Socioeconomic, Patient, and Hospital Determinants for the Utilization of Peripheral Nerve Blocks in Total Joint Arthroplasty.

BACKGROUND: While peripheral nerve blocks (PNBs) are associated with various improved outcomes in patients undergoing total hip or knee arthroplasty (THA/TKA), disparities in PNB utilization have been reported. This study assessed the importance of socioeconomic, demographic, clinical, and hospital determinants in explaining PNB utilization using the population-attributable risk (PAR) framework. Subsequently, we examined the association between PNB use and 3 secondary outcomes: Centers for Medicare and Medicaid Services (CMS)-defined complications, 90-day all-cause readmissions, and length of stay >3 days. METHODS: This retrospective cohort study included 52,926 THA and 94,795 TKA cases from the 5% 2012 to 2021 Medicare dataset. Mixed-effects logistic regression models measured the association between study variables and PNB utilization. Variables of interest were demographic (age, sex), clinical (outpatient setting, diagnosis, prior hospitalizations in the year before surgery, Deyo-Charlson index, obesity, (non)-opioid abuse, smoking), socioeconomic (neighborhood Social Deprivation Index, race and ethnicity) and hospital variables (beds, ownership, region, rurality, resident-to-bed ratio). The model was used for the calculation of variable-specific and variable category-specific PARs (presented in percentages), reflecting the proportion of variation in PNB use explained after eliminating variables (or groups of variables) of interest with all other factors held constant. Subsequently, regression models measured the association between PNB use and secondary outcomes. Associations are presented with odds ratios (ORs) and 95% confidence intervals (95% CIs). RESULTS: Socioeconomic and demographic variables accounted for only a small proportion of variation in PNB use (up to 3% and 7%, respectively). Clinical (THA: 46%; TKA: 34%) and hospital variables (THA: 31%; TKA: 22%) were the primary drivers of variation. In THA, variation by clinical variables was driven by increased PNB use in the inpatient setting (OR, 1.28 [95% CI, 1.07-1.53]) and decreased use in patients with ≥2 prior hospitalizations (OR, 0.72 [95% CI, 0.57-0.90]). Moreover, nonosteoarthritis diagnoses associated with reduced PNB utilization in THA (OR, 0.64 [95% CI, 0.58-0.72]) and TKA (OR, 0.35 [95% CI, 0.34-0.37]).In TKA, PNB use was subsequently associated with fewer complications (OR, 0.82 [95% CI, 0.75-0.90]) and less prolonged length of stay (OR, 0.90 [95% CI, 0.86-0.95]); no association was found for readmissions (OR, 0.98 [95% CI, 0.93-1.03]). In THA, associations did not reach statistical significance. CONCLUSIONS: Among THA and TKA patients on Medicare, large variations exist in the utilization of PNBs by clinical and hospital variables, while demographic and socioeconomic variables played a limited role. Given the consistent benefits of PNBs, particularly in TKA patients, more standardized provision may be warranted to mitigate the observed variation.

The Impact of Race/Ethnicity on Disparities in Utilization and Outcomes of Neuraxial Anesthesia for Hip and Femoral Shaft Fractures.

Background/Objectives: The use of neuraxial anesthesia versus general anesthesia for hip fracture surgery remains an active area of research, with recent studies demonstrating mixed findings supporting neuraxial over general anesthesia. The benefits of neuraxial anesthesia have been documented in associated surgeries, including total joint arthroplasty. However, racial disparities in the administration of neuraxial anesthesia have been identified in numerous procedures. We aimed to examine the association of race/ethnicity with neuraxial anesthesia use and the effect of neuraxial anesthesia on length of stay, non-home discharge, 30-day severe adverse events, and rates of readmission among patients undergoing isolated hip and femoral shaft fracture operations. Methods: The American College of Surgeons National Quality Improvement Program database was queried for isolated hip or femoral shaft fractures from 2015 to 2019. Stepwise logistic regression was performed to assess the relationship between race/ethnicity and neuraxial anesthesia use. Within each sex-race stratum, neuraxial anesthesia recipients were propensity-matched to general anesthesia recipients in a 1:2 ratio. Logistic regression and negative binomial regression were performed on the propensity-matched cohort. Results: A total of 12,004 neuraxial and 64,250 general anesthesia hip and femoral shaft fracture patients were identified. Compared to White patients, Black and Hispanic patients were between 0.64 and 0.61 times less likely to receive neuraxial anesthesia over general anesthesia, respectively (p < 0.05). 11,993 patients who received neuraxial anesthesia were propensity matched to 23,946 patients who received general anesthesia. Propensity-matched logistic regressions found that neuraxial anesthesia was associated with decreased length of stay, 30-day severe adverse events, and acute rehab/skilled nursing facility discharge for White patients (p < 0.05 for all), but only decreased length of stay in Black and Hispanic patients (p = 0.01 and p = 0.02, respectively). Conclusions: Notable disparities exist in the administration of neuraxial anesthesia for isolated hip and femoral shaft fracture patients. Hispanic and Black race/ethnicity in particular influences provision of neuraxial anesthesia. Further research is required to understand the degree of effect modification and root causes of regional anesthesia access and benefits for this high-volume patient population.

Is Limited English Proficiency Associated With Differences in Care Processes and Treatment Outcomes in Patients Undergoing Orthopaedic Surgery? A Systematic Review.

BACKGROUND: Approximately 25 million people in the United States have limited English proficiency. Current developments in orthopaedic surgery, such as the expansion of preoperative education classes or patient-reported outcome collection in response to bundled payment models, may exacerbate language-related barriers. Currently, there are mixed findings of the associations between limited English proficiency and care processes and outcomes, warranting a cross-study synthesis to identify patterns of associations. QUESTIONS/PURPOSES: In this systematic review, we asked: Is limited English proficiency associated with (1) differences in clinical care processes, (2) differences in care processes related to patient engagement, and (3) poorer treatment outcomes in patients undergoing orthopaedic surgery in English-speaking countries? METHODS: On June 9, 2023, a systematic search of four databases from inception through the search date (PubMed, Ovid Embase, Web of Science, and Scopus) was performed by a medical librarian. Potentially eligible articles were observational studies that examined the association between limited English proficiency and the prespecified categories of outcomes among pediatric and adult patients undergoing orthopaedic surgery or receiving care in an orthopaedic surgery setting. We identified 10,563 records, of which we screened 6966 titles and abstracts after removing duplicates. We reviewed 56 full-text articles and included 29 peer-reviewed studies (outcome categories: eight for clinical care processes, 10 for care processes related to patient engagement, and 15 for treatment outcomes), with a total of 362,746 patients or encounters. We extracted data elements including study characteristics, definition of language exposure, specific outcomes, and study results. The quality of each study was evaluated using adapted Newcastle-Ottawa scales for cohort or cross-sectional studies. Most studies had a low (48%) or moderate (45%) risk of bias, but two cross-sectional studies had a high risk of bias. To answer our questions, we synthesized associations and no-difference findings, further stratified by adjusted versus unadjusted estimates, for each category of outcomes. No meta-analysis was performed. RESULTS: There were mixed findings regarding whether limited English proficiency is associated with differences in clinical care processes, with the strongest adjusted associations between non-English versus English as the preferred language and delayed ACL reconstruction surgery and receipt of neuraxial versus general anesthesia for other non-Spanish versus English primary language in patients undergoing THA or TKA. Limited English proficiency was also associated with increased hospitalization costs for THA or TKA but not opioid prescribing in pediatric patients undergoing surgery for fractures. For care processes related to patient engagement, limited English proficiency was consistently associated with decreased patient portal use and decreased completion of patient-reported outcome measures per adjusted estimates. The exposure was also associated with decreased virtual visit completion for other non-Spanish versus English language and decreased postoperative opioid refill requests after TKA but not differences in attendance-related outcomes. For treatment outcomes, limited English proficiency was consistently associated with increased hospital length of stay and nonhome discharge per adjusted estimates, but not hospital returns. There were mixed findings regarding associations with increased complications and worse postoperative patient-reported outcome measure scores. CONCLUSION: Findings specifically suggest the need to remove language-based barriers for patients to engage in care, including for patient portal use and patient-reported outcome measure completion, and to identify mechanisms and solutions for increased postoperative healthcare use. However, interpretations are limited by the heterogeneity of study parameters, including the language exposure. Future research should include more-precise and transparent definitions of limited English proficiency and contextual details on available language-based resources to support quantitative syntheses. LEVEL OF EVIDENCE: Level III, therapeutic study.

Time to surgical treatment for hip fracture care.

BACKGROUND: Studies have demonstrated beneficial outcomes associated with timely surgical treatment of hip fracture. Subsequently, practice recommendations changed with 24-48 h as the recommended time for surgery from admission; however, recent data on timing of hip fracture surgery and how this impacts outcomes are lacking. METHODS: This retrospective cohort study included patients who had a primary diagnosis of hip fracture and underwent a subsequent surgical repair within 3 days of admission (Premier Healthcare claims 2006-2021 data). The primary exposure of interest was time from hip fracture diagnosis to surgery (categorized as 0-1 day, 2 days, and 3 days). Outcomes included any major complication, mortality, and intensive care unit (ICU) admission. Mixed-effects models measured the association between timing of surgery and outcomes. We report odds ratios (OR) and 95% confidence intervals. RESULTS: Among 501,267 surgical hip fracture patients, 26.0%, 56.0%, and 18.1% of patients received surgery on days 0-1, 2, and 3, respectively. The median ages were 83, 84, and 84 years old, and there were 73.3%, 72.2%, and 68.8% female in each group respectively. Compared with repair on day 0-1, hip fracture surgical treatment on day 2 or day 3 was associated with increased odds of major complications (OR 1.06, 95% CI 1.03-1.08 and OR 1.17, 95% CI 1.13-1.2), mortality (OR 1.08, 95% CI 1.02-1.14 and OR 1.2, 95% CI 1.12-1.28), and ICU admission (OR 1.06, 95% CI 1.04-1.09 and OR 1.36, 95% CI 1.32-1.4) after adjusting major comorbidities; all p < 0.001. CONCLUSION: Despite the publication of society guidelines in 2015, most fracture patients still received surgery on day 2 or day 3 of admission and were associated with worse outcomes. Balancing optimization of clinical factors with timing of surgery can be challenging, and further research is needed. Nonetheless, our findings reiterate the importance of timely surgical intervention.

Comparative effectiveness of neuraxial versus general anesthesia in total joint replacement surgery: an updated retrospective analysis using more recent data.

INTRODUCTION: Over a decade ago, our study group showed improved outcomes among total hip/knee arthroplasty (THA/TKA) patients given neuraxial versus general anesthesia. As the use of neuraxial anesthesia has increased and anesthesia practices evolve, updated analyses are critical to ensure if previously found differences still persist. METHODS: This retrospective cohort study included elective THA/TKAs from 2006 to 2021 as recorded in the all-payor Premier Healthcare Database. Multivariable regression models measured the association between anesthesia type (neuraxial, general, combined) and several adverse outcomes (pulmonary embolism, cerebrovascular events, pulmonary compromise, cardiac complications, acute myocardial infarction, pneumonia, all infections, acute renal failure, gastrointestinal complications, postoperative mechanical ventilation, intensive care unit admissions, and blood transfusions); models were run separately by period (2006-2015 and 2016-2021) and THA/TKA. RESULTS: We identified 587,919 and 499,484 THAs for 2006-2015 and 2016-2021, respectively; this was 1,186,483 and 803,324 for TKAs. Among THAs, neuraxial anesthesia use increased from 10.7% in 2006 to 25.7% in 2021; during both time periods, specifically neuraxial versus general anesthesia was associated with lower odds for most adverse outcomes, with sometimes stronger (protective) effect estimates observed for 2016-2021 versus 2006-2015 (eg, acute renal failure OR 0.72 CI 0.65 to 0.80 vs OR 0.56 CI 0.50 to 0.63 and blood transfusion OR 0.91 CI 0.89 to 0.94 vs OR 0.44 CI 0.41 to 0.47, respectively; all p<0.001). Similar patterns existed for TKAs. CONCLUSION: These findings re-confirm our study group's decade-old study using more recent data and offer additional evidence toward the sustained benefit of neuraxial anesthesia in major orthopedic surgery.

Prolonged Opioid Use and Associated Factors After Open Reduction and Internal Fixation of Tibial Shaft Fractures.

BACKGROUND: The aim of this retrospective cohort study was to determine the rate of prolonged opioid use and identify associated risk factors after perioperative opioid exposure for tibial shaft fracture surgery. MATERIALS AND METHODS: We used the MarketScan Commercial Claims and Encounters database (IBM) to identify patients 18 to 64 years old who filled a peri-operative opioid prescription after open reduction and internal fixation of a tibial shaft fracture from January 2016 to June 2020. Multivariable logistic regression identified factors (eg, demographics, comorbidities, medications) associated with prolonged opioid use (ie, filling an opioid prescription 91 to 180 days postoperatively); adjusted odds ratios (ORs) and 95% CIs were reported. RESULTS: The rate of prolonged opioid use was 10.5% (n=259/2475) in the full cohort and 6.1% (n=119/1958) in an opioid-naive subgroup. In the full cohort, factors significantly associated with increased odds of prolonged use included preoperative opioid use (OR, 4.76; 95% CI, 3.60-6.29; P<.001); perioperative oral morphine equivalents in the 4th (vs 1st) quartile (OR, 2.68; 95% CI, 1.75-4.09; P<.001); age (OR, 1.03; 95% CI, 1.02-1.04; P<.001); and alcohol or substance-related disorder (OR, 1.66; 95% CI, 1.15-2.40; P=.01). Patients in the Northeast and North Central (vs South) regions had decreased odds of prolonged use (OR, 0.61-0.69; P=.02-.04). When removing preoperative use, findings were similar in the opioid-naive subgroup. CONCLUSION: Prolonged opioid use is not uncommon in this orthopedic trauma population, with the strongest risk factor being preoperative opioid use. Nevertheless, shared risk factors exist between the opioid-naive and opioid-tolerant subgroups that can guide clinical decision-making. [Orthopedics. 2024;47(4):e188-e196.].

Preoperative Cervical Epidural Steroid Injections: Utilization and Postoperative Complications in ACDF, PCDF, and Decompression.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Identify factors associated with cervical epidural steroid injection (CESI) receipt before anterior cervical discectomy and fusion (ACDF), posterior cervical decompression and fusion (PCDF), or decompression; evaluate the association between CESI receipt and 90-day postoperative complications; and determine characteristics of CESI associated with complications. SUMMARY OF BACKGROUND DATA: Previous literature has suggested that a preoperative CESI may increase the risk of postoperative complications. However, these studies were limited in the procedures and complications they evaluated. METHODS: The IBM MarketScan database was queried for patients aged 18 years or older who underwent ACDF, PCDF, or cervical decompression for disc herniation, stenosis, radiculopathy, myelopathy, and/or spondylosis without myelopathy between January 1, 2014 and September 30, 2020. CESI receipt within 12 months preoperatively, injection characteristics, and postoperative complications were extracted. Multivariable logistic regression models were used to investigate associations between patient characteristics and receipt of CESI, receipt of a CESI and each 90-day postoperative complication, and CESI characteristics and each 90-day complication. RESULTS: Among the unique patients who underwent each procedure, 20,371 ACDF patients (30.93%), 1259 (22.24%) PCDF patients, and 3349 (36.30%) decompression patients received a preoperative CESI. In all 3 cohorts, increasing age, increasing comorbidity burden, smoker status, and diagnosis of myelopathy were associated with decreased odds of preoperative CESI receipt, while female sex and diagnosis of radiculopathy and spondylosis without myelopathy were associated with increased odds. There were no meaningful between-group comparisons or significant associations between preoperative CESI receipt and any 90-day postoperative complications in multivariable models (all P>0.05). CONCLUSIONS: This study elucidated the main determinants of CESI receipt and found no differences in the odds of developing 90-day postoperative complications, but did identify differential outcomes with regard to some injection characteristics. LEVEL OF EVIDENCE: Level III.

Differences in Perioperative Metrics by Race and Ethnicity and Insurance After Pelvic Fracture: A Nationwide Study.

BACKGROUND: Disparities in orthopedic trauma care have been reported for racial-ethnic minority and socially disadvantaged patients. We examined differences in perioperative metrics by patient race and ethnicity and insurance after pelvic fracture in a national sample in the United States. MATERIALS AND METHODS: The 2016-2019 National Inpatient Sample was queried for White, Black, and Hispanic patients 18 to 64 years old with private, Medicaid, or self-pay insurance who underwent non-elective pelvic fracture surgery. Associations between combined race and ethnicity and insurance subgroups and perioperative metrics (time to surgery, length of stay, inhospital complications, institutional discharge) were assessed using multivariable generalized linear and logistic regression models. Adjusted percent differences or odds ratios (ORs) were reported. RESULTS: A weighted total of 14,375 surgeries were included (68.8% in White patients, 16.1% in Black patients, and 15.1% in Hispanic patients; 60.0% private insurance, 26.3% Medicaid, and 13.7% self-pay). Compared with White patients with private insurance, all Black insurance subgroups had longer length of stay (+15.38% to +38.78%, P≤.001), as did Hispanic patients with Medicaid (+28.03%, P<.001), White patients with Medicaid (+13.08%, P<.001), and White patients with self-pay (+9.47%, P=.04). Additionally, compared with White patients with private insurance, decreased odds of institutional discharge were observed for all patients with self-pay (OR, 0.24-0.37, P<.001) as well as White patients with Medicaid (OR, 0.70, P=.003) and Hispanic patients with Medicaid (OR, 0.57, P=.002). There were no significant adjusted associations between race and ethnicity and insurance subgroups and in-hospital complications or time to surgery. CONCLUSION: These differences in perioperative metrics, primarily for Black patients and patients with self-pay insurance, warrant further examination to identify whether they reflect disparities that should be addressed to promote equitable orthopedic trauma care. [Orthopedics. 202x;4x(x):xx-xx.].

Impact of the Comprehensive Care for Joint Replacement Bundled Payment Model on Postoperative Utilization of Home Health and Outpatient Physical Therapy Services.

OBJECTIVE: To study the effect of the Comprehensive Care for Joint Replacement (CJR) bundled payment program on postoperative home health and outpatient physical therapy (PT) for total hip or knee arthroplasty (THA/TKA). DESIGN: Retrospective cohort with national Medicare data (5% claims) using a difference-in-differences analysis comparing January 2013-September 2015 (before) versus October 2016-September 2019 (after). SETTING: Administrative claims from hospitals in 34 metropolitan statistical areas with mandatory CJR participation as of 2018 and 42 control metropolitan statistical areas. PARTICIPANTS: Episodes in fee-for-service Medicare beneficiaries (5% claims) undergoing elective THA (n=6327) or TKA (n=10,764) with community discharge. INTERVENTIONS: Implementation of CJR bundled payment program. MAIN OUTCOME MEASURES: Home health and outpatient PT, including any use and number of visits. RESULTS: Program implementation was associated with an increased percentage of THA episodes using home health PT (+8.0 percentage-point change; 95% CI, +3.5 to +12.6; P=.001) but a decreased per-episode number of home health PT visits for THA (-1.1; 95% CI, -1.6 to -0.6; P<.001) and TKA (-1.1; 95% CI, -1.4 to -0.7; P<.001). The program was also associated with an increased per-episode number of outpatient PT visits for TKA in the primary but not sensitivity analyses (+0.8; 95% CI, +0.1 to +1.4; P=.02). CONCLUSIONS: Findings of increased home health PT may reflect an intentional shift in care from the inpatient postacute setting to the community to decrease costs. Alternatively, the limited effect of CJR, particularly on outpatient PT, could reflect challenges with care coordination in a retrospective bundle spanning multiple care settings.

Oral Postoperative Antibiotic Prophylaxis for Outpatient Total Hip and Knee Arthroplasty: Describing Current Practices.

BACKGROUND: Despite an increase in outpatient total hip arthroplasty (THA) and total knee arthroplasty (TKA), large-scale data are lacking on current practice for antibiotic prophylaxis prescribing. We aimed to describe current oral antibiotic prophylaxis practices nationally for outpatient THA and TKA. METHODS: This nationwide retrospective cohort study included primary outpatient THA or TKA procedures in patients aged 18 to 64 years from 2018 to 2021 using a national claims database. Oral antibiotic prescriptions filled perioperatively (defined as 5 days before to 3 days after surgery) were extracted; these were categorized and assumed to represent postoperative prophylaxis. Multivariable logistic regression measured associations between patient and surgery characteristics and perioperative oral antibiotic prophylaxis. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) are reported. RESULTS: Oral antibiotic prescriptions were filled in 16.5% of 73,015 outpatient THA and TKA (18.4% of 24,857 THAs, 15.5% of 48,158 TKAs) procedures. Prescriptions were most often for cephalosporins (74.3%), with cephalexin (52.8%), and cefadroxil (19.1%) being the most common. Non-cephalosporin antibiotics prescribed were mainly clindamycin (6.8%), sulfamethoxazole-trimethoprim (6.7%), and doxycycline (6.2%). The odds of receiving oral antibiotic prophylaxis were higher for THA compared to TKA (OR 1.13, 95% CI 1.09 to 1.18, P < .001) and in the presence of obesity, diabetes, and autoimmune conditions (OR 1.08 to 1.13, P < .001 to .01). Ambulatory surgery center procedures also had significantly increased odds of prophylaxis compared to hospital-based outpatient surgeries (OR 2.62, 95% CI 2.51 to 2.73, P < .001). Additionally, regional and time-based variations were noted. CONCLUSIONS: Perioperative oral antibiotic prophylaxis prescriptions were filled in only 16.5% of outpatient THA and TKA cases, with variation in the type of antibiotic prescribed. The receipt of any prophylaxis and specific medications was associated with demographic, clinical, and procedure-related characteristics. Follow-up research will evaluate associations with infection risk reduction.

Characteristics and Quality of Online Searches for Direct Anterior Versus Posterior Approach for Total Hip Arthroplasty.

BACKGROUND: Online resources are important for patient self-education and reflect public interest. We described commonly asked questions regarding the direct anterior versus posterior approach (DAA, PA) to total hip arthroplasty (THA) and the quality of associated websites. METHODS: We extracted the top 200 questions and websites in Google's "People Also Ask" section for 8 queries on January 8, 2023, and grouped websites and questions into DAA, PA, or comparison. Questions were categorized using Rothwell's classification (fact, policy, value) and THA-relevant subtopics. Websites were evaluated by information source, Journal of the American Medical Association Benchmark Criteria (credibility), DISCERN survey (information quality), and readability. RESULTS: We included 429 question/website combinations (questions: 52.2% DAA, 21.2% PA, 26.6% comparison; websites: 39.0% DAA, 11.0% PA, 9.6% comparison). Per Rothwell's classification, 56.2% of questions were fact, 31.7% value, 10.0% policy, and 2.1% unrelated. The THA-specific question subtopics differed between DAA and PA (P < .001), specifically for recovery timeline (DAA 20.5%, PA 37.4%), indications/management (DAA 13.4%, PA 1.1%), and technical details (DAA 13.8%, PA 5.5%). Information sources differed between DAA (61.7% medical practice/surgeon) and PA websites (44.7% government; P < .001). The median Journal of the American Medical Association Benchmark score was 1 (limited credibility, interquartile range 1 to 2), with the lowest scores for DAA websites (P < .001). The median DISCERN score was 55 ("good" quality, interquartile range 43 to 65), with the highest scores for comparison websites (P < .001). Median Flesch-Kincaid Grade Level scores were 12th grade level for both DAA and PA (P = .94). CONCLUSIONS: Patients' informational interests can guide counseling. Internet searches that explicitly compare THA approaches yielded websites that provide higher-quality information. Providers may also advise patients that physician websites and websites only describing the DAA may have less balanced perspectives, and limited information regarding surgical approaches is available from social media resources.

Should Chronological Age be a Consideration in Patients Undergoing Elective Primary Total Knee Arthroplasty?

BACKGROUND: The optimal time for total knee arthroplasty (TKA) requires a balance between patient disability and health state to minimize complications. While chronological age has not been shown to be predictive of complications in elective surgical patients, there is a point beyond which even optimized elderly patients would be at increased risk for complications. The purpose of this study was to examine the impact of chronological age on complications following primary TKA. METHODS: Using an administrative database, the records of 2,129,191 patients undergoing elective unilateral TKA between 2006 and 2021 were reviewed. The primary outcomes of interest were cardiac and pulmonary complications, and their relationship to the Charlson-Deyo Comorbidity Index (CDI) and chronological age. Secondary outcomes included risk of renal, neurologic, infection, and intensive care utilization postoperatively. The results were analyzed using a graphical method. The impact of chronological age as a modifier of overall risk for complications was modeled as a continuous variable. An age cutoff threshold of 80 years was also assigned for clinical convenience. RESULTS: The risk of complications correlated more closely to the CDI (odds ratio (OR) 1.37 to 2.1) than chronological age (OR 1.0 to 1.1) across the various complications [Table 1. However, beyond age 80 years, the risks of cardiac, pulmonary, renal, and cerebrovascular complications were significantly increased for all CDI categories (OR 1.73 to 3.40) compared to patients below age 80 years [Table 2] [Figures 1A and 1B]. CONCLUSIONS: Chronologic age can impact the risk of complications even in well-optimized elderly patients undergoing primary TKA. As arthroplasty continues to transition to outpatient settings and inpatient denials increase, these results can help patients, physicians, and payors mitigate risk while optimizing the allocation of resources.

Surgical treatment of displaced proximal humerus fractures is associated with decreased 1-year mortality in patients aged 65 years and older: a retrospective study of Medicare patients.

BACKGROUND: Proximal humerus fracture (PHF) is a risk factor for 1-year mortality. This study aimed to determine if surgery is associated with lower mortality compared to nonoperative treatment following PHF in older patients. METHODS: This retrospective cohort study used the Medicare Limited Data set. Patients aged 65 years and older with a PHF diagnosis in 2017-2020 were included. Treatment was classified as nonoperative, open reduction internal fixation (ORIF), total shoulder arthroplasty (TSA), or hemiarthroplasty. Multivariable logistic regression models examined (a) predictors of treatment type and (b) the association of treatment type with 1-year mortality, adjusting for patient demographics, comorbidities, frailty, and fracture severity among other variables. A subgroup analysis examined how the relationship between treatment type and 1-year mortality varied based on fracture severity. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) are reported. RESULTS: In total, 49,072 patients were included (mean age = 76.6 years, 82.3% female). Most were treated nonoperatively (77.5%), 10.9% underwent ORIF, 10.6% underwent TSA, and 1.0% underwent hemiarthroplasty. Examples of factors associated with receipt of operative (versus nonoperative treatment) included worse fracture severity and lower frailty. The 1-year mortality rate after the initial PHF diagnosis was 11.0% for the nonoperative group, 4.0% for ORIF, 5.2% for TSA, and 6.0% for hemiarthroplasty. Compared to nonoperative treatment, ORIF (aOR 0.55; 95% CI [0.47, 0.64]; P < .001) and TSA (aOR 0.59; 95% CI [0.50, 0.68]; P < .001) were associated with decreased odds of 1-year mortality. In the subgroup analysis, ORIF and TSA were associated with a lower 1-year mortality risk for 2-part and 3-/4-part fractures. CONCLUSIONS: Compared to nonoperative treatment, surgery (particularly TSA and ORIF) was associated with a decreased odds of 1-year mortality. This relationship remained significant for 2-part and 3-/4-part fractures after stratifying by fracture severity.

Impact of sugammadex and neostigmine on outcome after major orthopaedic surgery: A population-based analysis.

BACKGROUND: Residual neuromuscular blockade after surgery remains a major concern given its association with pulmonary complications. However, current clinical practices with and the comparative impact on perioperative risk of various reversal agents remain understudied. OBJECTIVE: We investigated the use of sugammadex and neostigmine in the USA, and their impact on postoperative complications by examining national data. DESIGN: This population-based retrospective study used national Premier Healthcare claims data. SETTING AND PARTICIPANTS: Patients undergoing total hip/knee arthroplasty (THA, TKA), or lumbar spine fusion surgery between 2016 and 2019 in the United States who received neuromuscular blocking agents. INTERVENTION: The effects of sugammadex and neostigmine for pharmacologically enhanced reversal were compared with each other and with controls who received no reversal agent. MAIN OUTCOMES: included pulmonary complications, cardiac complications, and a need for postoperative ventilation. Mixed-effects regression models compared the outcomes between neostigmine, sugammadex, and controls. We report odds ratios (OR) and 95% confidence intervals (CI). Bonferroni-adjusted P values of 0.008 were used to indicate significance. RESULTS: Among 361 553 patients, 74.5% received either sugammadex (20.7%) or neostigmine (53.8%). Sugammadex use increased from 4.4% in 2016 to 35.4% in 2019, whereas neostigmine use decreased from 64.5% in 2016 to 43.4% in 2019. Sugammadex versus neostigmine or controls was associated with significantly reduced odds for cardiac complications (OR 0.86, 95% CI, 0.80 to 0.92 and OR 0.83, 95% CI, 0.78 to 0.89, respectively). Both sugammadex and neostigmine versus controls were associated with reduced odds for pulmonary complications (OR 0.85, 95% CI, 0.77 to 0.94 and OR 0.91, CI 0.85 to 0.98, respectively). A similar pattern of sugammadex and neostigmine was observed for a reduction in severe pulmonary complications, including the requirement of invasive ventilation (OR 0.54, 95% CI, 0.45 to 0.64 and OR 0.53, 95% CI, 0.46 to 0.6, respectively). CONCLUSIONS: Population-based data indicate that sugammadex and neostigmine both appear highly effective in reducing the odds of severe life-threatening pulmonary complications. Sugammadex, especially, was associated with reduced odds of cardiac complications.

Multimodal pain management and postoperative outcomes in inpatient and outpatient shoulder arthroplasties: a population-based study.

INTRODUCTION: Multimodal analgesia has been associated with reduced opioid utilization, opioid-related complications, and improved recovery in various orthopedic surgeries; however, large sample size data is lacking for shoulder surgery. METHODS: A retrospective review using the Premier Healthcare Database of patients who underwent inpatient or outpatient (reverse, total, partial) shoulder arthroplasty from 2010 to 2019. Opioid-only analgesia was compared with multimodal analgesia, categorized into 1, 2, or >2 additional analgesic modes, with/without a nerve block. Multivariable regression models measured associations between multimodal analgesia and opioid charges (in oral morphine equivalents (OME)), cost and length of stay, and opioid-related adverse effects (approximated by naloxone use). We report % change and 95% CIs. RESULTS: Among 176 225 procedures, 169 679 (75.7% multimodal analgesia use) and 6546 (37.8% multimodal analgesia use) were inpatient and outpatient shoulder arthroplasties, respectively. Among inpatients, multimodal analgesia (>2 modes) without a nerve block (vs opioid-only analgesia) was associated with adjusted reductions in OMEs on postoperative day 1: -19.4% (95% CI -21.2% to -17.6%/representing unadjusted median OME reductions from 45 to 30 mg). For total hospitalization, this was -6.0% (95% CI -7.2% to -4.9%/representing unadjusted median OME reductions from 173 to 135 mg). Conversely, for outpatients, this was +13.7% change in OMEs (95% CI +4.4% to +23.0%/representing unadjusted median OME increases from 110 to 131 mg). In both settings, addition of a nerve block to multimodal analgesia attenuated effects in terms of opioid charges. CONCLUSIONS: Multimodal analgesia is associated with reductions in opioid charges-specifically inpatient setting-but not various other outcomes.

Association between timing of initiating supervised physical rehabilitation after rotator cuff repair and incidence of repeat repair and capsulitis: a population-based analysis.

BACKGROUND: There is limited consensus on the optimal time to initiate supervised physical rehabilitation after a rotator cuff repair (RCR). We examined whether timing of initiating supervised physical rehabilitation was associated with repeat RCR or development of adhesive capsulitis within 12 months postoperatively in an observational cohort of commercially insured adults. METHODS: This retrospective cohort study used the IBM MarketScan Commercial Claims and Encounters Database. We included adults aged 18-64 who underwent a unilateral outpatient RCR between 2017 and 2020 and initiated supervised physical rehabilitation 1-90 days postoperatively. Multivariable logistic regression models examined the adjusted association between time of initiating supervised physical rehabilitation (1-13, 14-27, 28-41, and 42-90 days postoperatively) and each of the primary outcomes: repeat RCR and capsulitis. In a sensitivity analysis, time to rehabilitation was alternatively categorized using a data-driven approach of quartiles (1-7, 8-16, 17-30, and 31-90 days postoperatively). We report adjusted odds ratios (OR). RESULTS: Among 33,841 patients (86.7% arthroscopic index RCR), the median time between index RCR and rehabilitation initiation was 16 days (interquartile range 7-30), with 39.9% initiating rehabilitation at 1-13 days. Additionally, 2.2% underwent repeat RCR within 12 months, and 12-month capsulitis was identified in 1.9% of patients. There were no significant associations between timing of initiating rehabilitation and 12-month repeat RCR (OR 0.85-0.93, P = .18-.49) or 12-month capsulitis (OR 0.83-0.94, P = .22-.63). Lack of associations between timing and outcomes was supported in sensitivity analyses. CONCLUSIONS: Timing of initiating rehabilitation was not significantly associated with adverse outcomes after RCR. The finding of no increased odds of repeat RCR or capsulitis with the earliest timing may support earlier initiation of rehabilitation to accelerate return to daily activities. Findings should be replicated in another dataset of similarly-aged patients.