Fibromyalgia Increases Post-operative Healthcare Utilization Following total Hip Arthroplasty.

BACKGROUND: Preoperative factors can complicate the postoperative course and increase health care utilization following total hip arthroplasty (THA). Fibromyalgia is not generally recognized as a modifiable risk factor prior to THA. The aim of this investigation was to assess the effect of fibromyalgia on postoperative health care utilization following THA. METHODS: Patients who underwent primary THA from 2018 to 2019 were identified from a large national database using Current Procedural Terminology and International Classification of Diseases, tenth revision (International Classification of Diseases-10) codes. Patient demographics, age, sex, and preoperative opioid use were collected. Analysis compared patients who did and did not have fibromyalgia for postoperative health care utilization metrics; lengths of stay (LOS), 90-day postoperative opioid usages, dislocations, and emergency room visits. Independent t-tests were used to compare LOS and rates of ongoing opioid use. Logistic regression analyses with adjusted odds ratios evaluated the risk of dislocation and emergency room visit after adjusting for demographic characteristics and comorbidities. RESULTS: Compared to those who did not have fibromyalgia, patients who had fibromyalgia experienced longer LOS (P < .0001), increased odds of opioid use 90 days postoperatively (P < .0001) as well as increased odds of hip dislocation (P < .0001) and presentation to the emergency room (P < .0001). Patients who had fibromyalgia were also more likely to be "frequent flyers" with ≥5 emergency room visits after THA (P < .0001). CONCLUSIONS: Fibromyalgia can complicate postoperative care following THA with increased LOS, higher rates of opioid use, and increased odds of dislocation and emergency room visits. As focus shifts to preoperative optimization and risk stratification, more attention should be placed on fibromyalgia prior to THA.

It is the Opioids Not the Spine Surgeon; Dislocation After Total Hip Arthroplasty is Associated With Opioid Use in Patients Who Have Prior Lumbar Spine Fusion.

BACKGROUND: Patients who have prior lumbar spine fusion (LSF) have an increased risk for dislocation after total hip arthroplasty (THA). These patients also have elevated rates of opioid use. We aimed to evaluate the associated risk of dislocation after THA in patients who have prior LSF comparing those who have opioid use to those who do not. METHODS: This was a retrospective review using a large national database of 246,617 primary and 34,083 revision THA cases from 2012 to 2019. There were 1,903 primary THA and 288 revision THA cases identified with LSF prior to THA. Postoperative hip dislocation was our primary outcome variable and patients were stratified to use or nonuse of opioid at THA. Demographic data including age, sex, and obesity were collected. Multivariate analyses evaluated association of opioid use and dislocation after adjusting for demographics. RESULTS: There was increased odds of dislocation for opioid use at THA for both primary (adjusted Odds Ratio [aOR] = 2.29, 95% Confidence Interval [CI] 1.46 to 3.57, P < .0003) and revision THA (aOR = 1.92, 95% CI 1.62 to 3.08, P < .0003), in patients who have prior LSF. Prior LSF without opioid use was associated with increased odds of dislocation (aOR = 1.38, 95% CI 1.01 to 1.88, P = .04), but this was lower than the associated risk of opioid use without LSF (aOR 1.72, 95% CI 1.63 to 1.81, P < .001). CONCLUSION: Increased odds of dislocation were noted with opioid use at time of THA in patients who have prior LSF. Associated risk of dislocation was higher for opioid use than prior LSF. This suggests that dislocation risk is multifactorial and we should look to strategies to reduce opioid use prior to THA.

Insurance-Mandated Stay Prolongs Hospitalization Following Total Shoulder Arthroplasty.

Medicare currently requires a 3-night hospitalization for a patient to be considered for skilled nursing facility (SNF) placement. The purpose of this study was to analyze the relationship between length of stay and (a) insurance status and (b) readmission rates in Medicare-age patients undergoing primary total shoulder arthroplasty. A retrospective review of 251 primary consecutive total shoulder arthroplasty cases was performed. In patients discharged to SNF, Medicare insurance was associated with a significantly longer hospital stay (p < .001) compared with patients with private insurance. Readmission rates for Medicare and private insurance patients were similar at 30 and 90 days after surgery (p = 1.000). Ninety-five percent of Medicare patients discharged to SNF had a prolonged hospital stay primarily to fulfill the 3-night requirement. These findings call into question the necessity of the current 3-night inpatient hospitalization requirement for facility placement following total shoulder arthroplasty.

Is Timing of Total Hip Arthroplasty and Lumbar Spine Fusion Associated With Risk of Hip Dislocation?

Background: In patients with concomitant hip and lumbar spine disease, the question of which surgery-total hip arthroplasty (THA) or lumbar spine fusion (LSF)-to address first has not been adequately answered. We aimed to evaluate the risk of dislocation after THA in patients with LSF first or after THA. Methods: Retrospective review utilizing the PearlDiver database querying Current Procedural Terminology codes for LSF in the year prior (LSF first) or in the year after primary or revision THA (THA first). International Classification of Disease codes identified postoperative hip dislocation as our primary outcome variable. Demographic data collected included age, sex, and obesity. Dislocation rates were described as a proportion of the cohort and compared with chi-square tests. Results: We identified 280,857 primary THA and 42,314 revision THA cases from 2012-2019. Of these, 2090 underwent primary THA and LSF, and 283 underwent revision THA and LSF within a year of each procedure. No differences in age, sex, or obesity between groups were noted. No difference in rate of all-time dislocation for primary THA was noted for the LSF first 51/1429 (3.6%) compared to the THA first 30/661 (4.0%) groups (P = .34), or for revision THA with LSF first 48/204 (23.5%) compared to THA first 27/117 (23.1%) groups (P = 1.0). Conclusions: There was no difference in the risk of dislocation after primary or revision THA if LSF occurred prior to or after the THA. These findings can help surgeons as they counsel patients with concomitant lumbar spine and hip degeneration.

Evaluation of the learning curve for reverse shoulder arthroplasty.

This purpose of this study was to quantify the surgical learning curve and provide guidelines to surgeons interested in teaching and performing reverse shoulder replacement. Sixty-two consecutive primary reverse shoulder replacements performed by a single surgeon were retrospectively reviewed. Using data from consecutive cases, surgical time was plotted against patient case order, and the linear regression slope was calculated. Case length slope analysis demonstrated a significantly negative slope with the first 18 cases, which subsequently leveled thereafter. The number of cases needed to arrive at this flat slope was defined as the proficiency point.The proficiency point was then verified using the measurable variables of baseplate screw number and glenosphere overhang by dividing the series into 2 groups: Group A included patients who had surgery prior to the proficiency point, and group B included patients who had surgery after the proficiency point. In group A, only 33% (6/18) had all 4 glenoid baseplate screws placed as compared to 66% (29/44) in group B (P=.02). Glenosphere overhang increased from a mean of 1.02 mm (+/-1.29 mm) in group A to 2.58 mm (+/-1.89 mm) in group B (P=.003).A learning curve of approximately 18 cases was found in this series based on the technical aspects of performing reverse shoulder replacement. This curve is likely even longer for lower volume shoulder surgeons. We recommend specialized training prior to performing this procedure.