Chronic exertional compartment syndrome is frequently diagnosed through static compartment pressure measurements and managed with fasciotomy: A systematic review.

OBJECTIVES: Chronic exertional compartment syndrome (CECS) can be diagnosed either clinically or with intra-compartmental pressure monitor measurements and can be treated surgically or conservatively. METHODS: A systematic review was performed on diagnostic and treatment modalities for CECS. Included studies were those that reported both their specific diagnostic modality and treatment regimens. Both surgical and conservative treatment strategies were considered. Demographic variables, diagnostic modalities, patient satisfaction and return to sport, the number of surgical incisions used for the anterior compartment fasciotomy, and the specific conservative treatment regimens were also recorded. Diagnostic modalities were grouped into one of three groups: 1) static compartment pressure monitor, 2) dynamic pressure monitoring, and 3) strictly clinical diagnosis. RESULTS: The literature search identified 373 studies, of which 29 were included for final analysis. In total, there were 1270 total patients. Twenty-four studies used static compartment pressure monitors, 5 studies used dynamic pressure monitors and 2 studies used a strictly clinical diagnosis. Surgical management with fasciotomy was performed in 25 studies with a total of 1018 patients, while conservative management was used in 252 patients in 9 studies (5 studies included surgical and conservative treatments). Among surgical studies, 15 used a single-incision technique for anterior compartment fasciotomy, while 6 used a 2-incision technique. The reported satisfaction after fasciotomy was 42-94% while the return to sport was 26-100%. The reported return to sport in conservative management studies was 25-35%. CONCLUSION: This systematic review found that the majority of clinical reports utilize static compartment pressure measurements to diagnose CECS, with fewer studies using dynamic intra-compartment pressure monitors. Additionally, surgical fasciotomy using a single-incision technique was the most common treatment strategy for anterior compartment CECC, with some studies reporting success with the two-incision technique. STUDY DESIGN: Systematic review, level 4.

Tramadol use before total shoulder arthroplasty: patients have lower risk of complications and resource utilization than those using traditional opioids.

BACKGROUND: Evidence continues to mount for the deleterious effects of preoperative opioid use in the setting of total shoulder arthroplasty (TSA). Tramadol, a synthetic opioid with concomitant neurotransmitter effects, has become a popular alternative to traditional opioids, but it has not been well studied in the preoperative setting of TSA. The purpose of this study is to evaluate postsurgical outcomes in TSA for patients with preoperative tramadol use compared with patients using traditional opioids and those who were opioid naïve. METHODS: Using the IBM Watson Health MarketScan databases, a retrospective cohort study was performed for patients who underwent TSA from 2009 to 2018. Filled pain prescriptions were collected, and prescribing trends were analyzed. Outcomes were compared between 4 patient cohorts defined by preoperative analgesia use-opioid naïve, tramadol, traditional opioids, and combination (opioids and tramadol). Multivariate analysis was used to account for small variations in cohort demographics and comorbidities. Analysis focused on resource utilization and complications. Revision rates at 1 and 3 years postoperatively were also compared. RESULTS: A total of 29,454 TSA patients were studied, with 8959 available for 3-year postoperative follow-up. Of these, 10,462 (35.5%) were prescribed traditional opioids and 2214 (7.5%) tramadol only. From 2009 to 2018, prescribing trends in the United States demonstrated a significant decrease in the number of patients prescribed preoperative narcotics, whereas the number of patients prescribed preoperative tramadol and those who were opioid naïve significantly increased. Compared with opioid-naïve patients, the traditional opioid cohort had significantly increased odds of resource utilization and complications, whereas the tramadol cohort did not. Specifically, the traditional opioid cohort had an increased risk of prosthetic joint infection compared with both opioid-naïve and tramadol cohorts. The traditional opioid cohort had higher revision rates than opioid-naïve patients at 1 and 3 years, whereas the tramadol cohort did not. CONCLUSION: Despite a decrease in opioid prescriptions over the study period, many patients in the United States remain on opioids. Although tramadol is not without its own risks, our results suggest that patients taking preoperative tramadol as an alternative to traditional opioids for glenohumeral arthritic pain had a lesser postoperative risk profile, comparable with opioid-naïve patients.

Upper extremity firearm injuries: epidemiology and factors predicting hospital admission.

INTRODUCTION: Civilian gun violence is a public health crisis in the USA that will be an economic burden reported to be as high as $17.7 billion with over half coming from US taxpayers dollars through Medicaid-related costs. The purpose of this study is to review the epidemiology of upper extremity firearm injuries in the USA and the associated injury burden. METHODS: The Inter-university Consortium for Political and Social Research's Firearm Injury Surveillance Study database, collected from the National Electronic Injury Surveillance System, was queried from 1993 to 2015. The following variables were reviewed: patient demographics, date of injury, diagnosis, injury location, firearm type (if provided), incident classification, and a descriptive narrative of the incident. We performed chi-square testing and complex descriptive statistics, and binomial logistic regression model to predict factors associated with hospital admission. RESULTS: From 1993 to 2015, an estimated 314,369 (95% CI: 291,528-337,750; 16,883 unweighted) nonfatal firearm upper extremity injuries with an average incidence rate of 4.76 per 100,000 persons (SD: 0.9; 03.77-7.49) occurred. The demographics most afflicted with nonfatal gunshot wound injuries were black adolescent and young adult males (ages 15-24 years). Young adults aged 25-34 were the second largest estimate of injuries by age group. Hands were the most commonly injured upper extremity, (55,014; 95% CI: 75,973-89,667) followed by the shoulder, forearm, and upper arm. Patients who underwent amputation (OR: 28.65; 95% CI: 24.85-33.03) or with fractures (OR: 26.20; 95% CI: 23.27-29.50) experienced an increased likelihood for hospitalization. Patients with a shoulder injury were 5.5× more likely to be hospitalized than those with a finger injury (OR:5.57; 95% CI:5.35-5.80). The incidence of upper extremity firearm injuries has remained steady over the last decade ranging between 4 and 5 injuries per 100,000 persons. Patients with proximal injuries or injuries involving the bone were more likely to require hospital admission. This study should bring new information to the forefront for policy makers regarding gun violence.

When Is It Safe to Operate After Therapeutic Carpal Tunnel Injections?

BACKGROUND: Recent studies suggest increased complications when surgery closely follows corticosteroid injection. The purpose of this study was to understand the occurrence of surgical site infection (SSI), wound complications, and reoperation rates after carpal tunnel release (CTR) when corticosteroid injections were given within 180 days preoperatively. METHODS: Data were collected from the Truven MarketScan database from 2009 to 2018. Cohorts were created based on preoperative timing of injection (<30, 30-60, 61-90, 91-180 days) and number of injections (0, 1, 2, 3+). Logistic regression was performed to assess the contribution of preoperative injections on 90-day surgical site complications and 1-year reoperation while controlling for demographics and comorbidities. RESULTS: Overall, 223 899 patients underwent CTR. Of these, 17 391 (7.76%) had a preoperative injection in the 180 days preceding surgery. Univariate analysis demonstrated a relationship between timing of injections and noninfectious wound complications (P = .006) and rate of 1-year reoperation (P = .045). Univariate analysis demonstrated a relationship between number of injections and 1-year reoperation (P < .001). On multivariate analysis, those receiving injections within 30 days preoperatively had increased rates of SSI (P = .034) and noninfectious wound complications (P = .006) compared with those with no injection or at other time points. Patients with 2 (P = .002) or 3 or more injections (P < .001) in the 180-day preoperative period had increased odds of 1-year reoperation. CONCLUSION: Our study suggests increased risk of SSI, wound complications, and 1-year reoperation when corticosteroid injections are administered in the 30-day preoperative period. In addition, multiple steroid injections may increase the risk of 1-year reoperation.

Medicaid payer status is associated with increased 90-day morbidity and resource utilization following primary shoulder arthroplasty: a propensity score-matched analysis.

BACKGROUND: Medicaid payer status has been shown to affect risk-adjusted patient outcomes and health care utilization across multiple medical specialties and orthopedic procedures. However, there is a paucity of data regarding the impact of Medicaid payer status on 90-day morbidity and resource utilization following primary shoulder arthroplasty (reverse total shoulder arthroplasty [rTSA], anatomic total shoulder arthroplasty [aTSA], and hemiarthroplasty [HA]). The purpose of this study was to examine 90-day readmission and reoperation rates, hospital length of stay (LOS), and direct cost following primary shoulder arthroplasty in the Medicaid population. METHODS: The National Readmission Database was queried for all patients undergoing primary aTSA, rTSA, and HA from 2011 to 2016. Medicaid or non-Medicaid payer status was determined. Patient demographic characteristics and comorbidities, along with 90-day readmission, 90-day reoperation, LOS, and inflation-adjusted cost, were queried. Propensity score matching was used to control for baseline differences in cohorts that could be acting as confounders in the exposure-outcome relationship. This was achieved with 1-to-1 propensity score matching between Medicaid and non-Medicaid patients. Odds ratios (ORs) and 95% confidence intervals (CIs) for 90-day readmission and reoperation rates were calculated, and a comparison of LOS and cost was performed between the propensity score-matched cohorts. RESULTS: A total of 4667 Medicaid and 161,147 non-Medicaid patients were identified from the 2011-2016 National Readmission Databases. Propensity score analysis was performed, and 4637 Medicaid patients were matched to 4637 non-Medicaid patients; each group comprised 1504 rTSAs (32.4%), 1934 aTSAs (41.7%), and 1199 HAs (25.9%). Patients with Medicaid payer status yielded significant increases in the 90-day all-cause readmission rate of 11.6% vs. 9.3% (P < .001; OR, 1.28 [95% CI, 1.12-1.46]), 90-day shoulder-related readmission rate of 3.3% vs. 2.3% (P = .004; OR, 1.44 [95% CI, 1.12-1.85]), and 90-day reoperation rate of 2.0% vs. 1.3% (P = .008; OR, 1.54 [95% CI, 1.12-1.94]). Furthermore, there was an increased risk of an extended LOS (ie, LOS > 2 days) (28.4% vs. 25.7%; P = .004; OR, 1.14 [95% CI, 1.04-1.25]) along with increased direct cost (median, $17,612 vs. $16,775; P < .001). DISCUSSION: This study demonstrates that Medicaid payer status is independently associated with increased 90-day readmission and reoperation rates, LOS, and direct cost following primary shoulder arthroplasty. Providers may have a disincentive to treat patient populations who require increased resource utilization following surgery. Risk adjustment models accounting for Medicaid payer status will be necessary to ensure good access to care for this patient population by avoiding penalties for physicians and hospital systems.

A Prospective Randomized Controlled Trial of Methylprednisolone for Postoperative Pain Management of Surgically Treated Distal Radius Fractures.

PURPOSE: Perioperative glucocorticoids have been effectively used as a pain management regimen for reducing pain after hand surgery. We hypothesize that a methylprednisolone taper (MPT) course following surgery will reduce pain and opioid consumption in the early postoperative period. METHODS: This study was a randomized controlled trial of patients undergoing surgical fixation for distal radius fracture. Before surgery, patients were randomly assigned to receive preoperative dexamethasone only or preoperative dexamethasone followed by a 6-day oral MPT. Patient pain and opioid consumption data were collected for 7 days after surgery using a patient-reported pain journal. RESULTS: Our study consisted of 56 patients enrolled from November 2018 to March 2020. Twenty-eight patients each were assigned to the control and treatment groups. Demographic characteristics such as age, body mass index, the dominant side affected, smoking status, diabetes status, and current narcotic use were similar between the control and treatment groups. With a noticeable, significant reduction starting on postoperative day 2, patients who received an MPT course consumed substantially less opioids during the first 7 days (7.8 ± 7.2 pills compared with 15.5 ± 11.5 pills, a 50% reduction). These patients also consumed significantly fewer oral morphine equivalents than the control group (81.2 vs 41.2). A significant difference in the pain visual analog scale scores between the 2 groups was noted starting on postoperative day 2, with 48% of the treatment group reporting no pain by postoperative day 6. No adverse events, including infection or complications of wound or bone healing, were seen in either group. CONCLUSIONS: There was an early improvement in pain and reduction in early opioid consumption with a 6-day MPT following surgical fixation for distal radius fracture. With no increased risk of adverse events in our sample, MPT may be a safe and effective way to reduce postoperative pain. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Projections and Epidemiology of Total Ankle and Revision Total Ankle Arthroplasty in the United States to 2030.

Background: Total ankle arthroplasty (TAA) utilization is increasing in the United States. As the incidence of this procedure grows, it is important for providers to understand the future projections for ankle arthroplasty and more importantly revision total ankle arthroplasty (rTAA). Methods: The National Inpatient Sample (USA) was queried from 2005 to 2017 for all TAA and rTAA. Poisson and linear regression analysis was performed to project annual incidence of TAA and rTAA to 2030, with subgroup analyses on septic rTAA. Results: There were 5315 TAAs performed in 2017, a 564% (P < .001) increase when compared with the TAAs performed in 2005. From 2017 to 2030, the incidence of TAAs is projected to increase from 110% to 796% (P < .001). There were 1170 rTAAs performed in 2017, a 155% (P < .001) increase when compared with rTAAs performed in 2005. There was a 256% increase in the incidence of septic rTAAs from 2005 to 2017 with a projected increase between 22% and 120% by 2030. Conclusions: The incidence of both TAAs and rTAAs is projected to significantly increase over the next decade. Given the known risk factors of TAA and rTAA, these findings reinforce the need for thoughtful consideration when selecting patients for TAA.

Racial Disparities in the Utilization of Shoulder Arthroplasty in the United States: Trends from 2011 to 2017.

As the incidence of shoulder arthroplasty rises at exponential rates, race is an important consideration, as racial disparities have been reported in lower-extremity arthroplasty in the United States. Our study sought to examine these disparities. Methods: Using the National Inpatient Sample (NIS) database, all anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (RSA) procedures from 2011 to 2017 were analyzed. The patients were divided into the Black, Hispanic, and White groups. Results: Overall, 91.4% of the patients undergoing any shoulder arthroplasty procedure were White, 4.75% were Black, and 3.85% were Hispanic. Age and sex-standardized RSA utilization rates (per 100,000) in White patients increased by 139% from 6.94 in 2011 to 16.60 in 2017. The disparity for Black patients, compared with White patients, was 118% in 2011 and 124% in 2017; the disparity for Hispanic patients was 112% in 2011 and 103% in 2017. Similar disparities in aTSA utilization rates were seen; when compared with White patients, there was a 150% disparity in 2011 and a 197% disparity in 2017 for Black patients, and a 169% disparity in 2011 and a 262% disparity in 2017 for Hispanic patients. Finally, Blacks had a higher rate of non-home discharge, longer length of stay, and higher overall costs, while Hispanics had a longer length of stay and higher cost than Whites. Conclusions: Despite many efforts to reduce racial disparities in health-care utilization, the chasm in shoulder arthroplasty in the United States appears to be large and widening further. The exponential increase in utilization of shoulder arthroplasty has not been shared equally among races, and the disparities are larger than those reported in lower-extremity arthroplasty.

Fixation vs Arthroplasty for Femoral Neck Fracture in Patients Aged 40-59 Years: A Propensity-Score-Matched Analysis.

Background: Internal fixation (IF) has historically been favored for the treatment of femoral neck fractures (FNFs) in young, nongeriatric patients. However, recent literature reporting high reoperation rates among those receiving IF, taken in conjunction with favorable survivorship of modern bearing surfaces in total hip arthroplasty (THA), has begun to question this paradigm. Our study sought to compare outcomes between IF and THA for FNFs in patients aged 40-59 years. Methods: Using the Truven MarketScan Database, we performed a retrospective propensity-score-matched cohort study on patients aged 40-59 years who underwent surgical management of an isolated FNF (THA or IF). Patients with pathologic fracture were not included. Analysis was conducted on patients aged 40-49 and 50-59 years separately. A subgroup analysis was performed on those patients with 1 year and 3 years of follow-up. Multivariate analysis, controlling for baseline patient information, was then performed. Results: Seven hundred sevety-eight 40- to 49-year-old patients and 3470 50- to 59-year-old matched patients (IF and THA) were included in this study. A multivariate analysis found that patients aged 40-49 years who underwent IF were at higher odds of both 1-year (odds ratio 2.35, 95% confidence interval 1.22-4.54, P = .011) and 3-year (odds ratio 5.68, 95% confidence interval 2.21-14.60, P < .001) reoperation. Similar results were found in those aged 50-59 years. While complication rates were similar, postoperative anemia and 90-day visits to the emergency room were more common after THA in both age cohorts. Conclusions: While THA is associated with increased postoperative anemia and resource utilization compared with IF, patients aged 40-59 years who undergo IF for FNF are at increased risk of reoperation in the first 3 postoperative years. This information should be used to assist in shared decision-making with patients in this age group.

Preoperative Depression Influences Outcomes Following Total Ankle Arthroplasty.

INTRODUCTION: Total ankle arthroplasty (TAA) is increasing in incidence. While preoperative depression is known to affect outcomes following other procedures, its effect on outcomes following TAA are unknown. Therefore, the purpose of this study was to investigate this relationship. METHODS: This is a retrospective cohort study using the Nationwide Readmission Database (NRD). All patients undergoing TAA were included. Two cohorts (those with and without preoperative depression) were created. Logistic regression was then performed to assess the contribution of a preoperative diagnosis of depression on rates of 90-day complications, while controlling for patient demographic and comorbid data. RESULTS: Overall, 8047 patients were included, of whom, 11.4% (918) were depressed. Compared to patients without depression, patients with depression had increased odds of the following: nonhome discharge (OR 1.61, 95% CI 1.31-1.98), extended length of stay (>2 days; OR 1.34, 95% CI 1.15-1.57), prosthetic complication (OR 1.39, 95% CI 1.10-1.74), wound complication (OR 1.59, 95% CI 1.11-2.29), prosthetic joint infection (OR 1.82, 95% CI 1.06-3.15), superficial surgical site infection (OR 1.62, 95% CI 1.02-2.58), and medical complication (OR 1.32, 95% CI 1.03-1.68). DISCUSSION: Depression in patients undergoing TAA is common and is associated with increased health care utilization and complications following surgery. The modifiability of depression should be investigated with future studies. LEVELS OF EVIDENCE: Prognostic, Level III: Comparative study.

Medicaid Payer Status Is a Predictor of Early Postoperative Pain Following Upper Extremity Procedures.

Background: The purpose of this study was to investigate the relationship between insurance status and patient-reported pain both before and after upper extremity surgical procedures. We hypothesized that patients with Medicaid payer status would report higher levels of pre- and postoperative pain and report less postoperative pain relief. Methods: In all, 376 patients who underwent upper extremity procedures by a single surgeon at an academic ambulatory surgery center were identified. Patient information, including insurance status and Visual Analog Scale pain score (VAS-pain) at baseline, 2 weeks, and 1, 3, and 6 months, were collected. VAS-pain scores were compared with t-tests and linear regression. Results: Preoperatively and at 2-week, 1-month, and 3-month follow-up, Medicaid patients reported statistically significant higher pain levels than patients with Private insurance, finding a mean adjusted increase of 0.51 preoperatively, 0.39 at 1 month, and 0.79 at 3 months. Preoperatively and at 3-month follow-up, Medicaid patients reported statistically significant higher pain than patients with Medicare, finding increases in VAS-pain of 0.99 preoperatively and 0.94 at 3 months. There was no difference in pain improvement between any insurance types at any time point (all P values > .05). Conclusions: Patients with Medicaid report higher levels of preoperative pain and early postoperative pain, but reported the same improvement in pain as patients with other types of insurance. As healthcare systems are becoming increasingly dependent on patient-reported outcomes, including pain, it is important to consider that differences may exist in subjective pain depending on insurance status.

Postoperative acetabular component position in revision hip arthroplasty: a comparison of the anterior and posterior approaches.

BACKGROUND: While previously considered unsuitable for revision total hip arthroplasty (rTHA), the direct anterior approach (DAA) can be extended to allow for safe acetabular component revision. In primary hip arthroplasty, the DAA and its associated fluoroscopy, has been shown to produce more acceptable component positioning. However, there is little data comparing the DAA to the posterior approach (PA) for rTHA. We hypothesised that, the DAA with intraoperative fluoroscopy would allow for more precise acetabular component positioning when compared to those performed using a PA. METHODS: 50 consecutive patients (25 DAA and 25 PA) undergoing rTHA were included. Radiographic analysis of postoperative acetabular component position was then performed. Univariate and multivariate analyses was performed to assess the contribution of approach on cup positioning inside classically defined "safe zones". RESULTS: Baseline patient characteristics were similar. The PA was associated with more cups placed outside the Lewinnek (48% vs. 12%, p = 0.005) and the Danoff (52% vs. 28%, p = 0.083) "safe zones" when compared to the DAA. Multivariate analysis revealed that operative approach was the only patient or surgical factor associated with component position outside of the "safe zones" (Lewinnek [OR = 13.6; 95% CI, 2.12-87.9, p = 0.006] and Danoff [OR = 7.7; 95% CI, 1.48-40.1, p = 0.015]). CONCLUSION: Our results suggest that the DAA allows for more reproducible and precise cup placement in RTHA. The safe-zone paradigm remains a useful index of accurate cup positioning and the DAA, with use of intraoperative fluoroscopy, offers more consistent acetabular component positioning when compared to the PA.

Preoperative opioid use is a risk factor for complication following revision total hip arthroplasty.

BACKGROUND: The demand for revision total hip arthroplasty (THA) procedures continues to increase. A growing body of evidence in primary THA suggests that preoperative opioid use confers increased risk for complication. However, it is unknown whether the same is true for patients undergoing revision procedures. The purpose of this study was to investigate whether or not there was a relationship between preoperative opioid use and surgical complications, medical complications, and healthcare utilisation following revision THA. METHODS: This is a retrospective cohort study using the Truven Marketscan database. Patients undergoing revision THA were identified. Preoperative opioid prescriptions were queried for 1 year preoperatively and were used to divide patients into cohorts based on temporality and quantity of opioid use. This included an opioid naïve group as well as an "opioid holiday" group (6 months opioid naïve period after chronic use). Demographic and complication data were collected and both univariate and multivariate analysis was then performed. RESULTS: 62.5% of patients had received an opioid prescription in the year preceding surgery. Patients with continuous preoperative opioid use had higher odds of the following: infection (superficial or deep surgical site infection; OR 1.29; 95% CI, 1.03-1.62, p = 0.029), wound complication (OR 1.36; 95% CI, 1.02-1.82, p = 0.037), sepsis (OR 1.90; 95% CI 1.08-3.34, p = 0.026), and revision surgery (OR 1.54, 95% CI, 1.28-1.85, p < 0.001). This group also had higher care utilisation including extended length of stay, non-home discharge, 90-day readmission, and emergency room visits (p < 0.001). An opioid holiday mitigated some of this increased risk as this cohort has baseline (i.e. same as opioid naïve) risk (p > 0.05 for all comparison). CONCLUSIONS: Opioid use prior to revision THA is common and is associated with increased risk of postoperative complication. Given that risk was reduced by a preoperative opioid holiday, this represents a modifiable risk factor which should be discussed and addressed preoperatively to optimise outcomes.

Medicaid Payer Status Is Associated With Increased 90-Day Resource Utilization, Reoperation, and Infection Following Aseptic Revision Total Hip Arthroplasty.

Background: Prior literature has demonstrated increased resource utilization and perioperative complications in patients with a Medicaid payor status undergoing primary total hip and knee arthroplasty. This relationship has yet to be explored in patients undergoing revision total hip arthroplasty (rTHA). Methods: The National Readmissions Database was queried from 2010 to 2015 for all patients undergoing aseptic rTHA. 90-day complication data were collected, and patients were separated into two cohorts based on insurance payor type: Medicaid and non-Medicaid. Patients were propensity score matched 2:1 on a number of comorbid and operative characteristics. The relationship between Medicaid payor status and postoperative outcomes was then assessed using binomial logistic regression analysis. Results: 3,110 Medicaid patients were identified and matched to 6,175 non-Medicaid patients. Medicaid patients had increased odds of an early prosthetic joint infection (Odds Ratio [OR] 1.29, p=0.019), superficial surgical site infection (OR: 1.48, p=0.003), and early reoperation (OR: 1.18, p=0.045). Medicaid patients also experienced higher odds of readmissions, extended length of stay, non-home discharge status, and medical complications. Finally, the Medicaid cohort had a $3,332 (95% CI: 2,412-4,253, p<0.001) increased adjusted total cost of care when compared to the non-Medicaid cohort. Conclusion: This study identifies the Medicaid payor status as an independent risk factor for increased resource utilization, reoperation, and infection in the early postoperative period for patients undergoing rTHA. This relationship is likely due to an interplay of multiple variables, including socioeconomic status and access to care. Level of Evidence: IV.

Hospital Burdens of Patients With Cerebral Palsy Undergoing Posterior Spinal Fusion for Scoliosis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Many patients undergoing posterior spinal fusion (PSF) for scoliosis have concurrent cerebral palsy (CP), which is associated with many medical comorbidities and inherent operative risk. We aimed to quantify the contribution of CP to increased cost, length of stay (LOS), and complication rates in patients with scoliosis undergoing PSF. METHODS: Using the National Inpatient Sample database, we collected data regarding patient demographics, hospital characteristics, comorbidities, in-hospital complications, and mortality. Primary outcomes included complications, hospital LOS, and total hospital costs. Multivariate regression models assessed the contribution of CP to in-hospital complications, discharge status, and mortality. Linear regression identified the contribution of a diagnosis of CP on hospital LOS and inflation-adjusted cost. RESULTS: Cerebral palsy was an independent predictor of several complications. The most striking differences were seen for mortality (odds ratio [OR]: 3.40, P < .001), a postoperative requirement for total parenteral nutrition (OR: 3.16, P < .001), urinary tract infection (OR: 2.75, P < .001), surgical site infection (OR: 2.67, P < .001), and pneumonia (2.21, P < .001). Patients with CP ultimately cost an additional $13 482 (P < .001) with a 2.07-day greater LOS (P < .001) than patients without CP. CONCLUSION: Most complications were seen in higher rates in the CP cohort, with higher cost and LOS in patients with CP versus those with idiopathic scoliosis (IS). Our findings represent important areas of emphasis during preoperative consultations with patients with CP and their families. Extra care in patient selection and multifaceted treatment protocols should continue to be implemented with further investigation on how to mitigate common complications.

Association of Preoperative Opioid Use With Complication Rates and Resource Use in Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement.

BACKGROUND: Preoperative opioid use has been shown to be a negative predictor of patient outcomes, complication rates, and resource utilization in a variety of different orthopaedic procedures. To date, there are no studies investigating its effect on outcomes after hip arthroscopy in the setting of femoroacetabular impingement (FAI). PURPOSE: To determine the association of preoperative opioid use with postoperative outcomes after hip arthroscopy in patients with FAI. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The Truven Health MarketScan Commercial Claims and Encounters Database was queried for all patients who underwent hip arthroscopy for FAI between 2011 and 2018. Opioid prescriptions filled in the 6 months preceding surgery were queried, and the average daily oral morphine equivalents (OMEs) in this period were computed for each patient. Patients were divided into 4 cohorts: opioid naïve, <1 OME per day, 1 to 5 OMEs per day, and >5 OMEs per day. Postoperative 90-day complications, health care utilization, perioperative costs, postoperative opioid use, and 1- and 3-year revision rates were then compared among cohorts. RESULTS: A total of 22,124 patients were ultimately included in this study; 31.2% of these patients were prescribed opioids preoperatively. Overall, the percentage of preoperative opioid-naïve patients increased from 64.5% in 2011 to 78.9% in 2018. Patients who received preoperative opioids had a higher rate of complications, increased resource utilization, and increased revision rates. Specifically, on multivariate analysis, patients taking >5 OMEs per day (compared with patients who were preoperatively opioid naïve) had increased odds of a postoperative emergency department visit (Odds Ratio, 2.23; 95% confidence interval [CI], 1.94-2.56; P < .001), 90-day readmission (OR, 2.25; 95% CI, 1.77-2.87; P < .001), increased acute postoperative opioid use (OR, 25.56; 95% CI, 22.98-28.43; P < .001), prolonged opioid use (OR, 10.45; 95% CI, 8.92-12.25; P < .001), and 3-year revision surgery (OR, 2.14; 95% CI, 1.36-3.36; P < .001). Perioperative adjusted costs were increased for all preoperative opioid users and were highest for the >5 OMEs per day cohort ($6255; 95% CI, $5143-$7368). CONCLUSION: A large number of patients with FAI are prescribed opioids before undergoing hip arthroscopy, and use of these pain medications is associated with increased health care utilization, increased costs, prolonged opioid use, and early revision surgery.

Preoperative Diagnosis of Depression Leads to Increased Opioid Tablets Taken After Total Hip Arthroplasty: A Prospective Study.

Balancing postoperative analgesia with minimizing opioid consumption remains a challenge. We aim to document trends in opioid consumption for patients undergoing total hip arthroplasty (THA) and hypothesize that preoperative patient education will decrease postoperative opioid consumption. This is a prospective study of patients undergoing elective primary THA. Preoperatively, patients completed a survey regarding opioid-use history, surgical history, and pain tolerance. Patients were randomized to receive preoperative education on opioid use or no formal education. Six weeks postoperatively, patients completed a questionnaire regarding opioid use, disposal, and pain control. Ninety-five patients were included. Preoperative education was not associated with taking fewer narcotic medications (p = 0.790) and did not significantly alter disposal practices (p = 0.255). Depression was correlated with increased opioid use (mean difference 24 tabs, p = 0.001) and linked to longer duration of opioid use postoperatively (20.3 +/- 15.6 versus 7.2 +/- 7.3 days, p < 0.001). History of prior surgical procedure was associated with fewer narcotics taken (mean difference 26 tabs, p = 0.01). Depression is correlated with increased opioid use. Preoperative education did not affect opioid use or disposal frequency. (Journal of Surgical Orthopaedic Advances 30(3):144-149, 2021).

Prevalence of Shoulder Arthroplasty in the United States and the Increasing Burden of Revision Shoulder Arthroplasty.

Existing data on the epidemiology of shoulder arthroplasty are limited to future projections of incidence. However, the prevalence of shoulder arthroplasty (the number of individuals with a shoulder arthroplasty alive at a certain time and its implications for the burden of revision procedures) remains undetermined for the United States. Hence, the purpose of this study was to estimate the prevalence of shoulder arthroplasty in the United States. METHODS: The National Inpatient Sample (NIS) was queried to count all patients who underwent total shoulder arthroplasty (TSA), including both anatomic and reverse TSA, and hemiarthroplasty between 1988 and 2017. The counting method was used to calculate the current prevalence of TSA and hemiarthroplasty using age and sex-specific population and mortality data from the U.S. Census Bureau. RESULTS: In 2017, an estimated 823,361 patients (95% confidence interval [CI], 809,267 to 837,129 patients) were living in the United States with a shoulder replacement. This represents a prevalence of 0.258%, increasing markedly from 1995 (0.031%) and 2005 (0.083%). Female patients had a higher prevalence at 0.294% than male patients at 0.221%. Over 2% of people who were ≥80 years of age in the United States were living with a shoulder replacement. Furthermore, approximately 60% of patients living with a shoulder replacement had undergone the operation between 2013 and 2017. The incidence of revision shoulder arthroplasty is increasing on an annual basis, with 10,290 revision procedures performed in 2017, costing the U.S. health-care system $205 million. CONCLUSIONS: The prevalence of shoulder arthroplasty in the United States has markedly increased over time. This trend will likely continue given increasing life expectancies and exponentially increasing shoulder arthroplasty incidence rates. Most patients do not have long-term follow-up, and revision shoulder arthroplasty rates are increasing, a trend that is projected to continue. The data from our study highlight the enormous public health impact of shoulder replacement and shed light on a potentially increasing revision burden.

The Cost of Getting in: Is It Time for Change in the Adult Reconstruction Fellowship Application Process?

BACKGROUND: The number of applicants to adult reconstruction fellowships (ARFs) has increased significantly in recent years, making the application process increasingly competitive. With this, applicants are applying to and interviewing at more programs which has inherent cost and time implications. The purpose of this study was to assess these implications as well as investigate applicant attitudes toward proposed changes. METHODS: This is a cross-sectional survey study of 2019 and 2020 ARF applicants (n = 278) to a single institution. A 10-question survey was distributed to applicants regarding the application and interview process. This survey focused on application and interview volumes, financial and temporal commitments, as well as perceptions regarding potential application process changes. Descriptive statistics and chi-squared analysis were then performed. RESULTS: Of the 110 (40%) respondents, 87% spent >$3000 and 43% spent >$5000 during the application process. Most respondents applied to ≥26 programs (84%) and both received and attended ≥11 interviews (87% and 74.5%, respectively). Applicants missed significant training time for interviews (99% missed at least 1 week, 62% two weeks, and 15% three weeks). Attending more interviews (P = .001) and multiple visits to the same city (P = .049) were associated with spending >$5000. Most applicants (72%) felt change to the process would be beneficial. CONCLUSIONS: Applicants to ARF are applying to and interviewing at many programs resulting in significant time away from training and financial investment. Most applicants feel that a change to the system would be beneficial, although no consensus on the best solution was delineated. These data should be considered during the continued evaluation of the match process.