What Factors Lead to Racial Disparities in Outcomes After Total Knee Arthroplasty?

Total knee arthroplasty (TKA) is one of the most commonly performed, major elective surgeries in the USA. African American TKA patients on average experience worse clinical outcomes than whites, including lower improvements in patient-reported outcomes and higher rates of complications, hospital readmissions, and reoperations. The mechanisms leading to these racial health disparities are unclear, but likely involve patient, provider, healthcare system, and societal factors. Lower physical and mental health at baseline, lower social support, provider bias, lower rates of health insurance coverage, higher utilization of lower quality hospitals, and systemic racism may contribute to the inferior outcomes that African Americans experience. Limited evidence suggests that improving the quality of surgical care can offset these factors and lead to a reduction in outcome disparities.

Defining recovery trajectories after shoulder arthroplasty: a latent class analysis of patient-reported outcomes.

BACKGROUND: Patients undergoing total shoulder arthroplasty (TSA) can have varying levels of improvement after surgery. As patients typically demonstrate a nonlinear recovery trajectory, advanced analysis investigating the degrees of variation in outcomes is needed. Latent class analysis (LCA) is a mixed and multilevel model that estimates random slope variance to evaluate heterogeneity in outcome patterns among patient subgroups and can be used to outline differing recovery trajectories. The purpose of this study was to determine recovery trajectory patterns after TSA and to identify factors that predict a given trajectory. METHODS: Data from a prospectively collected single institutional database of patients undergoing anatomic and reverse TSA were utilized. Patients were included if they had American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores preoperatively, as well as postoperative scores at 6 weeks, 6 months, 1 year, and 2 years. Patients were excluded if they underwent a revision procedure or hemiarthroplasty or had prior infection. LCA was used to subdivide the patient cohort into subclasses based on postoperative recovery trajectory. This was performed for all patients as well as anatomic TSA and reverse TSA as separate groups. Unpaired Student t tests, analysis of variance, and Fisher exact test were used to compare classes based on factors including age, body mass index, sex, preoperative diagnosis, and type of arthroplasty. RESULTS: A total of 244 TSAs were included in the final analysis, comprising 89 anatomic TSA and 155 reverse TSA. In the combined group, LCA modeling revealed 3 patterns for recovery: Resistant Responders had low baseline scores (ASES < 30) and poor final results (ASES < 50), Steady Progressors had moderate baseline scores (ASES 30-50) with moderate final results (ASES 50-75), and High Performers had moderate baseline scores (ASES > 50) with excellent final results (ASES > 75). For anatomic TSA, we identified Delayed Responders with moderate baseline scores and a delayed response before ultimately achieving moderate final results, Steady Progressors with moderate baseline scores and a steady progression to achieve moderate final results, and High Performers who had moderate baseline scores and excellent final results. For reverse TSA, we identified Late Regressors with low baseline scores and poor final results, Steady Progressors with moderate baseline scores and moderate final results, and High Performers with moderate baseline scores and excellent final results. CONCLUSIONS: Patients recover in a heterogenous manner following TSA. Through LCA, we identified different recovery trajectories for patients undergoing anatomic TSA and reverse TSA.

Incidence of anterior cruciate ligament graft tears in high-risk populations: An analysis of professional athlete and pediatric populations.

BACKGROUND: Professional athletes are at increased risk of injury with high activity levels and additional pressure to return to sports quickly after anterior cruciate ligament (ACL) injury. The purpose of this study was to determine ACL graft re-tear rates in National Basketball Association (NBA), Major League Baseball (MLB), and National Hockey League (NHL) athletes using publicly available databases and to compare these to general populations, National Football League (NFL) athletes, and the pediatric population to establish a baseline for those partaking in high-risk sporting activity. METHODS: A comprehensive online search was performed to identify athletes in the NBA, MLB, and NHL who had a reported ACL tear between 2007 and 2017. For each tear, the type of tear (initial or re-tear) and return to play data were documented. Comparisons of re-tear rates from these leagues to prior registry, meta-analyses, and epidemiologic studies were performed using Fisher's exact or Chi-squared tests. RESULTS: The aggregate re-tear rate was 11.9%. ACL re-tear rates by league did not statistically differ. Return to play rate after index surgery was 95.8%, whereas after a revision procedure was 92.3%. There was a statistically significant difference between the studied ACL re-tear rates (NBA, MLB, NHL) and those of national registries (P < 0.01), and no difference when compared with the pediatric population or with the NFL. CONCLUSIONS: Exposure to higher-risk sporting activity, common to pediatric patients and professional athletes, is a likely major influential factor in ACL re-tear.

Fracture Epidemiology in Professional Baseball From 2011 to 2017.

BACKGROUND: Fractures are a significant cause of missed time in Major League Baseball (MLB) and Minor League Baseball (MiLB). MLB and the MLB Players Association recently instituted rule changes to limit collisions at home plate and second base. PURPOSE: To evaluate the epidemiologic characteristics of fractures in professional baseball and to assess the change in acute fracture incidence secondary to traumatic collisions at home plate and second base after the recently instituted rule changes. STUDY DESIGN: Descriptive epidemiology study. METHODS: The MLB Health and Injury Tracking System (HITS) database was used to access injury information on MLB and MiLB players to analyze fracture data from 2011 to 2017. Injuries were included if the primary diagnosis was classified as a fracture in the HITS system in its International Classification of Diseases, Ninth Revision, codes; injuries were excluded if they were not work related, if they occurred in the offseason, or if they were sustained by a nonplayer. The proportion of fractures occurring due to contact with the ground or another person in the relevant area of the field-home plate or second base-in the years before rule implementation was compared with the years after. RESULTS: A total of 1798 fractures were identified: 342 among MLB players and 1456 among MiLB players. Mean time missed per fracture was 56.6 ± 48.4 days, with significantly less time missed in MLB (46.8 ± 47.7 days) compared with MiLB (59.0 ± 48.3 days) (P < .0001). A 1-way analysis of variance with post hoc Bonferroni correction demonstrated that starting pitchers missed significantly more time due to fractures per injury than all other position groups (P < .0001). Acute fractures due to contact with the ground or with another athlete were significantly decreased after rule implementation at home plate in 2014 (22 [3.0%] vs 14 [1.3%]; P = .015) and at second base in 2016 (90 [7.0%] vs 23 [4.5%]; P = .045). CONCLUSION: The recently instituted rule changes to reduce collisions between players at home plate and at second base are associated with reductions in the proportion of acute fractures in those areas on the field.

Social Determinants of Health and Patient-Reported Outcomes Following Total Hip and Knee Arthroplasty in Veterans.

BACKGROUND: Social determinants of health (SDOH) are the conditions in which people are born, grow, live, work, and age. They are associated with disparities in outcomes following total joint arthroplasty (TJA). These disparities occur even in equal-access healthcare systems such as the Veterans Health Administration (VHA). Our goal was to determine whether SDOH affect patient-reported outcome measures (PROMs) following TJA in VHA patients. METHODS: Patients scheduled to undergo total hip or knee arthroplasty at VHA Hospitals in Minneapolis, MN, Palo Alto, CA, and San Francisco, CA, prospectively completed PROMs before and 1 year after surgery. PROMs included the Hip disability and Osteoarthritis Outcome Score, the Knee injury and Osteoarthritis Outcome Score, and their Joint Replacement subscores. SDOH included race, ethnicity, marital status, education, and employment status. The level of poverty in each patient's neighborhood was determined. Medical comorbidities were recorded. Univariate and multivariate analyses were performed to determine whether SDOH were significantly associated with PROM improvement after surgery. RESULTS: On multivariate analysis, black race was significantly negatively correlated with knee PROM improvement and Hispanic ethnicity was significantly negatively correlated with hip PROM improvement compared to whites. Higher baseline PROM scores and lower age were significantly associated with lower PROM improvement. Significant associations were also found based on education, gender, comorbidities, and neighborhood poverty. CONCLUSION: Minority VHA patients have lower improvement in PROM scores after TJA than white patients. Further research is required to identify the reasons for these disparities and to design interventions to reduce them.

What Is the Appropriate Price for Platelet-Rich Plasma Injections for Knee Osteoarthritis? A Cost-Effectiveness Analysis Based on Evidence From Level I Randomized Controlled Trials.

PURPOSE: To identify the price of treatment at which platelet-rich plasma (PRP) is cost-effective relative to hyaluronic acid (HA) and saline solution intra-articular injections. METHODS: A systemized review process of the PubMed, Embase, and MEDLINE databases was undertaken to identify randomized controlled trials comparing PRP with HA and saline solution with up to 1 year of follow-up. Level I trials that reported Western Ontario and McMaster Universities Arthritis Index Likert scores were included. These scores were converted into utility scores. Cost data were obtained from Centers for Medicare & Medicaid Services fee schedules. Total costs included the costs of the injectable, clinic appointments, and procedures. The change in utility scores from baseline to 6 months and 1 year for the PRP, HA, and saline solution groups was divided by total cost to determine utility gained per dollar and to identify the price needed for PRP to be cost-effective relative to these other injection options. RESULTS: Nine randomized controlled trials met the inclusion criteria. A total of 882 patients were included: 483 in the PRP group, 338 in the HA group, and 61 in the saline solution group. Baseline mean utility scores ranged from 0.55 to 0.57 for the PRP, HA, and saline solution groups. The 6-month gains in utility were 0.12, 0.02, and -0.06, respectively. The 12-month gains in utility from before injection were 0.14, 0.03, and 0.06, respectively. The lowest total costs for HA and saline solution were $681.93 and $516.29, respectively. For PRP to be cost-effective, the total treatment cost would have to be less than $3,703.03 and $1,192.08 for 6- and 12-month outcomes, respectively. CONCLUSIONS: For patients with symptomatic knee osteoarthritis, PRP is cost-effective, from the payer perspective, at a total price (inclusive of clinic visits, the procedure, and the injectable) of less than $1,192.08 over a 12-month period, relative to HA and saline solution. LEVEL OF EVIDENCE: Level I, systematic review.

Body Mass Index Screening in Knee Arthroscopy: An Analysis Using the National Surgical Quality Improvement Database.

PURPOSE: To analyze patients undergoing knee arthroscopy stratified by body mass index (BMI) and assess the tradeoffs in complications avoided versus access to care that occur when instituting BMI eligibility criteria. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was used to identify patients who underwent knee arthroscopy from 2015 to 2016. Patients were categorized by BMI, and differences in complication rates between BMI categories were assessed. The positive predictive value (PPV) was calculated for various BMI cutoffs, with further analysis performed to identify the number of surgeries that would be denied to avoid a single complication. RESULTS: There were 44,153 knee arthroscopy cases identified and an overall complication rate of 1.7%. There was no significant difference found in major complication rate between those with a BMI >40 kg/m2 and those with a BMI <40 (1.7% vs 1.7%, P = .70), and no significant associations between increased complications and a higher BMI were found on binary logistic regression. Instituting a BMI cutoff of 40 has a PPV of 1.7% and would result in the avoidance of 11% of complications while denying 10% of otherwise uncomplicated surgeries. This cutoff would deny 57 surgeries for every complication avoided. CONCLUSION: In patients undergoing knee arthroscopy, this study failed to detect a significant increased risk of major complications associated with having a BMI >40. The institution of BMI eligibility cutoffs would result in low PPVs and a high number of denials for surgery that would otherwise be complication free. LEVEL OF EVIDENCE: Level IV, retrospective cohort-based database study.

The Impact of Body Mass Index on Complications After Shoulder Arthroscopy: Should Surgery Eligibility Be Determined by Body Mass Index Cutoffs?

PURPOSE: The goal of this study is to analyze postoperative complications after shoulder arthroscopy stratified by body mass index (BMI) and to quantify the trade-off in postsurgical complications and access to care that occurs with BMI eligibility cutoffs. METHODS: Patients who underwent shoulder arthroscopy in the National Surgical Quality Improvement Program database from 2015 to 2016 were identified. Patients were categorized on the basis of their BMI. χ2 tests were used to identify differences in complication rates between different BMI categories. Logistic regression was used to calculate the odds ratio of having a major complication by BMI category. The positive predictive value (PPV) was calculated at different BMI cutoffs. RESULTS: There were 26,509 shoulder arthroscopy cases identified in the National Surgical Quality Improvement Program database with 383 major complications, for an overall rate of 1.4%. Patients with a BMI >40 had a higher overall complication rate (2.3% vs 1.4%, P = .001), as well as higher rates of readmission (P = .012), pneumonia (P = .030), progressive renal insufficiency (P = .006), and cardiac arrest (P = .008). BMI >40 was associated with an increased risk of major complications (odds ratio, 1.84; confidence interval, 1.29-2.61). A BMI cutoff of 40 would avoid 12% of major complications while excluding 8% of complication-free surgeries. At a BMI cutoff of 40, the PPV was 2.3% where 43 surgeries would be denied for every complication avoided. CONCLUSION: Patients with a BMI >40 have a statistically significant but only slightly increased risk of 30-day complications after shoulder arthroscopy. Instituting a BMI eligibility cutoff at 40 has a low PPV and would prevent 43 complication-free surgeries from proceeding for every complication prevented. Patients should be counseled individually about their risk factors, but denial of shoulder arthroscopy on the basis of BMI alone may not be an appropriate strategy for risk reduction. LEVEL OF EVIDENCE: Level III, comparative prognostic trial.

Risk factors for complications after primary repair of Achilles tendon ruptures.

PURPOSE: To identify patient characteristics associated with adverse events in Achilles tendon rupture (ATR) surgical repair cases. METHODS: A high risk (HR) cohort group of ATR patients were compared to healthy controls in the ACSNSQIP database with multivariate regression analysis. RESULTS: Overall, 2% (n = 23) of the group sustained an AE postoperatively, most commonly superficial SSI (0.9%, n = 10). Multivariate analysis did not reveal any patient characteristics to be significantly associated with the occurrence of an AE or superficial SSI. CONCLUSIONS: Obesity, diabetes and a history of smoking did not predispose patients to significantly more AEs in the 30 day postoperative period following ATR repair in this study.

TNF-α and sTNF-RII Are Associated with Pain Following Hip Fracture Surgery in Older Adults.

Objective: To explore whether plasma inflammatory mediators on postoperative day 3 (POD3) are associated with pain scores in older adults after hip fracture surgery. Design: Cross-sectional study. Setting: Mount Sinai Hospital, New York, New York. Subjects: Forty patients age 60 years or older who presented with acute hip fracture at Mount Sinai Hospital between November 2011 and April 2013. Methods: Plasma levels of six inflammatory mediators of the nuclear factor kappa B pathway were measured using blood collected on POD3. Self-reported pain scores (i.e., pain with resting, walking, and transferring) were assessed at baseline (prefracture) and on POD3. Linear regression models using log-transformed data were performed to determine associations between inflammatory mediators and postoperative pain. Results: Interleukin 18 (IL-18) was positively associated with POD3 resting pain score in the unadjusted model (ß = 0.66, P = 0.03). Tumor necrosis factor α (TNF-α) and soluble TNF receptor II (sTNF-RII) were positively associated with POD3 resting pain score in the adjusted model (ß = 0.99, P = 0.03, and ß = 0.86, P = 0.04, respectively). Moreover, TNF-α was positively associated with POD3 walking pain score in the adjusted model (ß = 1.59, P = 0.05). Pain with transferring was not associated with these inflammatory mediators. Conclusions: These findings suggest that TNF-α and its receptors may influence pain following hip fracture. Further study of the TNF-α pathway may inform future clinical applications that monitor and treat pain in the vulnerable elderly who are unable to accurately report pain.

The Influence of Incision Type on Patient Satisfaction After Plate Fixation of Clavicle Fractures.

BACKGROUND: Open reduction and internal fixation (ORIF) of the clavicle is a common procedure that has been shown to have improved outcomes over nonoperative treatment. Several incisions can be used to approach clavicle fractures, the decision of which is variable among surgeons. PURPOSE: To compare patient satisfaction and subjective outcomes between patients with a longitudinal incision versus those with a necklace incision for the treatment of diaphyseal clavicle fractures. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Thirty-six patients with a diaphyseal clavicle fracture (Orthopaedic Trauma Association type 15-B) were treated by 1 of 7 orthopaedic surgeons. The intervention was ORIF with anatomic contoured plates. Patients were divided into a necklace incision group and a longitudinal incision group depending on the surgical approach used. Medical records were reviewed, and participants completed an online survey with questions related to pain, numbness, scar appearance, and satisfaction. Function was assessed using the American Shoulder and Elbow Surgeons score. Statistical significance was determined with P < .05. RESULTS: There were 16 patients in the necklace incision group and 20 in the longitudinal incision group. Patients in the necklace incision group were significantly more satisfied with the appearance of their scars (P = .01), which correlated with overall satisfaction (P = .05). There were no differences in overall satisfaction, pain, numbness, or reoperation rates for hardware removal between the necklace (6%) and longitudinal groups (15%). CONCLUSION: Patients undergoing clavicle ORIF with a necklace incision are more satisfied with their scar appearance than those with a longitudinal incision. The overall satisfaction, rate of numbness, and plate removal were similar in both groups.

Cost-benefit analysis of routine pathology examination in primary shoulder arthroplasty.

BACKGROUND: The annual number of shoulder arthroplasty procedures is continuing to increase. Specimens from shoulder arthroplasty cases are routinely sent for pathologic examination. This study sought to evaluate the clinical utility and associated costs of routine pathologic examination of tissue removed during primary shoulder arthroplasty cases and to determine cost-effectiveness of this practice. METHODS: This is a retrospective review of primary shoulder arthroplasty cases. Patients whose humeral head was sent for routine pathologic examination were included. Cases were determined to have concordant, discrepant, or discordant diagnoses based on preoperative/postoperative diagnosis and pathology diagnosis. Costs were estimated in 2015 U.S. dollars, and cost-effectiveness was determined by the cost per discrepant diagnosis and cost per discordant diagnosis. RESULTS: We identified 714 cases of primary shoulder arthroplasty in 646 patients who met inclusion criteria. The prevalence of concordant diagnoses was 94.1%, the prevalence of discrepant diagnoses was 5.9%, and no cases had discordant diagnoses. There were 172 cases that had biceps tendon specimens sent for pathology examination, and none led to a change in patient care. Total estimated costs were $77,309.34 in 2015 U.S. dollars. Cost per discrepant diagnosis for humeral head specimens was $1424.09, and cost per discordant diagnosis is at least $59,811.78. DISCUSSION/CONCLUSION: Primary shoulder arthroplasty has a high rate of concordant diagnosis. Discrepant diagnoses were 5.9% in our study, and there were no discordant diagnoses. This study showed limited clinical utility in routinely sending specimens from primary shoulder arthroplasty cases for pathology examination, and calculation using a traditional life-year value of $50,000 showed that the standard for cost-effectiveness is not met.

Shoulder Arthroscopy in Adults 60 or Older: Risk Factors That Correlate With Postoperative Complications in the First 30 Days.

PURPOSE: To investigate the 30-day postoperative adverse event (AE) rates of adults 60 years or older after shoulder arthroscopy and identify risk factors for complications in this patient population. METHODS: Patients aged 60 or more who underwent shoulder arthroscopy were identified in the American College of Surgeons National Surgery Quality Improvement Program database from 2006 to 2013 using 12 Current Procedural Terminology codes related to shoulder arthroscopy. Complications were categorized as severe AEs, minor AEs, and infectious AEs for separate analyses. Pearson's χ2 tests were used to identify associations between patient characteristics and AE occurrence and binary logistic regression for multivariate analysis of independent risk factors. RESULTS: In total, 7,867 patients were included for analysis. Overall, 1.6% (n = 127) of the older adults experienced at least one AE with 1.1% (n = 90) severe AEs, 0.6% (n = 46) minor AEs, and 0.4% (n = 28) infectious complications. Multivariate analysis revealed that age 80 years or older (odds ratio [OR] = 2.2, 95% confidence interval [CI] = 1.2-2.7, P = .01), body mass index greater than 35 (OR = 1.8, 95% CI = 1.1-2.7, P = .01), functionally dependent status (OR = 2.9, 95% CI = 1.3-6.8, P = .01), American Society of Anesthesiologists class greater than 2 (OR = 1.5, 95% CI = 1.0-2.2, P = .04), congestive heart failure (OR = 6.1, 95% CI = 1.8-21.2, P = .03), disseminated cancer (OR = 7.9, 95% CI = 1.4-43.9, P = .02), and existence of an open wound at the time of surgery (OR = 4.0, 95% CI = 1.1-14.6, P = .03) were independently associated with the occurrence of an AE. Nineteen of the patients included in the study required readmission to the hospital within the 30-day period for an overall readmission rate of 0.2%. CONCLUSIONS: Patients 60 years or older who underwent shoulder arthroscopy for a variety of indications have a low overall 30-day postoperative complication rate of 1.6%. Although low, this is a higher rate than previously reported for the overall shoulder arthroscopy population. Independent patient characteristics associated with increased risk of AE occurrence included age 80 years or older, body mass index greater than 35, functional dependent status, American Society of Anesthesiologists score of 3 or 4, congestive heart failure, disseminated cancer, and existence of an open wound. LEVEL OF EVIDENCE: Level III, retrospective comparative study.