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.

The impact of robotic assistance for lumbar fusion surgery on 90-day surgical outcomes and 1-year revisions.

Objectives: To evaluate the (1) 90-day surgical outcomes and (2) 1-year revision rate of robotic versus nonrobotic lumbar fusion surgery. Methods: Patients >18 years of age who underwent primary lumbar fusion surgery at our institution were identified and propensity-matched in a 1:1 fashion based on robotic assistance during surgery. Patient demographics, surgical characteristics, and surgical outcomes, including 90-day surgical complications and 1-year revisions, were collected. Multivariable regression analysis was performed. Significance was set to P < 0.05. Results: Four hundred and fifteen patients were identified as having robotic lumbar fusion and were matched to a control group. Bivariant analysis revealed no significant difference in total 90-day surgical complications (P = 0.193) or 1-year revisions (P = 0.178). The operative duration was longer in robotic surgery (287 + 123 vs. 205 + 88.3, P ≤ 0.001). Multivariable analysis revealed that robotic fusion was not a significant predictor of 90-day surgical complications (odds ratio [OR] = 0.76 [0.32-1.67], P = 0.499) or 1-year revisions (OR = 0.58 [0.28-1.18], P = 0.142). Other variables identified as the positive predictors of 1-year revisions included levels fused (OR = 1.26 [1.08-1.48], P = 0.004) and current smokers (OR = 3.51 [1.46-8.15], P = 0.004). Conclusion: Our study suggests that robotic-assisted and nonrobotic-assisted lumbar fusions are associated with a similar risk of 90-day surgical complications and 1-year revision rates; however, robotic surgery does increase time under anesthesia.

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.

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.

Irreparable Massive Rotator Cuff Tears: Subacromial Balloon Surgical Technique.

Massive irreparable rotator cuff tears pose a significant challenge for both the treating orthopedic surgeon and patient. Surgical treatment options for massive rotator cuff tears include arthroscopic debridement, biceps tenotomy or tenodesis, arthroscopic rotator cuff repair, partial rotator cuff repair, cuff augmentation, tendon transfers, superior capsular reconstruction, subacromial balloon spacer, and ultimately reverse shoulder arthroplasty. The present study will provide a brief overview of these treatment options along with a description of the surgical technique for subacromial balloon spacer placement.

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.

Do Patient Outcomes Predict Loss to Long-Term Follow-Up After Spine Surgery?

OBJECTIVE: To determine if spine surgery patients with greater improvement in patient-reported outcomes measures (PROMs) at early postoperative follow-up are more likely to be lost to follow-up at the 1-year and 2-year postoperative visits. METHODS: All patients older than 18 years who underwent primary or revision decompression or fusion surgery for degenerative spinal conditions at an academic institution were retrospectively identified. Univariate analysis compared patient demographics, surgical factors, and changes in short-term and long-term postoperative PROMs (Neck Disability Index, Oswestry Disability Index, visual analog scale [VAS] neck, VAS arm, VAS back, VAS leg, and Short-Form 12 Physical and Mental Component Scores) across groups with and without 1 year and 2 years follow-up. Logistic regression isolated predictors of loss to follow-up. RESULTS: A total of 1412 patients were included. Younger patient age, primary surgery, and single surgical approach independently predicted loss at 1 year follow-up. Female sex predicted loss at 2 years follow-up, whereas multilevel fusion surgery predicted attendance at 2 years clinical follow-up. In patients lost at 1 year follow-up compared with those who attended, preoperative to 3-month Mental Component Score and VAS neck pain improvement was significantly greater. When comparing patients based on 2 years follow-up status, VAS back pain improvement at 1 year postoperatively was significantly greater in patients lost to 2 years follow-up. All other changes in PROMs did not differ significantly by 1 or 2 years follow-up attendance. CONCLUSIONS: Overall patient outcomes were not found to affect loss to long-term follow-up after spine surgery. The general lack of association between postoperative follow-up status and clinical outcome may limit bias introduced in retrospective PROM studies.

Acetabular Retroversion: Dysplasia in Disguise that Leads to Early Arthritis of the Hip.

We aimed to assess the prevalence of acetabular retroversion (AR) in patients undergoing total hip replacement (THA) based on age. We retrospectively compared preoperative anteroposterior pelvic radiographs of patients younger than 40 years of age who underwent THA with the age- and body mass index-matched control of 40 years and older patients. Retroversion was determined based on the presence of cross-over sign, ischial spine sign, posterior wall sign, and elephant's ear sign with data stratified based on presence of dysplasia.

Marijuana Use and its Effect on Clinical Outcomes and Revision Rates in Patients Undergoing Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: To determine if (1) preoperative marijuana use increased complications, readmission, or reoperation rates following anterior cervical discectomy and fusion (ACDF), (2) identify if preoperative marijuana use resulted in worse patient-reported outcome measures (PROMs), and (3) investigate if preoperative marijuana use affects the quantity of opioid prescriptions in the perioperative period. SUMMARY OF BACKGROUND DATA: A growing number of states have legalized recreational and/or medical marijuana, thus increasing the number of patients who report preoperative marijuana use. The effects of marijuana on clinical outcomes and PROMs in the postoperative period are unknown. METHODS: All patients 18 years of age and older who underwent primary one- to four-level ACDF with preoperative marijuana use at our academic institution were retrospectively identified. A 3:1 propensity match was conducted to compare patients who used marijuana versus those who did not. Patient demographics, surgical characteristics, clinical outcomes, and PROMs were compared between groups. Multivariate regression models measured the effect of marijuana use on the likelihood of requiring a reoperation and whether marijuana use predicted inferior PROM improvements at the one-year postoperative period. RESULTS: Of the 240 patients included, 60 (25.0%) used marijuana preoperatively. Multivariate logistic regression analysis identified marijuana use (odds ratio=5.62, P <0.001) as a predictor of a cervical spine reoperation after ACDF. Patients who used marijuana preoperatively had worse one-year postoperative Physical Component Scores of the Short-Form 12 (PCS-12) ( P =0.001), Neck Disability Index ( P =0.003), Visual Analogue Scale (VAS) Arm ( P =0.044) and VAS Neck ( P =0.012). Multivariate linear regression found preoperative marijuana use did not independently predict improvement in PCS-12 (ß=-4.62, P =0.096), Neck Disability Index (ß=9.51, P =0.062), Mental Component Scores of the Short-Form 12 (MCS-12) (ß=-1.16, P =0.694), VAS Arm (ß=0.06, P =0.944), or VAS Neck (ß=-0.44, P =0.617). CONCLUSION: Preoperative marijuana use increased the risk of a cervical spine reoperation after ACDF, but it did not significantly change the amount of postoperative opioids used or the magnitude of improvement in PROMs. LEVEL OF EVIDENCE: Levwl III.

Increased Surgical Site Subcutaneous Fat Thickness Is Associated with Infection after Posterior Cervical Fusion.

Background: Previous literature has associated increased body mass index (BMI) with risk of surgical site infection (SSI) after posterior cervical fusion (PCF) surgery. However, few studies have examined the association between local adiposity and risk of SSI, re-admission, and re-operation after PCF. Local adiposity is easily measured on pre-operative magnetic resonance imaging (MRI) and may act as a more accurate predictor compared with BMI. Patients and Methods: Subjects undergoing PCF from 2013-2018 at a single institution were identified retrospectively. Posterior cervical subcutaneous fat thickness, paraspinal muscle thickness, and lamina-to-skin distance measurements were obtained from computed tomography (CT) or MRI scans. Subjects with active infection, malignancy, or revision procedures were excluded. Results: Two hundred five patients were included with 20 developing SSIs. Subjects with SSIs had a longer fusion construct (4.90 vs. 3.71 levels; p = 0.001), higher Elixhauser comorbidity index (ECI; 2.05 vs. 1.34; p = 0.045), had a history of diabetes mellitus (30% vs. 10.8%; p = 0.026), higher subcutaneous fat thickness (30.5 vs. 23.6 mm; p = 0.013), and higher lamina-to-skin distance (66.4 vs. 57.9 mm; p = 0.027). Subcutaneous fat thickness (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.01-1.10]; p = 0.026) and lamina-to-skin distance (OR, 1.05; 95% CI, 1.01-1.09]; p = 0.014) were associated with SSI in multivariable analysis. A subcutaneous fat thickness cutoff value of 23.2 mm had 90% sensitivity and 54.1% specificity for prediction of SSI. There was no association need for re-admission or re-operation. Conclusions: Increased posterior cervical fat may increase the risk of SSI after PCF. Pre-operative advanced imaging may be a valuable tool for assisting with patient counseling, optimization, and risk stratification.