Implant-related complications in patients with opioid use disorder undergoing primary shoulder arthroplasties: a matched-controlled analysis.

Background: The purpose of this study was to investigate whether patients undergoing primary shoulder arthroplasty with opioid use disorder have higher rates of (1) implant-related complications; (2) in-hospital lengths of stay; (3) readmission rates; and (4) costs of care. Methods: Opioid use disorder patients undergoing primary shoulder arthroplasty were queried and matched in a 1:5 ratio to controls by age, sex, and medical comorbidities within the Medicare database. The query yielded 25,489 patients with (n = 4253) and without (n = 21,236) opioid use disorder. Primary outcomes analyzed included: 2-year implant related complications, in-hospital lengths of stay, 90-day readmission rates, and 90-day costs of care. A p value less than 0.01 was considered statistically significant. Results: Opioid use disorder patients had significantly longer in-hospital lengths of stay (3 days vs. 2 days; p < 0.0001) compared to matched controls. Opioid use disorder patients were also found to have higher incidence and odds (OR) of readmission rates (12.84 vs. 7.45%; OR: 1.16, p < 0.0001) and implant-related complications (20.03 vs. 7.95%; OR: 1.82, p < 0.0001). Study group patients also incurred significantly higher 90-day costs of care ($16,918.85 vs. $15,195.37, p < 0.0001). Discussion: This study can be used to help further augment efforts to reduce opioid prescriptions from healthcare providers in shoulder arthroplasty settings.

Comparison study of patient demographics and risk factors for infections following primary total hip arthroplasty for femoral neck fractures.

INTRODUCTION: While studies have shown favorable outcomes in the treatment of femoral neck fractures with the utilization of total hip arthroplasty (THA), adverse events, such as infections, can still occur. Therefore, the aims of this study were to 1) compare baseline demographics and 2) identify risk factors associated with developing either surgical site infections (SSIs) or peri-prosthetic joint infections (PJIs). MATERIALS AND METHODS: A retrospective analysis of patients who underwent primary THA for femoral neck fractures were queried from the Medicare database. The inclusion criteria consisted of patients developing SSIs within 90 days or PJIs within 3 years following the index procedure. The query yielded 2502 patients who developed infections in the form of either SSIs (n = 987) or PJIs (n = 1515) out of 57,191 patients treated for femoral neck fractures with primary THA. Primary endpoints were to compare baseline demographic profiles and determine risk factors associated with developing infections. Multivariate binomial logistic regression analyses were performed to determine the odds (OR) of developing infections. A p value less than 0.001 was considered to be statistically significant. RESULTS: Patients who developed either infections were found to be significantly different when compared to patients who did not develop infections. SSI (10 vs. 8, p < 0.0001) and PJI (9 vs. 5, p < 0.0001) patients both had significantly higher mean Elixhauser Comorbidity Index (ECI) scores compared to their counterparts. The regression model found the greatest risks for developing SSIs included hypertension (OR 1.63, p = 0.001), pathologic weight loss (OR 1.58, p < 0.0001), and iron deficiency anemia (IDA) (OR 1.48, p < 0.0001), whereas IDA (OR 2.14, p < 0.0001), pathologic weight loss (OR 1.75, p < 0.0001), and rheumatoid arthritis (OR 1.57, p < 0.0001) increased the odds for PJIs. CONCLUSION: This study can be utilized by orthopedic surgeons and other healthcare professionals to adequately educate these patients of the complications which may occur following their surgery.

A matched-control study on the effects of depressive disorders following open reduction and internal fixation for acetabular fractures.

INTRODUCTION: The World Health Organization (WHO) postulates that depressive disorders (DD) will be the leading cause of morbidity and mortality by 2030. Studies evaluating the association of DD following open reduction and internal fixation (ORIF) for the treatment of acetabular fractures are limited. Therefore, the purpose of this matched-control study was to determine whether DD patients undergoing ORIF for acetabular fractures have higher rates of: (1) in-hospital lengths of stay (LOS); (2) readmissions; (3) medical complications; and (4) costs of care. MATERIALS AND METHODS: A retrospective query from the 100% Medicare Standard Analytical Files (SAF) was performed to identify patients who underwent ORIF for acetabular fractures. The study group consisted of those patients with DD, whereas patients without the condition served as controls. Primary endpoints of the study were to compare in-hospital LOS, readmission rates, ninety-day medical complications, and costs of care. A p-value less than 0.01 was considered statistically significant. RESULTS: The query yielded 7084 patients within the study (ORIF = 1187, control = 5897). DD patients were found to have significantly longer in-hospital LOS (11 days vs. 10 days, p < 0.0001); however, odds (OR) of readmission rates were similar (23.16 vs. 18.68%; OR: 0.91, p = 0.26). Multivariate regression demonstrated DD to be associated with significantly higher (67.69 vs. 25.54%; OR: 2.64, p < 0.0001) 90-day medical complications. DD patients had significantly higher day of surgery ($30,505.93 vs. $28,424.85, p < 0.0001) and total global 90-day costs ($41,721.98 vs. $37,330.16, p < 0.0001) of care. CONCLUSION: After adjusting for covariates, DD is associated with longer in-hospital, complications, and costs of care in patients undergoing ORIF for the treatment of acetabular fractures, whereas readmission rates are similar. The study is vital as it can be used by orthopaedists and healthcare professionals to adequately educate these patients of the potential outcomes following their surgical procedure.

Comparison of Patient Demographics and Patient-Related Risk Factors for Infections After Primary Total Hip Arthroplasty for Acetabular Fractures.

INTRODUCTION: In the proper age group, there is evidence that total hip arthroplasty (THA) has superior outcomes for the treatment of acetabular fractures compared with open reduction and internal fixation. Studies comparing patient demographics and identifying risk factors for either surgical site infections (SSIs) or periprosthetic joint infections (PJIs) are limited. Therefore, the purpose of this study was to (1) compare baseline demographics of patients who did and did not develop infections and (2) identify risk factors associated with developing either SSIs or PJIs. METHODS: A retrospective study from 2005 to 2014 was done using a nationwide claims database. The inclusion criteria consisted of patients sustaining an acetabular fracture and treated with THA who developed either SSIs or PJIs within 90 days or 2 years, respectively, whereas patients not developing infections served as control subjects. The final study yielded 13,059 patients within the study (n = 988) and control cohort (n = 12,071). Baseline demographics were compared. A multivariate regression model calculated the odds ratio (OR) associated with development of infections. P value less than 0.002 was considered statistically significant. RESULTS: The study demonstrated significant differences among the cohorts regarding baseline demographics. The greatest risk factors for SSIs within 90 days were morbid obesity (OR: 1.84, P < 0.0001), pathologic weight loss (OR: 1.64, P < 0.0001), and iron deficiency anemia (OR: 1.59, P = 0.001). An increased risk of PJIs was associated with iron deficiency anemia (OR: 1.97, P < 0.0001), pathologic weight loss (OR: 1.72, P < 0.0001), and morbid obesity (OR: 1.70, P = 0.0001). CONCLUSION: This study found notable differences between baseline demographics of the cohorts and a myriad of risk factors associated with developing infections after THA for acetabular fractures. This study provides insight into orthopaedic surgeons and other healthcare professionals on the need of properly educating these high-risk patients of the potential consequences which they may encounter after their procedure. LEVEL OF EVIDENCE: Level III.

The Psychological Effects of Musculoskeletal Trauma.

Musculoskeletal injuries comprise a large percentage of hospital admissions for adults and often contribute to persistent daily pain as an illness; opioid dependence; disability; and complaints of increased depression, anxiety, and symptoms of post-traumatic stress disorder. The prevalence of depression and post-traumatic stress disorder after orthopaedic trauma has been found to be considerably greater than the general adult cohort. Soon after sustaining a fracture, psychological factors can predict pain and disability many months after injury, even after controlling for injury severity. Thus, early in the care of orthopaedic trauma, there exists an opportunity to improve overall health by attending to psychological and social concerns, along with physical health. Recent literature has identified clinically actionable subgroups within the orthopaedic trauma cohort that are at psychological risk after an injury. Improving positive factors such as resilience, social support, and self-efficacy via validated interventions such as Cognitive-Behavioral Therapy, mindfulness training, and other types of mindset training has helped people return to their daily routine. Raising awareness of the psychological effects of trauma among the orthopaedic community could improve post-treatment planning, increase referrals to appropriate nonmedical professionals, and implement earlier effective interventions.

Effect of weekend admission on geriatric hip fractures.

BACKGROUND: The care discrepancy for patients presenting to a hospital on the weekend relative to the work week is well documented. With respect to hip fractures, however, there is no consensus about the presence of a so-called "weekend effect". This study sought to determine the effects, if any, of weekend admission on care of geriatric hip fractures admitted to a large tertiary care hospital. It was hypothesized that geriatric hip fracture patients admitted on a weekend would have longer times to medical optimization and surgery and increased complication and mortality rates relative to those admitted on a weekday. AIM: To determine if weekend admission of geriatric hip fractures is associated with poor outcome measures and surgical delay. METHODS: A retrospective chart review of operative geriatric hip fractures treated from 2015-2017 at a large tertiary care hospital was conducted. Two cohorts were compared: patients who arrived at the emergency department on a weekend, and those that arrived at the emergency department on a weekday. Primary outcome measures included mortality rate, complication rate, transfusion rate, and length of stay. Secondary outcome measures included time from emergency department arrival to surgery, time from emergency department arrival to medical optimization, and time from medical optimization to surgery. RESULTS: There were no statistically significant differences in length of stay (P = 0.2734), transfusion rate (P = 0.9325), or mortality rate (P = 0.3460) between the weekend and weekday cohorts. Complication rate was higher in patients who presented on a weekend compared to patients who presented on a weekday (13.3% vs 8.3%; P = 0.044). Time from emergency department arrival to medical optimization (22.7 h vs 20.0 h; P = 0.0015), time from medical optimization to surgery (13.9 h vs 10.8 h; P = 0.0172), and time from emergency department arrival to surgery (42.7 h vs 32.5 h; P < 0.0001) were all significantly longer in patients who presented to the hospital on a weekend compared to patients who presented to the hospital on a weekday. CONCLUSION: This study provided insight into the "weekend effect" for geriatric hip fractures and found that day of presentation has a clinically significant impact on delivered care.

Does Care at a Trauma Center Affect Geriatric Hip Fracture Patients?

INTRODUCTION: With respect to care setting, there are mixed results in the literature with respect to the role of trauma centers in management of isolated geriatric hip fractures. During a transition from a Level 3 to a Level 1 trauma center, significant protocol changes were implemented that sought to standardize and improve the care of hip fracture patients. The objective of this study was to determine the effects of this transition on the management, efficiency, morbidity, mortality, and discharge of geriatric hip fracture patients. METHODS: A retrospective chart review of geriatric hip fractures treated operatively was conducted. Two cohorts were compared: hip fractures in the year prior to (2015) and year following (2017) Level 1 Trauma designation. Primary outcome measures were length of stay (LOS), transfusion rate, complication rate, and mortality rate. Secondary outcome measures were time from emergency department (ED) arrival to medical optimization, time from medical optimization to surgery, time from ED arrival to surgery, and discharge destination. RESULTS: There were no differences in LOS, transfusion rate, or complication rate between the two cohorts. There was a nonsignificant trend toward lower in-hospital mortality after the transition (2.24% vs 0.83%). There were no differences in time from ED arrival to medical optimization, time from medical optimization to surgery, time from ED arrival to surgery, and percentage of patients discharged home between the cohorts. DISCUSSION: Management of operative geriatric hip fractures at our institution has remained consistent following transition to a Level 1 trauma center. There was a trend toward lower mortality after transition, but this difference was not statistically significant. We attribute the variety of findings in the literature with respect to trauma center management of hip fractures to individualized institutional trauma protocols as well as the diverse patient populations these centers serve.

Patient outcomes for the Internal Joint Stabilizer of the Elbow (IJS-E).

BACKGROUND: Recently, the Internal Joint Stabilizer of the Elbow (IJS-E) was developed as an internal dynamic fixator for use in the setting of traumatic elbow instability. This study reviews the patients who had an IJS-E placed at our institution. Specifically, postoperative complications, postoperative functional outcomes, and need for subsequent procedures were reviewed. METHODS: A retrospective chart review was conducted of patients in whom the IJS-E was implanted from June 2016 to July 2018. Indications for use, range of motion at final follow-up, and the need for subsequent procedures were reviewed. Disabilities of the Arm, Shoulder, and Hand (DASH) and Broberg-Morrey scores were also obtained. RESULTS: Ten IJS-E devices were implanted into 10 patients. Average length of follow-up was 13.4 months. Average flexion-extension and pronation-supination motion arcs at final follow-up were 106° and 141°, respectively. Seventy-eight percent of patients achieved >100° arcs of both flexion-extension and pronation-supination. Average DASH and Broberg-Morrey scores were 28.7 and 68.2, respectively. Four subsequent procedures were required in 4 patients: 2 contracture releases, 1 medial collateral ligament reconstruction, and 1 total elbow arthroplasty. There were no postoperative infections or nerve injuries. DISCUSSION: The IJS-E has replaced the use of external hinged fixation at our institution. Final range of motion was consistent with that reported for terrible triad and complex elbow dislocation injuries. The IJS-E is a good option for use in patients with traumatic elbow instability, as it restores motion and function without immediate postoperative complication. However, it does not eliminate the potential for future operative intervention in these complex injuries.

Self-Reduction of Displaced Bucket-Handle Medial Meniscal Tear in a 71-Year-Old Patient: A Case Report.

BACKGROUND: Bucket-handle meniscal tears are rare in geriatric patients. Displaced bucket-handle meniscal tears are usually treated operatively. Due to the rarity of these tears in elderly patients and conflicting evidence regarding the use of arthroscopy versus conservative treatment, it is valuable to report the clinical presentation, treatment, and outcome of these injuries in elderly patients. CASE DESCRIPTION: We describe a 71-year-old man who presented with an acute, displaced, magnetic resonance imaging (MRI)-confirmed right medial meniscal bucket-handle tear with mild effusion and no signs of degenerative joint disease. On physical examination, the patient was unable to fully extend the right leg due to locking of the knee. At 2-month follow-up, MRI showed mild degenerative changes and an anatomically reduced tear. At 6-month follow-up, the patient reported normal, pain-free knee function, and MRI showed the tear healing in anatomic position with minimal inferior surface changes and no effusion. He returned to his pain-free baseline level of physical activity. LITERATURE REVIEW: Upon review of the English literature, this 71-year-old patient is an exceptional case and one of the oldest patients reported to have sustained a displaced medial meniscal bucket-handle tear treated successfully with nonoperative means. Two reported cases of spontaneously reduced meniscal bucket-handle tears were found in the English literature, although both cases were seen in much younger males and involved the lateral meniscus. CLINICAL RELEVANCE: This case suggests that in elderly patients with displaced medial meniscus bucket-handle tears that reduce spontaneously, the physician can safely and efficaciously use conservative, nonoperative management to achieve restoration of baseline knee function and anatomic meniscal healing while avoiding the risks of arthroscopic surgery. Surgical intervention for reduction without repair may be an available option, but no literature is present to direct care; however, complete documentation as in the current case would be instructive. Katz et al have reported that physical therapy was as efficacious as surgical intervention, although the specific displaced bucket-handle tear was not reported.