow-up. Male sex (OR, 4.38-9.15) and regular exercise participation (OR, 6.45-18.94) positively predicted CSO achievement, whereas preoperative opioid use (OR, 0.06), depression (OR, 0.23), and living alone (OR, 0.90) were negative predictors of CSO achievement. LEVEL OF EVIDENCE: Level IV, case series.

Preoperative Corticosteroid Injections Demonstrate a Temporal and Dose-Dependent Relationship with the Rate of Postoperative Infection Following Total Hip Arthroplasty.

BACKGROUND: Corticosteroid injections (CSI) are commonly used for the treatment of osteoarthritis of the hip. There is concern, however, that these injections may increase the risk of postoperative infection if a subsequent total hip arthroplasty (THA) is performed. The purpose of the present investigation is to determine the relationship between CSI and the risk of periprosthetic joint infection (PJI) and surgical site infections (SSIs) following THA. METHODS: The PearlDiver database was reviewed for patients undergoing THA from 2011 to 2018. Patients with unilateral hip osteoarthritis who received an intra-articular hip CSI prior to ipsilateral THA were matched in a sequential 1:1 fashion based on age, gender, and Charlson Comorbidity Index with THA patients who did not receive an injection in the preoperative period. PJI and SSI within 6 months of the surgical procedure were recorded. Statistical analysis included chi-squared test and multivariate logistic regression. Results were considered significant at P < .05. RESULTS: In total, 29,058 patients underwent a hip CSI within 6 months prior to THA. CSI within 4 months of surgery was associated with a higher incidence of PJI at 6-month follow up (1.6% vs 1.1%, P = .040). An injection within 1 month of surgery corresponded to a higher odds of PJI (odds ratio [OR] 1.97) than an injection 4 months prior to surgery (OR 1.24). Furthermore, the quantity of CSI administered within the 3 months prior to THA demonstrated a dose-dependent relationship, with each subsequent injection increasing odds of PJI (OR 1.45-3.59). A similar relationship was observed for SSI. CONCLUSION: There appears to be both a time and dose-dependent association of hip CSI and PJI following THA. Surgeons should consider delaying elective THA if a CSI has been administered within the 4 months prior to the planned procedure.

Editorial Commentary: Time to Transition to Opioid-Sparing Orthopaedic Surgery: The Writing Is on the Wall.

Opioid pain medications continue to play a role in postoperative pain control following elective arthroscopic surgery. Recent evidence suggests that patients who consume opioids preoperatively are at risk for inferior patient-reported outcomes. They are also more likely to consume opioids for longer periods of time following surgery relative to their opioid-naïve counterparts. However, limited evidence currently exists regarding whether discontinuing opioid use in anticipation of surgery avoids these deleterious effects. Orthopaedic surgeons have an obligation to limit the number of opioids necessary to control postoperative pain.

Preoperative Opioid Use Predicts Prolonged Postoperative Opioid Use and Inferior Patient Outcomes Following Anterior Cruciate Ligament Reconstruction.

PURPOSE: (1) To determine patient factors associated with prolonged opioid use following anterior cruciate ligament reconstruction (ACLR) and (2) to evaluate the influence of preoperative opioid use on patient-reported outcomes. METHODS: Patients who underwent ACLR and used opioids before the perioperative period, which was defined as the window 30 days before 15 days following the index surgery, were designated as preoperative opioid users. Patients who used opioids only in the perioperative period or post-operative period were designated as opioid-naïve. Predictors of opioid use at 6 and 12 months postoperatively and associations between preoperative opioid use and patient outcomes were assessed. RESULTS: After institutional review board approval, we identified 253 patients (225 opioid-naïve and 28 opioid users ) who underwent ACLR from 2014 to 2018 at a single institution and had one year follow up (median: 11.6 months; interquartile range [8.9-14.3]). Patients with a history of preoperative opioid use (odds ratio [OR] 3.63, P = .034), greater preoperative visual analog scale pain scores (OR 1.32, 95% CI 1.04-1.67; P = .003), and greater body mass index (OR 1.09, P = .018) were significantly more likely to be taking opioids at 6 months postoperatively. Patients with a perioperative opioid intake of greater than 513 oral morphine equivalents were significantly more likely to continue taking opioids at the 6 month (OR 3.17, P = .024) and the 1 year (OR 3.34, P = .048) postoperative time points. Patients with preoperative opioid use were significantly less likely to achieve the patient acceptable symptomatic state (PASS) on the International Knee Documentation Committee, Knee Injury and Osteoarthritis Outcome Score (KOOS) Sport, KOOS Joint Replacement, KOOS Pain, KOOS Symptoms, KOOS Quality of Life, and KOOS Activities of Daily Living. CONCLUSIONS: Preoperative opioid use, body mass index >30, and greater visual analog scale pain scores were predictors of continued opioid use at 6 months postoperatively. Preoperative opioid users were more likely to continue taking opioids, demonstrate significantly worse patient reported outcomes at baseline and 1-year postoperatively, and were less likely to achieve patient acceptable symptomatic state. LEVEL OF EVIDENCE: Level III, Retrospective Cohort Study.

Preoperative Corticosteroid Injections Are Not Associated with Deep Infection after Unicompartmental Knee Arthroplasty.

Prior to unicompartmental knee arthroplasty (UKA), corticosteroid injections (CSI) are a common nonoperative treatment for arthritis. It is unclear whether CSI prior to UKA impacts the likelihood of postoperative infection. This study sought to determine if there is a time- and/or dose-dependent relationship between preoperative CSI and postoperative infection. An administrative claims database was queried for patients undergoing UKA with more than 1 year of pre-enrollment and follow-up. Of 31,676 patients with a UKA who met enrollment criteria, 8,628 patients had a CSI 0 to 3 months prior to surgery, 111 had a CSI 3 to 12 months prior to surgery, and 22,937 never received an injection. Overall, 246 postoperative deep infections were reported (0.8%). Time-dependent and dose-dependent relationships were modeled using multivariable logistic regressions. Postoperative deep infections occurred in 64 patients with CSI 0 to 3 months prior to surgery (0.7%), compared with 0 patients with CSI 3 to 12 months before surgery (0.0%) and 182 controls (0.8%, p = 0.58). CSI within 1 month prior to UKA was not statistically associated with postoperative infection (p = 0.66). Two or more CSI within 3 months prior to UKA were associated with a twofold elevated odds of infection, compared with receiving a single injection (odds ratio [OR]: 2.08, p = 0.03). Univariable predictors of infection included younger age, increasing Charlson Comorbidity Index, smoking, asthma, chronic obstructive pulmonary disease, chronic kidney disease, diabetes, liver disease, and obesity. Multivariable analysis controlling for these characteristics elicited no relationship between recent CSI administration and postoperative infection. CSI within 3 months of surgery (1.5%) or 3 to 12 months (1.8%) were associated with increased conversion to total knee arthroplasty (TKA) compared with those who did not receive an injection (1.1%, p = 0.01), although TKA for indication of periprosthetic joint infection was not statistically different (p = 0.72). Preoperative CSI within 3 months of UKA is not associated with postoperative infection, although significant medical comorbidity does show an association. Preoperative CSI is associated with increased conversion from UKA to TKA for noninfectious indications.