Predicting operative outcomes of total shoulder arthroplasty using the model for end-stage liver disease score.

Background: The aim of this study was to assess the efficacy of the Model for End-Stage Liver Disease (MELD) score in predicting postoperative complications following total shoulder arthroplasty (TSA). Methods: The American College of Surgeons National Surgical Quality Improvement database was queried for all patients who underwent TSA between 2015 and 2019. The study population was subsequently classified into two categories: those with a MELD score ≥ 10 and those with a MELD score < 10. A total of 5265 patients undergoing TSA between 2015 and 2019 were included in this study. Among these, 4690 (89.1%) patients had a MELD score ≥ 10, while 575 (10.9%) patients had a MELD score < 10. Postoperative complications within 30 days of the TSA were collected. Multivariate logistic regression analysis was conducted to explore the correlation between a MELD score ≥ 10 and postoperative complications. The anchor based optimal cutoff was calculated by receiver operating characteristic analysis to determine the MELD score cutoff that most accurately predicts a specific complication. Youden's index (J) determined the optimal cutoff point calculation for the maximum sensitivity and specificity; these were deemed to be "acceptable" if the area under curve (AUC) was greater than 0.7 and "excellent" if greater than 0.8. Results: Multivariate regression analysis found a MELD score ≥ 10 to be independently associated with higher rates of reoperation (OR, 2.08; P = .013), cardiac complications (OR, 3.37; P = .030), renal complications (OR, 7.72; P = .020), bleeding transfusions (OR, 3.23; P < .001), and nonhome discharge (OR, 1.75; P < .001). The receiver operating characteristic analysis showed that AUC for a MELD score cutoff of 7.61 as a predictor of renal complications was 0.87 (excellent) with sensitivity of 100.0% and specificity of 70.0%. AUC for a MELD score cutoff of 7.76 as a predictor of mortality was 0.76 (acceptable) with sensitivity of 81.8% and specificity of 71.0%. Conclusion: A MELD score ≥ 10 was correlated with high rates of reoperation, cardiac complications, renal complications, bleeding transfusions, and nonhome discharge following TSA. MELD score cutoffs of 7.61 and 7.76 were effective in predicting renal complications and mortality, respectively.

Cumulative effect of chronic dehydration and age on postoperative complications after total shoulder arthroplasty.

Background: Dehydration is a modifiable risk factor that should be optimized prior to all surgical procedures. The aim of this study was to determine the effects of dehydration on postoperative complications following total shoulder arthroplasty (TSA). Methods: The American College of Surgeons National Surgical Quality Improvement database was queried for all patients who underwent TSA between 2015 and 2019 and a total of 16,993 patients were included in this study. The study population was subsequently classified into 3 categories: 8498 (50.0%) nondehydrated patients with blood urea nitrogen/creatinine (BUN/Cr) < 20, 4908 (28.9%) moderately dehydrated patients with 20 ≤ BUN/Cr ≤ 25, and 3587 (21.1%) severely dehydrated patients with 25 < BUN/Cr. A subgroup analysis involving only elderly patients aged > 65 years and normalized gender-adjusted Cr values was also performed. Postoperative complications within 30 days of the TSA were collected. Multivariate logistic regression analysis was conducted to explore the correlation between dehydration and postoperative complications. Results: Adjusted multivariate logistic regression analysis showed that the severely dehydrated cohort had a greater risk of postoperative transfusion, mortality, nonhome discharge, and increased length of stay (all P < .05). The moderately dehydrated cohort had a greater risk of wound dehiscence (P = .044). Among the elderly, severely dehydrated patients had a greater risk of cardiac complications, postoperative transfusion, mortality, nonhome discharge, and increased length of stay (all P < .05). Finally, the elderly moderately dehydrated cohort had a greater risk of postoperative transfusion and nonhome discharge (all P < .05). Conclusion: BUN/Cr ratio is an important preoperative diagnostic tool to identify at-risk dehydrated patients. Providers should optimize dehydration to prevent complications, decrease costs, and improve discharge planning.

Chronic Steroid Use, Complications, and Readmission Following Open Reduction Internal Fixation of Distal Radius Fracture.

Purpose: The increasing incidence of both distal radius fractures (DRFs) and chronic conditions that necessitate long-term steroid use has resulted in a growing intersection between the patient populations of the two. Chronic steroid use is known to increase bone frailty and the likelihood of fractures but may also contribute to poorer outcomes following the repair of DRF. The purpose of this study was to investigate the association between preoperative chronic steroid use, postoperative complications, and readmission after open reduction internal fixation (ORIF) of DRF. Methods: The American College of Surgeons National Surgical Quality Improvement database was queried for all patients who underwent DRF ORIF between 2015 and 2021. However, 30-day postoperative complications after DRF ORIF were collected. Multivariate logistic regression analysis was conducted to investigate the relationship among preoperative chronic steroid use, postoperative complications, and patient factors associated with readmission. Results: The postoperative complications associated with the steroid cohort were categorized as major, minor, and overall complications. Additionally, pneumonia, stroke, myocardial infarction, bleeding transfusions, deep vein thrombosis, pulmonary embolism, readmission, non-home discharge, and mortality were recorded. Chronic steroid use was found to be independently associated with major , minor, and overall complications, deep vein thrombosis, and readmission. Further investigation of readmission showed that male sex and comorbid chronic obstructive pulmonary disease were the only two patient factors independently associated with a greater likelihood of readmission after DRF ORIF. Conclusions: Preoperative chronic steroid use was associated with an increasing rate of postoperative complications after DRF ORIF. Male sex and comorbid chronic obstructive pulmonary disease were characteristics of chronic steroid-use patients independently associated with increased risk of readmission after DRF ORIF. A better understanding of preoperative chronic steroid use as a risk factor for postoperative complications may allow surgeons to improve preoperative risk stratification and patient counseling in the management of DRF. Type of study/level of evidence: Prognostic III.

Identifying risk factors for 30-day readmission after outpatient total shoulder arthroplasty to aid in patient selection.

Background: A recent meta-analysis comparing inpatient and outpatient total shoulder arthroplasty (TSA) showed no statistically significant differences in complications, readmissions, revisions, and infections. However, there remains no research on the appropriate patient selection for outpatient TSA surgeries. This retrospective review seeks to aid surgeons in refining a safe patient selection algorithm by evaluating risk factors through a large database analysis of TSA surgeries. Methods: Patients who underwent TSA between 2015 and 2020 were identified in the National Surgical Quality Improvement Program database. Patients with a hospital stay of 0 days were designated as outpatient procedures. Multivariate analyses were used to determine risk factors for 30-day readmission following outpatient TSA and whether risk factors remained significant following overnight hospital stay. Results: A total of 2431 outpatient TSA patients were identified. The incidence of 30-day readmission was 1.8%. The majority of readmissions were due to pulmonary complications. The clinically significant risk factors for 30-day readmission were chronic steroid use (odds ratio [OR] 3.55, 95% confidence interval [CI] 1.34-9.43; P = .011), chronic obstructive pulmonary disease (COPD) (OR 3.11, 95% CI 1.16-8.34; P = .024), and current smoking status (OR 2.27, 95% CI 1.02-5.03; P = .045). After overnight hospital stay, chronic steroid use and current smoking status were not significant, but COPD remained significant. Conclusion: Patients with chronic steroid use, COPD, or current smoking status are at increased risk for 30-day readmission. Inpatient hospital stay appears to benefit patients with chronic steroid use and current smoking status. Patients with COPD should be admitted for inpatient stay postoperatively but may still have high 30-day readmission rates following discharge.

Abnormal preoperative leukocyte counts and postoperative complications following total shoulder arthroplasty.

Background: Total shoulder arthroplasty (TSA) has become the mainstay of treatment for degenerative glenohumeral arthritis, proximal humerus fracture, and rotator cuff arthropathy. The expanding indications for reverse TSA have increased the overall demand for TSA. This necessitates higher quality preoperative testing and risk stratification. White blood cell counts can be obtained from routine preoperative complete blood count testing. The association between abnormal preoperative white blood cell counts and postoperative complications has not been extensively studied. The purpose of this study was to investigate the association between abnormal preoperative leukocyte counts and 30-day postoperative complications following TSA. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent TSA between 2015-2020. Patient demographics, comorbidities, surgical characteristics, and 30-day postoperative complication data were collected. Multivariate logistic regression was used to identify postoperative complications associated with preoperative leukopenia and leukocytosis. Results: In this study, 23,341 patients were included: 20,791 (89.1%) were in the normal cohort, 1307 (5.6%) were in the leukopenia cohort, and 1243 (5.3%) were in the leukocytosis cohort. Preoperative leukopenia was significantly associated with higher rates of bleeding transfusions (P = .011), deep vein thrombosis (P = .037), and non-home discharge (P = .041). After controlling for significant patient variables, preoperative leukopenia was independently associated with higher rates of bleeding transfusions (odds ratios [OR] 1.55, 95% confidence intervals [CI] 1.08-2.23; P = .017) and deep vein thrombosis (OR 2.26, 95% CI 1.07-4.78; P = .033). Preoperative leukocytosis was significantly associated with higher rates of pneumonia (P < .001), pulmonary embolism (P = .004), bleeding transfusions (P < .001), sepsis (P = .007), septic shock (P < .001), readmission (P < .001), and non-home discharge (P < .001). After controlling for significant patient variables, preoperative leukocytosis was independently associated with higher rates of pneumonia (OR 2.20, 95% CI 1.30-3.75; P = .004), pulmonary embolism (OR 2.43, 95% CI 1.17-5.04; P = .017), bleeding transfusions (OR 2.00, 95% CI 1.46-2.72; P < .001), sepsis (OR 2.95, 95% CI 1.20-7.25; P = .018), septic shock (OR 4.91, 95% CI 1.38-17.53; P = .014), readmission (OR 1.36, 95% CI 1.03-1.79; P = .030), and non-home discharge (OR 1.61, 95% CI 1.35-1.92; P < .001). Conclusion: Preoperative leukopenia is independently associated with higher rates of deep vein thrombosis within 30 days following TSA. Preoperative leukocytosis is independently associated with higher rates of pneumonia, pulmonary embolism, bleeding transfusion, sepsis, septic shock, readmission, and non-home discharge within 30 days following TSA. Understanding the predictive value of abnormal preoperative lab values will aid in perioperative risk stratification and minimize postoperative complications.

A Biomechanical Comparison of Alternative Graft Preparations for All-Inside Anterior Cruciate Ligament Reconstruction.

PURPOSE: To biomechanically compare alternative graft constructs for all-inside anterior cruciate ligament (ACL) reconstruction in the event that the semitendinosus harvested is too narrow or too short to make a graft larger than 8 mm. METHODS: Bovine extensor tendons were used to make 6 different 9-mm-diameter grafts: traditional 4-strand, anastomosis 4-strand, 6-strand, 3-strand, button-fixation 4-strand, and loop-and-tack 4-strand grafts. The grafts were then subjected to cyclic biomechanical testing followed by failure loading. Force at 3 and 5 mm of displacement and ultimate force were recorded for all grafts. RESULTS: Compared with the traditional 4-strand graft, the only graft that showed significant biomechanical differences during the cyclic phase of testing was the button-fixation 4-strand graft, which was characterized by lower force at 3 mm of displacement (74 ± 34 N vs 122 ± 13 N, P = .004) and 5 mm of displacement (122 ± 35 N vs 172 ± 3 N, P = .006). During failure loading, ultimate force was significantly lower for both the 6-strand graft (491 ± 186 N, P = .041) and button-fixation 4-strand graft (326 ± 27 N, P < .001) than for the traditional 4-strand graft (778 ± 176 N). All other grafts were equivalent for the parameters tested. CONCLUSIONS: The anastomosis 4-strand, 3-strand, and loop-and-tack 4-strand grafts do not biomechanically differ in cyclic loading and ultimate force from traditional 4-strand grafts. This study supports the use of anastomosis 4-strand, 3-strand, or loop-and-tack 4-strand grafts in the event that a traditional all-inside 4-strand graft cannot be prepared from a harvested semitendinosus tendon in ACL reconstruction. CLINICAL RELEVANCE: This study tests and describes alternatives to the traditional 4-strand semitendinosus autograft for all-inside ACL reconstruction in the event that the harvested tendon is not adequate.

Functional Outcomes of Modular Conversion of Hemiarthroplasty or Total to Reverse Total Shoulder Arthroplasty.

BACKGROUND: The advent of modular shoulder arthroplasty systems has allowed the conversion of hemiarthroplasty or total shoulder arthroplasty to reverse total shoulder arthroplasty (RTSA) without removing a well-fixed stem. QUESTIONS/PURPOSES: To determine the feasibility, functional outcome, and complication profile of RTSA modular conversion. METHODS: A prospective shoulder arthroplasty registry was queried for consecutive patients scheduled for a modular conversion from January 1, 2007, to April 1, 2015. Eligible patients had medical charts and operative records reviewed for preoperative diagnosis, age, medical comorbidities, preoperative American Shoulder and Elbow Society (ASES) score, preoperative Visual Analogue Scale (VAS) pain and instability scores, and intraoperative findings. Each patient was then contacted by telephone or mail to complete up-to-date ASES and VAS questionnaires. RESULTS: Seventeen patients underwent a modular conversion. Nine patients were scheduled for modular conversion but underwent humeral revision due to excessive soft tissue tension (65.3% modular conversion rate). Average follow-up was 37.4 months (range 10.0-67.6 months). Pain scores improved from 5.3 (range 0.4 to 8.0) to 2.4 (range 0 to 9.3) (p < 0.01), instability VAS from 5.2 (range 0 to 10) to 1.1 (range 0 to 6.8) (p < 0.01), and ASES scores improved from 35.2 (range 20.7 to 61.3) to 65.6 (range 11.8 to 92) (p < 0.01). CONCLUSIONS: Modular conversion of an anatomic to a RTSA is feasible in a majority of patients. Despite the complexity of the procedure, modular conversion of hemiarthroplasty or TSA to RTSA can significantly improve functional outcomes with a low rate of complications.

Pectoralis major tendon tears: functional outcomes and return to sport in a consecutive series of 40 athletes.

BACKGROUND: There are limited data on the outcomes of surgically repaired pectoralis major tendon (PMT) tears. The purpose of this study was to report the functional outcomes, return to sport, and second surgery rates in a consecutive series of PMT tears. METHODS: Forty patients with acutely repaired PMT tears were retrospectively identified. Follow-up was conducted with functional outcome scores and adduction strength testing at final follow-up. Return to sport and incidence of subsequent surgery were also recorded. RESULTS: The average age of the patients was 34.4 years (range, 23-59 years). Average follow-up was 2.5 years (range, 2-7.0 years). Twenty-three injuries (58%) occurred in the nondominant extremity. Bench press (n = 26) and contact sport participation (n = 14) were the most common mechanisms. Postoperative Single Assessment Numeric Evaluation scores averaged 93.6 (range, 62-100), with patient satisfaction of 9.6 of 10 (range, 6-10). All athletes returned to preinjury level of function approximately 5.5 months postoperatively (range, 4.5-6.5 months); 23.1% and 2.6% described mild or moderate difficulties with sport participation. Isokinetic strength evaluation revealed an average decrease of 9.9% (range, -18% to 41%). Application of the Bak criteria revealed 37% excellent, 26% good, and 37% fair outcomes, with most in the fair group reporting cosmetic concerns. Removing cosmesis, 46% scored excellent, 37% good, and only 17% fair. Three athletes required a second surgical procedure (7.5%). CONCLUSIONS: Surgical repair of PMT tears resulted in high patient satisfaction, with excellent restoration of function and adduction strength, early return to sport, and few reoperations, albeit with the potential for mild cosmetic concerns.

A Systematic Review of Preoperative Fatty Infiltration and Rotator Cuff Outcomes.

BACKGROUND: Fatty infiltration (FI) of the muscle as graded by the Goutallier classification (GC) is a well-known sequela following rotator cuff injury. The degree to which this predicts the success of rotator cuff repair is unknown. QUESTIONS/PURPOSES: We conducted a systematic review to address the following questions: (1) Does the grade of FI of the rotator cuff muscles present preoperatively predict retear rates postoperatively? (2) Are amounts of preoperative FI predictive of functional outcomes following repair? METHODS: Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Central Register of Controlled Trials online databases were searched for all literature published between January 1966 and March 2015. Keywords were chosen to achieve a broad search category. All articles were reviewed by three of the authors, and those meeting the study inclusion criteria were selected for data abstraction. RESULTS: The systematic literature review yielded 11 studies reporting on a total of 925 shoulders. Rotator cuffs with moderate or significant FI preoperatively (grades 2-4) had a significantly higher retear rate than those with no or minimal FI (grades 0-1) (59 vs. 25%, p = 0.045). Four studies reported postoperative Constant scores and preoperative GC scores. One study found that lower GC scores were associated with higher Constant scores postoperatively, one found no association, and the data was inconclusive in the other two. CONCLUSIONS: While lower preoperative GC scores are associated with lower rates of rotator cuff retear following repair, there is insufficient data to make conclusions on the effects of FI on functional outcomes following repair.