Routine postoperative laboratory tests are unnecessary after primary reverse shoulder arthroplasty.

BACKGROUND: Obtaining postoperative laboratory studies after primary reverse shoulder arthroplasty (RSA) is a common practice. However, justification of this practice remains unclear. This study assesses the utility of routine postoperative laboratory studies in RSA. METHODS: The electronic medical records of 369 patients who underwent RSA over 10 years were retrospectively reviewed. A total of 213 patients qualified for analysis. Primary outcomes were intervention related to abnormal laboratory values, length of stay, and 90-day emergency department visits/readmissions. Multivariate logistic regression analysis was performed to identify risk factors associated with abnormal laboratory values and postoperative visits/readmissions. RESULTS: Of 213 patients analyzed, 188 (88.7%) had abnormal postoperative laboratory values: 69% had an abnormal hemoglobin (Hgb) or hematocrit level, but only 12% underwent interventions. Lower preoperative Hgb was a significant predictor of receiving a transfusion. A significant association existed between abnormal postoperative electrolyte and creatinine levels with lower body mass index (BMI) and higher Charlson Comorbidity Index (CCI). Only 4 patients (1.8%) received non-transfusion related intervention. Emergency department visits were not statistically different between patients with positive or negative laboratory tests (P = .73). CONCLUSION: Because 87.3% of laboratory studies did not influence patient management, we recommend against routine testing for primary RSA. This study demonstrates that the practice of obtaining routine postoperative laboratory studies is not justified. We recommend selectively obtaining a postoperative basic metabolic profile in patients with increased American Society of Anesthesiologists classification and/or CCI with a lower BMI. We also recommend selectively ordering postoperative complete blood count in patients with a lower preoperative Hgb.

Analysis of perioperative morbidity and mortality in shoulder arthroplasty patients with preexisting alcohol use disorders.

BACKGROUND: Shoulder arthroplasty is becoming increasingly popular in the United States. Given the high prevalence of alcohol abuse and its implications in postoperative morbidity and the increasing incidence of shoulder arthroplasty, it is prudent to explore the effect of alcohol use disorders (AUDs) in this patient population. In this study, we considered numerous outcome variables, including perioperative complications, in-hospital death, prolonged hospital stay, and nonroutine discharge. METHODS: Using the Nationwide Inpatient Sample, we performed a retrospective cohort study to identify a population of 422,371 adults (≥18 years old) undergoing total shoulder arthroplasty or hemiarthroplasty between January 1, 2002, and December 31, 2011. We then further subdivided this cohort into those who were classified as having AUDs and those who did not. Comparisons of early postoperative outcome measures were performed by bivariate and multivariable analyses with logistic regression modeling. RESULTS: Compared with those without AUDs, patients undergoing shoulder arthroplasty with a preexisting AUD have a greater likelihood to experience death, pneumonia, deep venous thrombosis, acute renal failure, transfusion, prolonged length of stay, and nonroutine discharge irrespective of age, gender, race, and other medical comorbidities. Patients with a preexisting AUD are 2.7 times more likely to experience perioperative complications after shoulder arthroplasty. CONCLUSION: Patients undergoing shoulder arthroplasty with a preexisting AUD have a greater likelihood of perioperative complications and health care resource utilization after shoulder arthroplasty. Presurgical alcohol screening may prove effective in identifying at-risk patients, and providing interventions before surgery may effectively limit the complication profile.

Behind the Match Process: Is There Any Financial Difference Lurking Below the Specialty of Choice?

The Match was developed in response to a chaotic residency selection process. While the match has remained relatively unchanged since it was introduced, the number of medical school graduates has increased at a rate outpacing the number of residency positions leading to a more competitive process for applicants. In May 2014, an 18-question mixed-response questionnaire was distributed to fourth year allopathic medical students via an E-mail distribution list for student affairs representatives. The individual surveys were accessible via SurveyMonkey and available for completion over the course of a 4-week period. Approximately 65.1 per cent of students performed at least one audition rotation and documented average expenditures of $2494 on housing, food, and transportation. The average applicant applied to 32 programs and attended 12 interviews while spending $4420 on the interview trail. Applicants for surgical programs applied to approximately 42 programs and attended 13 interviews compared with primary care applicants who averaged 23 programs (P < 0.001) and attended 12 interviews (P = 0.002). Surgical applicants averaged 20 days on the interview trail while spending $5500 ($423/interview) on housing, food, and transportation compared with primary care applicants averaged 19 days away from home (P < 0.05) and spending $3400 ($283/interview) on these same items (P < 0.001). The findings in our study indicate that the "Match process" contributes to the financial burden of graduating medical students and it is more expensive and time consuming for the candidates interested in surgical specialties.

Is the orthopedic fellowship interview process broken? A survey of program directors and residents.

Most orthopedic surgery residents pursue fellowship training. The fellowship interview process requires considerable time and financial investment from residents and residency programs. We conducted a study of the time, financial, and program disruption impact the fellowship interview process has on residents and residency programs. Two mixed-response questionnaires were sent to orthopedic surgery residency directors and postgraduate year 4 and 5 residents. Responses were received from 45 program directors and 129 residents. Sixty-two percent of the directors thought the interview process was extremely disruptive to their program. On average, the residents applied to 19 programs, received 14 interview offers, attended 11 interviews, were away from residency training 11 days, and spent $5875 on travel. About 70% of directors and residents wanted changes made to the orthopedic fellowship interview process. Sixty percent of the directors wanted interviews conducted in a central location. Our results highlight that time away from residency training, financial costs associated with the fellowship interview process, and disruption of the residency program are substantial.

Risk factors for in-hospital myocardial infarction after shoulder arthroplasty.

As cardiovascular complications are associated with significant morbidity and mortality in patients who have arthroplasty, it is important to analyze risk factors for perioperative cardiac morbidity after shoulder arthroplasty. Using the Nationwide Inpatient Sample, we stratified patients who underwent shoulder arthroplasty into those who had an acute myocardial infarction after arthroplasty and a larger cohort of patients who did not. The top 4 predictors for acute myocardial infarction after shoulder arthroplasty were congestive heart failure, angina pectoris, complicated diabetes mellitus, and male sex. Other pertinent factors were older age, Caucasian ethnicity, and primary diagnosis of proximal humerus fracture. It is prudent for surgeons and patients to understand the degree to which perioperative cardiac morbidity affects surgical recovery.