Effects of Socioeconomic Burden on Opioid Use Following Total Shoulder Arthroplasty.

BACKGROUND: Preoperative opioid users (POU) experience worse outcomes and higher complication rates compared to opioid naïve patients (ONP) following shoulder arthroplasty. This study evaluates the effects of socioeconomic status (SES), as measured by the distressed communities index (DCI), on pre- and postoperative opioid use and its influence on clinical outcomes such as readmission and revision surgery. METHODS: A retrospective review of patients who underwent primary shoulder arthroplasty (CPT code 23472) from 2014-2022 at a single academic institution was performed. Exclusion criteria included arthroplasty for fracture, active malignancy, and revision arthroplasty. Demographics, Charlson Comorbidity Index (CCI), DCI, and clinical outcomes including 90-day readmission and revision surgery were collected. Patients were classified according to the DCI score of their zip code. Using the Prescription Drug Monitoring Program database, patient pre- and postoperative opioid use in morphine milligram equivalents (MME) was gathered. RESULTS: Individuals from distressed communities utilized more opioids within 90 days preoperatively compared to patients from prosperous, comfortable, mid-tier, and at-risk populations respectively. Patients from distressed communities also used significantly more opioids within 90 days postoperatively compared to prosperous, comfortable, and mid-tier respectively. Of patients from distressed communities, 35.1% developed prolonged opioid use (filling prescriptions >30 days after surgery), significantly more than all other cohorts. Among all patients, 3.5% were readmitted within 90 days and were more likely to be prolonged opioid users (38.9 vs 21.3%, p<0.001). Similarly, 1.5% of patients underwent revision surgery. Those who underwent revision were significantly more likely to be prolonged opioid users (38.2 vs 21.7%, p=0.002). CONCLUSIONS: Shoulder arthroplasty patients from distressed communities use more opioids within 90 days before and after their surgery and are more likely to become prolonged opioid users placing them at risk for readmission and revision surgery. Identifying patients at an increased risk for excess opioid use is essential to employ appropriate strategies that minimize the detrimental effects of prolonged use following surgery.

Surgeon Factors and Trends Associated With the Use of Subacromial Decompression at the Time of Rotator Cuff Repair.

PURPOSE: Subacromial decompression (SAD) has historically been described as an essential part of the surgical treatment of rotator cuff disorders. However, investigations throughout the 21st century have increasingly questioned the need for routine SAD during rotator cuff repair (RCR). Our purpose was to assess for changes in the incidence of SAD performed during RCR over a 12-year period. In addition, we aimed to characterize surgeon and practice factors associated with SAD use. METHODS: Records from two large tertiary referral systems in the United States from 2010 to 2021 were reviewed. All cases of RCR with and without SAD were identified. The outcome of interest was the proportion of SAD performed during RCR across years and by surgeon. Surgeon-specific characteristics included institution, fellowship training, surgical volume, academic practice, and years in practice. Yearly trends were assessed using binomial logistic regression modeling, with a random effect accounting for surgeon-specific variability. RESULTS: During the study period, 37,165 RCR surgeries were performed by 104 surgeons. Of these cases, 71% underwent SAD during RCR. SAD use decreased by 11%. The multivariable model found that surgeons in academic practice, those with lower surgical volume, and those with increasing years in practice were significantly associated with increased odds of performing SAD. Surgeons with fellowship training were significantly more likely to use SAD over time, with the greatest odds of SAD noted for sports medicine surgeons (odds ratio = 3.04). CONCLUSIONS: Although SAD use during RCR appears to be decreasing, multiple surgeon and practice factors (years in practice, fellowship training, volume, and academic practice) are associated with a change in SAD use. CLINICAL RELEVANCE: These data suggest that early-career surgeons entering practice are likely driving the trend of declining SAD. Despite evidence suggesting limited clinical benefits, SAD remains commonly performed; future studies should endeavor to determine factors associated with practice changes among surgeons.

The impact of preoperative benzodiazepine use on postoperative opioid use in total shoulder arthroplasty.

BACKGROUND: As the rate of total shoulder arthroplasty (TSA) and preoperative benzodiazepine use rise, there is an increased need to understand the impact of preoperative benzodiazepine use on postoperative opioid consumption following TSA, especially amid the current opioid epidemic. The relationship between preoperative benzodiazepine use and chronic opioid use postoperatively has been well described following other orthopedic procedures; however, the impact on patients undergoing TSA remains unclear. This study aims to identify the impact of preoperative benzodiazepine use on opioid use following TSA. METHODS: A retrospective chart review of 4488 patients undergoing primary TSA (Current Procedural Terminology code 23472) at a single institution from 2014 to 2022 was performed. Patient demographics, surgical variables, comorbidities, Distressed Communities Index (DCI), and clinical outcomes, including readmission and revision, were collected. The Charlson Comorbidity Index (CCI) was used to assess preoperative health status. Opioid use in morphine milligram equivalents (MMEs) and benzodiazepine use were also recorded using the Prescription Drug Monitoring Program Database. Opioid use was collected at 30-, 60-, and 90-day intervals both before and after each patient's date of surgery. Statistical analysis included stepwise logistic regression to identify variables independently affecting benzodiazepine use pre- and postoperatively. RESULTS: Overall, 16% of patients used benzodiazepines within 90 days before their date of surgery. Of those patients, 46.4% were also using preoperative opioids, compared with just 30.0% of patients who were benzodiazepine-naïve (P < .001). Preoperative benzodiazepine use was also associated with increased pre- and postoperative total opioid use in MMEs and the number of opioid prescriptions across all time points when compared to benzodiazepine-naïve patients (P < .001). Furthermore, 37.4% of preoperative benzodiazepine users went on to prolonged opioid use (filled prescriptions >30 days after surgery) compared to 19.0% of those who were benzodiazepine-naïve (P < .001). CONCLUSION: This study demonstrates a significant association between preoperative benzodiazepine use and increased and prolonged opioid use following TSA. Further exploration of risk factors contributing to preoperative benzodiazepine use may help to reduce overall opioid use in patients undergoing TSA.

Augmented Fixation in Transverse Midshaft Humerus Fractures Using a Nitinol Staple: Surgical Technique and Case Series.

Maintaining the reduction of a transverse humeral shaft fracture can be particularly challenging while applying a compression plate for definitive fixation. Nitinol compression staples are being increasingly utilized in orthopedic surgery due to their unique ability to apply continuous compression between staple legs at body temperature. We have found them to be particularly useful in the maintenance of the reduction of transverse humeral shaft fractures before compression plate application. This simple technique allows for the removal of reduction clamps and precise plate placement. We describe our technique for using nitinol compression staples to augment fracture fixation in transverse humeral shaft fractures as well as our experience using this technique in a case series of 4 patients.

Outcomes after salvage reverse shoulder arthroplasty for failed primary fixation or hemiarthroplasty for proximal humerus fractures: A systematic review.

Background: Salvage reverse shoulder arthroplasty (RSA) for failed proximal humerus fractures (PHFs) fixation and hemiarthroplasty (HA) may maximize outcomes in the absence of tuberosity healing or a chronically torn rotator cuff. The purpose of this systematic review was to examine the improvement in clinical outcomes for patients after revision RSA was performed for failed PHFs fixation or HA. Methods: An electronic database search of SCOPUS, PubMed, Embase, MEDLINE, SPORTDiscus, CINAHL, and ClinicalTrials.gov was performed. A meta-analysis was carried out to determine weighted mean outcome differences between two primary intervention cohorts (failed fixation: open reduction and internal fixation, intramedullary nail, or K-wire vs. failed HA). Results: Fifteen studies were included (primary fixation: 208 patients; HA: 162 patients). Patients improved meaningfully in all clinical outcomes after revision surgery (constant: 18.5-48.3; abduction: 44-95; forward flexion: 47-107; external rotation: 5-10), with a 16.2% complication and 9.4% revision rate. The failed fixation group performed significantly better than the failed HA group in postoperative constant (fixation: 53.3 vs. HA: 45.1, p = 0.016) and shoulder abduction (fixation: 102 vs. HA: 87, p = 0.026). Conclusions: RSA is a successful revision intervention for primary PHF operative failures with the greatest benefit for failures of primary fixation versus HA.

Distressed communities demonstrate increased readmission and health care utilization following shoulder arthroplasty.

BACKGROUND: Socioeconomic status (SES) has been shown to affect outcomes following total shoulder arthroplasty (TSA), but little is known regarding how SES and the communities in which patients reside can affect postoperative health care utilization. With the growing use of bundled payment models, understanding what factors put patients at risk for readmission and the ways in which patients utilize the health care system postoperatively is crucial for preventing excess costs for providers. This study helps surgeons predict which patients are high-risk and may require additional surveillance following shoulder arthroplasty. METHODS: A retrospective review of 6170 patients undergoing primary shoulder arthroplasty (anatomic and reverse; Current Procedural Terminology code 23472) from 2014-2020 at a single academic institution was performed. Exclusion criteria included arthroplasty for fracture, active malignancy, and revision arthroplasty. Demographics, patient zip code, and Charlson Comorbidity Index were attained. Patients were classified according to the Distressed Communities Index (DCI) score of their zip code. The DCI combines several metrics of socioeconomic well-being to generate a single score. Zip codes are then classified by scores into 5 categories based on national quintiles. The primary outcome of interest was 90-day readmissions. Secondary outcomes included number of postoperative medication prescriptions, patient telephone calls to the office, and follow-up office visits. RESULTS: Among all patients undergoing total shoulder arthroplasty, individuals from distressed communities were more likely than their prosperous counterparts to experience an unplanned readmission (odds ratio = 1.77, P = .045). Patients from comfortable (relative risk [RR] = 1.12, P < .001), midtier (RR = 1.13, P < .001), at-risk (RR = 1.20, P < .001), and distressed (RR = 1.17, P < .001) communities were all more likely to use more medications compared to those from prosperous communities. Likewise, those from comfortable (RR = 0.92, P < .001), midtier (RR = 0.88, P < .001), at-risk (RR = 0.93, P = .008), and distressed (RR = 0.93, P = .033) communities, respectively, were at a lower risk of making calls compared to prosperous communities. CONCLUSIONS: Following primary total shoulder arthroplasty, patients who reside in distressed communities are at significantly increased risk of experiencing an unplanned readmission and increased health care utilization postoperatively. This study revealed that patient socioeconomic distress is more associated with readmission than race following TSA. Increased awareness and employing strategies to maintain and ultimately improve communication with patients offers a potential solution to reduce excessive health care utilization, benefiting both patients and providers alike.

Analysis of Orthopaedic In-Training Examination Trauma Questions: 2017 to 2021.

INTRODUCTION: The Orthopaedic In-Training Examination (OITE) is a multiple-choice examination developed by the American Academy of Orthopaedic Surgeons annually since 1963 to assess orthopaedic residents' knowledge. This study's purpose is to analyze the 2017 to 2021 OITE trauma questions to aid orthopaedic residents preparing for the examination. METHODS: The 2017 to 2021 OITEs on American Academy of Orthopaedic Surgeons' ResStudy were retrospectively reviewed to identify trauma questions. Question topic, references, and images were analyzed. Two independent reviewers classified each question by taxonomy. RESULTS: Trauma represented 16.6% (204/1,229) of OITE questions. Forty-nine percent of trauma questions included images (100/204), 87.0% (87/100) of which contained radiographs. Each question averaged 2.4 references, of which 94.9% were peer-reviewed articles and 46.8% were published within 5 years of the respective OITE. The most common taxonomic classification was T1 (46.1%), followed by T3 (37.7%) and T2 (16.2%). DISCUSSION: Trauma represents a notable portion of the OITE. Prior OITE trauma analyses were published greater than 10 years ago. Since then, there has been an increase in questions with images and requiring higher cognitive processing. The Journal of Orthopaedic Trauma (24.7%), Journal of the American Academy of Orthopaedic Surgeons (10.1%), and Journal of Bone and Joint Surgery, American Volume (9.3%) remain the most cited sources.

Unicompartmental Knee Arthroplasty Is Cost-Effective in an Outpatient Setting.

INTRODUCTION: Increasingly, unicompartmental knee arthroplasty (UKA) is being performed on an outpatient basis, with the growing utilization of ambulatory surgery centers (ASCs). The purpose of this study was to compare the costs of UKAs performed in an ASC to UKAs done in a hospital, either on an outpatient or inpatient basis. METHODS: This study involved three matched groups, each with 50 consecutive patients, undergoing UKA either on an outpatient basis in an ASC or a community hospital, or who were admitted overnight to the same community hospital. Identical perioperative analgesic regimens and care protocols were used in each group. The primary outcomes evaluated included direct facility costs. Secondary outcomes were postoperative complications and readmissions. RESULTS: Average age, gender ratio, and comorbidities were similar in all three cohorts. Only two patients in the study experienced complications and these were without secondary adverse consequences. Mean costs were substantially reduced when UKAs were performed in an ASC ($9,025) compared to a community hospital on either an outpatient ($12,032) or inpatient basis ($14,542). CONCLUSION: UKA can be safely performed in the outpatient setting, in appropriately selected patients, at substantial cost savings, particularly when performed in an ASC.

Effects of Patient Comorbidities and Demographics on Episode-of-Care Costs Following Total Shoulder Arthroplasty.

BACKGROUND: As demand for shoulder arthroplasty grows, adequate cost containment is of importance. Given the historical use of bundle payments for lower extremity arthroplasty, it is reasonable to anticipate that such programs will be universally implemented in shoulder arthroplasty. This project evaluates how patient demographics, medical comorbidities, and surgical variables affect episode-of-care costs in an effort to ensure accurate reimbursement scales and equitable access to care. METHODS: Consecutive series of primary total shoulder arthroplasty (anatomic and reverse) procedures were retrospectively reviewed at a single academic institution from 2014 to 2020 using claims cost data from Medicare and a private insurer. Patient demographics, comorbidities, and clinical outcomes were collected. A stepwise multivariate regression was performed to determine the independent effect of comorbidities and demographics on 90-day episode-of-care costs. RESULTS: Overall, 1,452 shoulder arthroplasty patients were identified (1,402 Medicare and 50 private payer patients). The mean 90-day cost for Medicare and private payers was $25,822 and $31,055, respectively. Among Medicare patients, dementia ($3,407, P = 0.003), history of stroke ($3,182, P = 0.005), chronic pulmonary disease ($1,958, P = 0.007), anemia ($1,772, P = 0.039), and heart disease ($1,699, P = 0.014) were associated with significantly increased costs. Demographics that significantly increased costs included advanced age ($199 per year in age, P < 0.001) and elevated body mass index ($183 per point, P < 0.001). Among private payers, hyperlipidemia ($6,254, P = 0.031) and advanced age ($713 per year, P < 0.001) were associated with an increase in total costs. CONCLUSION: Providers should be aware that certain demographic variables and comorbidities (history of stroke, dementia, chronic pulmonary disease, anemia, heart disease, advanced age, and elevated body mass index) are associated with an increase in total costs following primary shoulder arthroplasty. Further study is required to determine whether bundled payment target costs should be adjusted to better compensate for specific comorbidities. LEVEL OF EVIDENCE: Level IV case series.

Predicting Hospital Readmissions After Total Shoulder Arthroplasty Within a Bundled Payment Cohort.

INTRODUCTION: Given the rising demand for shoulder arthroplasty, understanding risk factors associated with unplanned hospital readmission is imperative. No study to date has examined the influence of patient and hospital-specific factors as a predictive model for 90-day readmissions within a bundled payment cohort after primary shoulder arthroplasty. The purpose of this study was to determine predictive factors for 90-day readmissions after primary shoulder arthroplasty within a bundled payment cohort. METHODS: After obtaining IRB approval, a retrospective review of a consecutive series of Medicare patients undergoing primary shoulder arthroplasty from 2014 to 2020 at a single academic institution was conducted. Patient demographic data, surgical variables, medical comorbidity profiles, medical risk scores, and social risk scores were collected. Postoperative variables included length of hospital stay, discharge location, and 90-day readmissions. Multivariate analysis was conducted to determine the independent risk factors of 90-day readmission. RESULTS: Overall, 3.6% of primary shoulder arthroplasty patients (127/3,523) were readmitted within 90 days. Readmitted patients had a longer hospital course (1.75 versus 1.45 P = 0.006), higher comorbidity profile (4.64 versus 4.24 P = 0.001), higher social risk score (7.96 versus 6.9 P = 0.008), and higher medical risk score (10.1 versus 6.96 P < 0.001) and were more likely to require a home health aide or be discharged to an inpatient rehab facility or skilled nursing facility ( P = 0.002). Following multivariate analysis, an elevated medical risk score was associated with an increased risk of readmission (odds ratio = 1.05, P < 0.001). DISCUSSION: This study demonstrates medical risk scores to be an independent risk factor of increased risk of 90-day hospital readmissions after primary shoulder arthroplasty within a bundled payment patient population. Additional incorporation of medical risk scores may be a beneficial adjunct in preoperative prediction for readmission and the potentially higher episode-of-care costs. LEVEL OF EVIDENCE: Level III, retrospective cohort.

Total shoulder arthroplasty using an inlay glenoid component for glenoid deficiency: mid- to long-term follow-up of a previously published cohort.

BACKGROUND: The short-term results of total shoulder arthroplasty with an inlay glenoid component performed by a single surgeon in patients with glenoid bone loss have previously been reported. The purpose of this study was to investigate the mid- to long-term clinical and radiographic outcomes of these patients. METHODS: We identified a cohort of patients who underwent total shoulder arthroplasty with an inlay glenoid component performed by a single surgeon between 2010 and 2019 for severe glenoid dysplasia and/or glenoid bone loss. Patients with a minimum of 2 years' follow-up were evaluated regarding preoperative and postoperative range of motion, radiographic findings, visual analog scale pain scores, and Single Assessment Numeric Evaluation scores. RESULTS: Overall, 39 shoulders in 33 patients were treated with an inlay glenoid component for severe glenoid bone loss. Four patients were lost to follow-up, and 1 patient died with a well-functioning implant in place. The final cohort included 34 shoulders in 28 patients (46.4% female patients [13 of 28] and 53.6% male patients [15 of 28]) with a mean age of 66.9 years (range, 58-81 years) and mean follow-up period of 68.3 months. Of the 34 cases, 5 were revision cases. One patient died following 2-year follow-up. Of the shoulders, 10 were classified as Walch type A2, 4 were classified as Walch type B3, and 15 were classified as Walch type C; 5 shoulders were unable to be classified. We observed statistically significant increases in range of motion (forward elevation, 38.1° [P < .001]; external rotation, 18.8° [P < .001]) and improvement in the Single Assessment Numeric Evaluation score (from 26.6 to 81.0, P < .001). Two patients underwent conversion to reverse shoulder arthroplasty at 2.2 and 1.7 years postoperatively. CONCLUSION: Inlay glenoid components provide a low rate of revision and improved clinical and functional outcomes at mid- to long-term follow-up.

Shoulder Synovitis Does not Affect Pain After Arthroscopic Rotator Cuff Repair.

Background: The goal of this study was to determine if there is an association between glenohumeral synovitis and early post-operative pain after arthroscopic rotator cuff repair. Methods: Fifty patients with symptomatic rotator cuff tears were prospectively enrolled prior to RCR. Baseline ASES score, VAS Pain score, forward elevation, and external rotation were recorded. Intra-operatively, synovitis was graded on a scale of zero to six as based on a previously validated scoring system. VAS Pain scores were obtained from patients post-operatively on days one through 14, week 6, and 3 months. Results: Average intra-operative synovitis score was 2.4 ± 1.6. No significant correlation was found between synovitis score and pre-operative forward elevation (P=0.171), external rotation (P=0.126), VAS Pain (P=0.623), or ASES (P=0.187) scores. No significant correlation was found between synovitis score and post-operative VAS Pain level at any time point. There was a moderate correlation between both pre-operative VAS Pain and ASES scores and post-operative VAS Pain in the first post-operative week. Workers' compensation patients had worse pain at 3 months post-operatively compared to non-workers compensation patients (P=0.038). Conclusion: This study reveals that macroscopically assessed glenohumeral synovitis does not have any significant correlation with pre-operative or post-operative pain in patients undergoing arthroscopic rotator cuff repair; although higher pre-operative pain levels, worse pre-operative ASES scores, and workers compensation status do influence post-operative pain levels in arthroscopic rotator cuff repair.

Trends Related to the Treatment of Superior Labral Tears at a Single Institution.

BACKGROUND: As preferred treatment options for superior labral tears continue to evolve, this study aims to describe the recent longitudinal trends in the treatment of SLAP tears in a sub-specialized practice at a single institution. We hypothesized that there was a trend toward biceps tenodesis over repair for Type II SLAP lesions. METHODS: A retrospective review was performed using an institutional billing database to identify all patients with a SLAP tear who underwent surgical intervention between January 2002 and January 2016. Procedural codes associated with the surgery were analyzed to determine type of treatment each patient received. RESULTS: Of the 6,055 patients who underwent surgery for a SLAP tear during the study period, 39.1% (2,370) underwent labral repair, 15.4% (930) underwent tenodesis without repair, and 45.5% (2,755) underwent arthroscopy without tenodesis or repair. Labral repair made up a significantly higher proportion of surgical interventions in 2002 (82.2%) compared to in 2015 (21.8%; p <0.001). Surgeon experience did not impact trends. Over the study period, the mean age of patients receiving labral repair decreased from 40.4 years (range: 16.2 - 63.9) to 32.6 years (range: 14.0 - 64.7; p <0.001). CONCLUSION: This study demonstrates that over the 14-year study period the rate of labral repairs for SLAP tears has decreased significantly and that these repairs have been directed towards a younger patient population.

Importance of Advocacy from the Orthopedic Surgeon.

Over the past century, governmental involvement in the delivery of health care has grown steadily through health policy initiatives and increased regulations. Traditionally, the involvement in this process for the orthopedic surgeon was minimal because they were focused primarily on direct patient care. These two pathways have met a crossroads, however, where it has now become necessary for the orthopedic surgeon to advocate on behalf of themselves and their patients to guide and influence the legislative and regulatory processes. This article reviews the background of orthopedic advocacy and discusses ways in which the interested surgeon can become involved.

Successful Outcomes Achieved Via Web-based, Home Program after Total Shoulder Arthroplasty.

BACKGROUND: The primary goals of total shoulder arthroplasty (TSA) are to relieve pain, improve range of motion, and restore function. Physical therapy is commonly used to help achieve these goals. Recent evidence has pointed to the success and safety of a purely physician-guided, home-based or internet-based, program versus the traditional therapist guided program. The purpose of this study was to evaluate outcomes of TSA in patients using a web-based, home therapy program. METHODS: A retrospective review was performed of TSA patients who were given the option of using a web-based, home therapy program. Functional outcomes were collected preoperatively, 6-month, and 12-month post-operative examinations. Physical examination parameters were recorded at preoperative, 3-month, 6-month, and 12-month time-points. RESULTS: Forty-seven patients used the web-based, home therapy program and had complete follow-up data at all time intervals. All mean range of motion parameters and functional scores improved significantly from preoperatively to postoperatively. There was one reported complication in a patient who sustained a subscapularis rupture and underwent subsequent open repair at 10 months postoperatively. CONCLUSION: This study demonstrates successful improvements in range of motion and functional outcomes in a subset of patients who utilized an online therapy program after TSA. Future study will be necessary to directly compare results in patients enrolled in formal, outpatient therapy programs and to determine barriers to utilization of web-based therapy programs.

Interobserver reliability of the rotator cable and its relationship to rotator cuff congruity.

BACKGROUND: This study evaluated the presence of the rotator cable intraoperatively and compared its prevalence according to both patient age and rotator cuff integrity. The study hypothesis was that the cable would be more prevalent in older patients and patients with partial-thickness tears. METHODS: Patients who were undergoing shoulder arthroscopy and were aged at least 16 years were included in this study, whereas those who had a cuff tear of more than 1 tendon or who had a video with poor visualization of the rotator cuff insertion were excluded. Intraoperative videos were collected, deidentified, and distributed to 7 orthopedic surgeons to define rotator cable and cuff tear characteristics. RESULTS: A total of 58 arthroscopic videos (average patient age, 46 years; range, 16-75 years) were evaluated. The observers were in the most agreement on identifying the presence of a cable, with a κ coefficient of 0.276. Patients with the rotator cable were significantly older than those without it (mean age, 52.1 years vs. 42.5 years; P = .008), and a positive and significant correlation was found between rotator cable presence and increasing patient age (r = 0.27, P = .04). A significant association was noted between tear degree and cable presence (P = .002). There was no significant association with cable presence in patients with a full-thickness tear. CONCLUSIONS: In this study, an intraoperative analysis was performed to define the presence of the rotator cable and correlate this with both patient age and rotator cuff integrity. The hypothesis was confirmed in that patients older than 40 years had a significantly higher rotator cable prevalence.

Cost Effectiveness of Laminar Flow Systems for Total Shoulder Arthroplasty: Filtering Money from the OR?

BACKGROUND: Laminar flow ventilation systems were developed to reduce surgical contamination in joint arthroplasty to avoid periprosthetic joint infection (PJI). The goals of this study are to evaluate the cost-effectiveness and economic viability of installing and maintaining a laminar flow system in an operating room. METHODS: A Monte Carlo simulation was used to evaluate the cost effectiveness of laminar flow. The variables included were cost to treat PJI, incidence of PJI, cost of laminar flow, years of operating room use, and arthroplasty volume as the dependent variable. RESULTS: Laminar flow would be financially-justified when 1,217 (SD: 319) TSA cases are performed annually with assumed 10% reduction in PJI from laminar flow and 487 (SD: 127) with assumed 25% reduction. In a high volume OR, laminar flow costs $25.24 per case (assuming 10% reduction) and $8.24 per case (assuming 25% reduction). Laminar flow would need to reduce the incidence of PJI by 35.1% (SD: 9.1) to be a cost-effective strategy. CONCLUSION: This analysis demonstrates the substantial arthroplasty volume and large reduction in PJI rates required to justify the installation and maintenance costs of this technology. This high cost of implementation should be considered prior to installing laminar flow systems.

Predicting Postoperative Course After Total Shoulder Arthroplasty Using a Medical-Social Evaluation Model.

INTRODUCTION: The ability to predict successful outcomes is important for patient satisfaction and optimal results after shoulder arthroplasty. We hypothesize that a medical-social scoring tool will predict resource requirements in doing total shoulder arthroplasty (TSA). METHODS: A retrospective analysis of 453 patients undergoing TSA was undertaken. Preoperatively, medical and social surveys were completed by each patient. Demographics, comorbidity scores, hospital course, postdischarge disposition, and readmissions were collected. RESULTS: The average length of stay was 1.6 days (0 to 7). There was an association with utilization of home care or inpatient rehabilitation and both the medical (7.3 versus 3.9; P = 0.0002) and social (7.1 versus 3.4; P < 0.0001) components of the survey. There was a weak correlation between hospital length of stay and the social component of the survey (R = 0.29; P < 0.001), but not the medical component (R = 0.04; P = 0.38). No variable was predictive of readmission. Social score of eight was found to be predictive of postoperative requirement of home care or rehabilitation. CONCLUSION: This study found that Medical and Social Survey Scores can stratify patients who are at risk of requiring more advanced postdischarge care and/or a longer hospital stay. With this, we can match patients to the most appropriate level of postoperative care.

Addition of 3% hydrogen peroxide to standard skin preparation reduces Cutibacterium acnes-positive culture rate in shoulder surgery: a prospective randomized controlled trial.

BACKGROUND: Hydrogen peroxide is an inexpensive and effective antimicrobial agent that can be implemented in surgical skin preparations. The purpose of this study was to evaluate the decolonization effect of Cutibacterium acnes when adding hydrogen peroxide to a standard sterile preparation for shoulder surgery. METHODS: This was a single-institution, prospective, randomized controlled trial of male patients undergoing shoulder arthroscopy (April 2018 and May 2019). Patients were randomized to a standard skin preparation vs. an additional sterile preparation with 3% hydrogen peroxide. After draping, a 3-mm punch biopsy was obtained from the posterior arthroscopic portal site of all patients. Anaerobic and aerobic culture substrates were used and held for 13 days. RESULTS: Seventy male patients were randomized into the hydrogen peroxide group and 70 male patients were in the traditional group. Twelve (17.1%) patients in the hydrogen peroxide group and 24 (34.2%) patients in the traditional group had positive cultures for C acnes (P = .033). Cultures were positive at a mean of 4.5 days (range 3-7) in the hydrogen peroxide group and 4.1 days (range 3-8) in the traditional group (P = .48). There were no cases of skin reaction to the surgical preparation in either group. DISCUSSION: The results of this study suggest that the addition of hydrogen peroxide to preoperative surgical site preparation can reduce the C acnes culture rate. Hydrogen peroxide is inexpensive and can be added to the typical skin preparation used prior to shoulder surgery without substantial risk of skin reactions.

Revision total elbow arthroplasty failure rates: the impact of primary arthroplasty failure etiology on subsequent revisions.

BACKGROUND: The number of primary total elbow arthroplasties (TEAs) performed is increasing annually, necessitating a rise in the number of revision procedures. No studies exist to illustrate reliable indications for revision arthroplasty. The purpose of this study was to determine the impact of the etiology of primary TEA failure on the failure rate of revision surgery. METHODS: We retrospectively analyzed the patient charts of all revision TEAs performed at a single institution between 2006 and 2016. The primary outcome was revision failure, defined as the need for a second revision surgical procedure. Patients were organized into cohorts by etiology of primary implant failure. Failure rates, time to second revision, and average number of additional revisions were compared among cohorts. RESULTS: A total of 46 patients with a mean age of 62.7 years and minimum 2-year follow-up were included. The etiologies of failure identified were infection (n = 20), aseptic loosening (n = 17), periprosthetic fracture (n = 6), and bushing wear (n = 3). All noninfectious etiologies were grouped into an additional cohort. Patients who underwent revision for infection demonstrated a significantly greater failure rate and greater number of additional revisions per patient than those with aseptic loosening, those with periprosthetic fracture, and the noninfectious group, as well as a shorter time to failure than the noninfectious group. CONCLUSION: Patients in whom primary TEA fails because of infection are more likely to experience revision failure and require a greater number of subsequent operations than patients with other etiologies of primary TEA failure. These data question the efficacy of revision surgery in the treatment of infected TEAs.