The impact of social deprivation on healthcare utilization patterns following rotator cuff repair.

BACKGROUND: Disparities in social determinants of health have been linked to worse patient reported outcomes, higher pain, and increased risk of revision surgery following rotator cuff repair. Identification of perioperative predictors of increased healthcare utilization is of particular interest to surgeons to improve outcomes and mitigate the total cost of care. The effect of social deprivation on healthcare utilization has not been fully characterized. METHODS: This is a retrospective review of a single institution's experience with primary rotator cuff repair between 2012 and 2020. Demographic variables (age, race, gender, American Society of Anesthesiologists (ASA) score) and healthcare utilization (hospital readmission, emergency department visits, follow-up visits, telephone calls) were recorded within 90 days of surgery. The Area Deprivation Index (ADI) was recorded, and patients were separated into terciles according to their relative level of social deprivation. Outcomes were then stratified based on ADI tercile and compared. RESULTS: A total of 1695 patients were included. The upper, middle, and lower terciles of ADI consisted of 410, 767, and 518 patients, respectively. The most deprived tercile had greater emergency department visitation and office visitation within 90 days of surgery relative to the least and intermediate deprived terciles. Higher levels of social deprivation were independent risk factors for increased emergency department (ED) visitation and follow-up visitation. There was no difference in 90-day readmission rates or telephone calls made between the least, intermediate, and most deprived patients. CONCLUSIONS: Patients with higher levels of deprivation demonstrated greater postoperative hospital utilization. We hope to use these results to identify risk factors for increased hospital use, guide clinical decision making, increase transparency, and manage patient outcomes following rotator cuff repair surgery.

Reverse shoulder arthroplasty in upper extremity ambulators: a matched-cohort analysis.

BACKGROUND: Upper extremity ambulators (UEAs) who require prolonged use of assistive devices for mobility have a high incidence of shoulder pathology secondary to increased stress across the shoulder joint with upper extremity weight-bearing. Reverse shoulder arthroplasty (RSA) for rotator cuff arthropathy has historically been associated with increased complications in UEA, but more recent studies have shown more promising outcomes. The objective of this study is to evaluate clinical outcomes and complication rates between these 2 groups to define the relative risk of RSA in the UEA population and identify opportunities to improve treatment outcomes. METHODS: An institutional review board-approved retrospective chart review was performed in patients who underwent RSA at our institution by the senior author from 2004 to 2019. UEAs were defined as patients who used regular upper extremity assistive devices for community ambulation before initial consultation for the surgical extremity. Pre- and postoperative range of motion, visual analog scale scores, American Shoulder and Elbow Surgeons scores, Constant-Murley scores, and Simple Shoulder Test scores were measured at defined intervals. Complications including infection, instability, and need for revision surgery were also compared. All patients were followed for a minimum of 2 years postoperatively. RESULTS: A total of 159 RSA procedures (70 UEAs, 89 controls) were performed during the study period. On average, UEA patients had more preoperative pain and less shoulder function than controls, with statistically significant differences in visual analog scores (6.897 vs. 5.532, P = .0010) and American Shoulder and Elbow Surgeons scores (33.50 vs. 40.20, P = .0290), respectively. Despite the lower baseline values, UEA patients experienced excellent postoperative improvement, leading to similar postoperative pain and shoulder function except for a lower average forward flexion in the UEA group (127° vs. 135°, P = .0354). Notching and complication rates were also similar between the 2 groups, with notching rates of 59% and 50% and complication rates of 14.3% and 13.5% in the UEA and control groups, respectively. CONCLUSIONS: RSA in the UEA population can achieve similar pain and functional outcomes as compared with age-matched controls without a significant increase in complication rates; however, further studies are required to assess long-term comparative outcomes in this challenging patient population.

Association Between Nonsurgical Weight Loss From Body Mass Index >40 to Body Mass Index <40 and Complications and Readmissions Following Total Hip Arthroplasty.

BACKGROUND: Elevated body mass index (BMI) is a risk factor for adverse outcomes following total hip arthroplasty (THA). It is unknown if preoperative weight loss to a BMI <40 kg/m2 is associated with reduced risk of adverse outcomes. METHODS: We retrospectively reviewed elective, primary THA performed at an academic center from 2015 to 2019. Patients were split into groups based on their BMI trajectory prior to THA: BMI consistently <40 ("BMI <40"); BMI >40 at the time of surgery ("BMI >40"); and BMI >40 within 2 years preoperatively, but <40 at the time of surgery ("Weight Loss"). Length of stay (LOS), 30-day readmissions, and complications as defined by Centers for Medicare and Medicaid Services were compared between groups using parsimonious regression models and Fisher's exact testing. Adjusted analyses controlled for sex, age, and American Society of Anesthesiologists class. RESULTS: In total, 1589 patients were included (BMI <40: 1387, BMI >40: 96, Weight Loss: 106). The rate of complications in each group was 3.5%, 6.3%, and 8.5% and the rate of 30-day readmissions was 3.0%, 4.2%, and 7.5%, respectively. Compared to the BMI <40 group, the weight loss group had a significantly higher risk of 30-day readmission (odds ratio [OR] 2.70, 95% confidence interval [CI] 1.19-6.17, P = .02), higher risk of any complication (OR 2.47, 95% CI 1.09-5.59, P = .03), higher risk of mechanical complications (OR 3.07, 95% CI 1.14-8.25, P = .03), and longer median LOS (16% increase, P = .002). The BMI >40 group had increased median LOS (10% increase, P = .03), but no difference in readmission or complications (P > .05) compared to BMI <40. CONCLUSION: Weight loss from BMI >40 to BMI <40 prior to THA was associated with increased risk of readmission and complications compared to BMI <40, whereas BMI >40 was not. LEVEL OF EVIDENCE: Level III - Retrospective Cohort Study.

The Impact of Pre-Operative Healthcare Utilization on Complications, Readmissions, and Post-Operative Healthcare Utilization Following Total Joint Arthroplasty.

BACKGROUND: Identifying risk factors for adverse outcomes and increased costs following total joint arthroplasty (TJA) is needed to ensure quality. The interaction between pre-operative healthcare utilization (pre-HU) and outcomes following TJA has not been fully characterized. METHODS: This is a retrospective cohort study of patients undergoing elective, primary total hip arthroplasty (THA, N = 1785) or total knee arthroplasty (TKA, N = 2159) between 2015 and 2019 at a single institution. Pre-HU and post-operative healthcare utilization (post-HU) included non-elective healthcare utilization in the 90 days prior to and following TJA, respectively (emergency department, urgent care, observation admission, inpatient admission). Multivariate regression models including age, gender, American Society of Anesthesiologists, Medicaid status, and body mass index were fit for 30-day readmission, Centers for Medicare and Medicaid services (CMS)-defined complications, length of stay, and post-HU. RESULTS: The 30-day readmission rate was 3.2% and 3.4% and the CMS-defined complication rate was 3.8% and 2.9% for THA and TKA, respectively. Multivariate regression showed that for THA, presence of any pre-HU was associated with increased risk of 30-day readmission (odds ratio [OR] 2.85, 95% confidence interval [CI] 1.48-5.50, P = .002), CMS complications (OR 2.42, 95% CI 1.27-4.59, P = .007), and post-HU (OR 3.65, 95% CI 2.54-5.26, P < .001). For TKA, ≥2 pre-HU events were associated with increased risk of 30-day readmission (OR 3.52, 95% CI 1.17-10.61, P = .026) and post-HU (OR 2.64, 95% CI 1.29-5.40, P = .008). There were positive correlations for THA (any pre-HU) and TKA (≥2 pre-HU) with length of stay and number of post-HU events. CONCLUSION: Patients who utilize non-elective healthcare in the 90 days prior to TJA are at increased risk of readmission, complications, and unplanned post-HU. LEVEL OF EVIDENCE: Level III.

Do In-Hospital Rothman Index Scores Predict Postdischarge Adverse Events and Discharge Location After Total Knee Arthroplasty?

BACKGROUND: There have been efforts to reduce adverse events and unplanned readmissions after total joint arthroplasty. The Rothman Index (RI) is a real-time, composite measure of medical acuity for hospitalized patients. We aimed to examine the association among in-hospital RI scores and complications, readmissions, and discharge location after total knee arthroplasty (TKA). We hypothesized that RI scores could be used to predict the outcomes of interest. METHODS: This is a retrospective study of an institutional database of elective, primary TKA from July 2018 until December 2019. Complications and readmissions were defined per Centers for Medicare and Medicaid Services. Analysis included multivariate regression, computation of the area under the curve (AUC), and the Youden Index to set RI thresholds. RESULTS: The study cohort's (n = 957) complications (2.4%), readmissions (3.6%), and nonhome discharge (13.7%) were reported. All RI metrics (minimum, maximum, last, mean, range, 25th%, and 75th%) were significantly associated with increased odds of readmission and home discharge (all P < .05). RI scores were not significantly associated with complications. The optimal RI thresholds for increased risk of readmission were last ≤ 71 (AUC = 0.65), mean ≤ 67 (AUC = 0.66), or maximum ≤ 80 (AUC = 0.63). The optimal RI thresholds for increased risk of home discharge were minimum ≥ 53 (AUC = 0.65), mean ≥ 69 (AUC = 0.65), or maximum ≥ 81 (AUC = 0.60). CONCLUSION: RI values may be used to predict readmission or home discharge after TKA.

Ventilation monitoring during moderate sedation in GI patients.

Sedation in locations outside the operating room (OR) is common. Guidelines for safe patient monitoring have been updated by the American Society of Anesthesiology to include monitoring of ventilation and/or carbon dioxide (CO2). Although technologies exist to monitor these variables, the quality and/or availability of these measurements in non-OR settings is not optimal. This quality improvement project assessed the value of impedance technology for monitoring minute ventilation (MV) compared to standard end-tidal monitoring of CO2 (ETCO2). Patients undergoing GI exams with moderate sedation provided by anesthesia providers were monitored for MV with a respiratory volume monitor (ExSpiron 1Xi, Respiratory Motion, Waltham, MA) and ETCO2 via nasal cannula (NC). Calibration and baseline data were collected prior to sedation. Continuous MV and ETCO2 data were collected and averaged, providing minute values after sedation medications throughout the procedure. Stable periods of reduced MV were averaged and used in comparison to ETCO2. Data from 20 patients were evaluated. After sedation, the expected decrease in MV after sedation was observed in 18 of 20 patients (average -47.82 %), while an increase in ETCO2 was observed in just 10 of 20 patients (average -5.17 mm Hg). The correlation coefficient between changes in MV and ETCO2 in response to sedation administration was positive and not significant, r = 0.223. Ventilation monitoring may provide an element of safety for earlier and more reliable detection of reduced ventilation compared to a surrogate for hypoventilation, ETCO2, in patients undergoing sedation for GI procedures outside of the OR.

Knee Arthrofibrosis following Tibial Plateau Fracture Treated with Arthroscopic Lysis of Adhesions with Manipulation.

Posttraumatic arthrofibrosis is a common problem encountered in the orthopaedic setting for which there is no agreement on the optimal management strategy. The literature does not optimally describe the efficacy of arthroscopic lysis of adhesions for arthrofibrosis following tibial plateau fracture. The purpose of this study is to quantify the efficacy of arthroscopic lysis of adhesions with manipulation for the treatment of arthrofibrosis of the knee in patients who previously underwent surgical management of tibial plateau fracture. All patients who underwent arthroscopic lysis of adhesions from a single surgeon since 1999 were retrospectively reviewed. Clinical outcomes were evaluated by flexion, extension, and range of motion (ROM) preoperatively, intraoperatively, and postoperatively at intervals of 1, 4, 8, and 12 weeks, and any additional long-term follow-up. A total of 28 patients who had developed arthrofibrosis following surgical management of a tibial plateau fracture and failed nonsurgical management of knee stiffness were included in this study. There were significant improvements in total ROM following intervention at all time points compared with preoperative values (p < 0.001), with mean improvements of 59.3 degrees intraoperatively, 32.9 degrees (1 week), 37.1 degrees (4 weeks), 41.5 degrees (8 weeks), and 47.6 degrees (12 weeks). There were significant improvements in degrees of knee flexion following intervention at all time points compared with preoperative values (p < 0.001), with mean improvements of 50.8 degrees intraoperatively, 27.3 degrees (1 week), 36.0 degrees (4 weeks), 38.3 degrees (8 weeks), and 43.9 degrees (12 weeks). There were significant increases in degrees of knee extension intraoperatively (8.5 degrees) and at 1 week postoperatively (5.9 degrees) compared with preoperative values (p <0.01). At 12 weeks postoperatively, those who had previously undergone external fixation had significantly greater increases in ROM (p = 0.048). Arthroscopic lysis of adhesions for knee arthrofibrosis following surgical management of tibial plateau fracture significantly improves knee ROM.

Arthroscopic Lysis of Adhesions With Manipulation for Management of Late-Presenting Stiffness After Total Knee Arthroplasty.

BACKGROUND: Arthrofibrosis is a known complication of total knee arthroplasty (TKA). Closed manipulation is the treatment of choice for arthrofibrosis within 90 days of TKA. Treatment for arthrofibrosis that has failed prior interventions remains controversial, and the role for arthroscopic lysis of adhesions has not been examined for late-presenting arthrofibrosis. METHODS: A retrospective analysis of patients who underwent arthroscopic lysis of adhesions (LOAs) with manipulation for post-TKA arthrofibrosis was performed. Chart review included patient characteristics, time from TKA, prior interventions, and range of motion (ROM) data. Knee extension, flexion, and total ROM were recorded preoperatively, intraoperatively, and throughout follow-up. Knee ROM was compared at the different time intervals using Wilcoxon signed-rank tests. RESULTS: A total of 13 patients (6 male and 7 female) with a mean age of 66.3 years were included. Average time since index TKA was 57.2 months (3.7-209.5). Ten of 13 patients had undergone prior interventions for arthrofibrosis, which included closed manipulation under anesthesia, open LOA, and revision arthroplasty. The mean preoperative knee flexion and extension values for the cohort were 76.5 ± 17.4 and -4.6 ± 6.1 degrees, respectively. Postoperative improvements in knee ROM were significant at all time points, with mean improvements of 17.2 ± 16.3 degrees at 1 week (P = .022), 17.2 ± 13.2 degrees at 4 weeks (P = .001), 19.2 ± 16.0 degrees at 8 weeks (P = .004), and 25.2 ± 13.1 degrees at 12 weeks (P = .005). No complications were recorded. CONCLUSIONS: Arthroscopic LOAs with manipulation achieves significant improvements in knee ROM for late-presenting arthrofibrosis after TKA.

Complete brachial plexus palsy following shoulder dislocation due to sneeze: a case report.

BACKGROUND: Traumatic shoulder dislocation is a frequent condition presenting to the emergency department. Due to the anatomy of the shoulder, associated neurovascular damage is not uncommon. Although clinical intuition may suggest that a higher-energy mechanism is required to produce neurovascular sequelae, the existing literature does not support this supposition. CASE PRESENTATION: A 55-year-old woman presented to the emergency department with a complete brachial plexus palsy from an acute anterior shoulder dislocation following a violent sneeze. The shoulder was reduced without difficulty in the emergency department within 90 min of dislocation, and the patient was discharged. Her neurologic deficits gradually improved through a program of supervised therapy and orthopedic care. Follow-up at 1 year revealed marked improvement of motor and sensory function of the affected extremity with mild residual weakness and paresthesias in the affected hand. CONCLUSION: Neurovascular injuries in the setting of shoulder dislocation may be present despite low-energy injury mechanisms.