Quantifying Patient Expectations for Total Knee Arthroplasty: Expectations for Improvement Are Greater Than Minimal Clinically Important Difference.

BACKGROUND: Achieving a minimal clinically important difference (MCID) in patient-reported outcomes following total knee arthroplasty (TKA) is common, yet up to 20% patient dissatisfaction persists. Unmet expectations may explain post-TKA dissatisfaction. No prior studies have quantified patient expectations using the same patient-reported outcome metric as used for MCID to allow direct comparison. METHODS: This was a prospective study of patients undergoing TKA with 5 fellowship-trained arthroplasty surgeons at one academic center. Baseline Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) domains were assessed. Expected PROMIS scores were determined by asking patients to indicate the outcomes they were expecting at 12 months postoperatively. Predicted scores were generated from a predictive model validated in the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) dataset. T-tests were used to compare baseline, expected, and predicted PROMIS scores. Expected scores were compared to PROMIS MCID values obtained from the literature. Regression models were used to identify patient characteristics associated with high expectations. RESULTS: There were 93 patients included. Mean age was 67 years (range, 30 to 85) and 55% were women. Mean baseline PROMIS PF and PI was 34.4 ± 6.7 and 62.2 ± 6.4, respectively. Patients expected significant improvement for PF of 1.9 times the MCID (MCID = 11.3; mean expected improvement = 21.6, 95% confidence interval [CI] 19.6 to 23.5, P < .001) and for PI of 2.3 times the MCID (MCID = 8.9; mean expected improvement = 20.6, 95% CI 19.1-22.2, P < .001). Predicted scores were significantly lower than expected scores (mean difference = 9.5, 95% CI 7.7 to 11.3, P < .001). No unique patient characteristics were associated with high expectations (P > .05). CONCLUSIONS: To our knowledge, this study is the first to quantify preoperative patient expectations using the same metric as MCID to allow for direct comparison. Patient expectations for improvement following TKA are ∼2× greater than MCID and are significantly greater than predicted outcome scores. This discrepancy challenges currently accepted standards of success after TKA and indicates a need for improved expectation setting prior to surgery.

Adoption of Health System Innovations: Evidence of Urban-Rural Disparities from the Ohio Primary Care Marketplace.

BACKGROUND: Accountable care organizations (ACOs), patient-centered medical homes (PCMHs), and the meaningful use of electronic health records (EHRs) generated particular attention during the last decade. Translating these reforms into meaningful increases in population health depends on improving the quality and clinical integration of primary care providers (PCPs). However, if these innovations spread more quickly among PCPs in urban and wealthier areas, then they could potentially worsen existing geographic disparities in health outcomes. OBJECTIVE: To determine the market penetration of Medicare Shared Savings Program (MSSP) ACOs, PCMHs, and the meaningful use of EHRs among PCPs across urban and rural counties in Ohio. DESIGN: Retrospective, observational study of the percent of PCPs in a county who are affiliated with PCMH, ACO, and meaningful use (MU) of EHR. PARTICIPANTS: PCPs in all of Ohio's 88 counties from 2011 to 2015. MAIN MEASURES: Primary care market penetration of ACO, PCMH, and meaningful use of EHR KEY RESULTS: In 2015, the Ohio primary care market penetration of PCMH was 23.4%, ACO was 27.7%, MU stage 1 was 55.8%, and MU stage 2 was 26.6%. During the study period, PCMH and ACO market penetration increased faster in urban counties relative to rural counties, and market penetration of meaningful use of EHR increased faster in rural counties. CONCLUSIONS: Market penetration of PCMH and ACOs increased faster in urban markets compared to rural markets. However, the adoption of EHRs increased faster in rural markets. The results are a cause for optimism as well as a call to action: although recent efforts to increase PCMH and ACO adoption were less effective among the rural population in Ohio, federal programs to accelerate adoption of EHRs were overwhelmingly successful in rural areas.

Prevalence of Bennett lesions based on sex, ancestry, and age in an osteologic collection of 5,662 scapulae.

BACKGROUND: Bennett lesions represent an extra-articular ossification on the posteroinferior aspect of the glenoid fossa and a potential source of posterior shoulder pain and limitation. The prevalence of Bennett lesions in the general population is unknown. MATERIALS AND METHODS: A total of 5,662 scapulae from 2,831 individual cadaveric specimens greater than 18 years of age at the time of death were examined. Matching scapulae were evaluated for Bennett lesions by two independent authors. Lesion prevalence was calculated and statistical analysis performed to evaluate differences in prevalence based on specimen sex (males vs. females), ancestry (African-American vs. Caucasian) and with increasing age at the time of death. RESULTS: Bennett lesions were observed in 3.5% (n = 98 of 2,831) of specimens and 1.8% (n = 104 of 5,662) of scapulae. Interobserver reliability was 0.83, indicating excellent agreement among authors. Males possessed significant higher odds of possessing a Bennett lesion when compared to females (p = .009) and African-American specimens when compared to Caucasian specimens (p < .001). Each additional year of age was associated with a 1.4% increase in odds of a specimen having a Bennett lesion, while no significant increase in Bennett lesion prevalence was appreciated with increasing specimen age at the time of death when comparing male to female specimens (p = .07) or African-American to Caucasian specimens (p = .73). CONCLUSIONS: Bennett lesions were identified in 3.5% of osseous specimens and 1.8% of scapulae, with significantly higher prevalence in male and African-American specimens.

Recurrent Labral Tearing on Magnetic Resonance Imaging Is Not Predictive of Diminished Participation Among National Football League Athletes.

PURPOSE: To investigate the prevalence of shoulder labral repair and utility of magnetic resonance imaging (MRI) in determining the risks of recurrent labral tearing and impact on future participation in the National Football League (NFL). METHODS: Athletes invited to the NFL Combine between 2012 and 2015 were retrospectively reviewed. Athletes with a history of labral repair and MRI of the operative shoulder at the Combine were included in the study for further analysis, excluding athletes without a history of labral repair, labral repair without MRI at the Combine, additional procedure to the operative shoulder, or athletes still undergoing rehabilitation at the time of the Combine after labral repair. All MRIs were reviewed to determine initial labral repair location, the presence of recurrent tearing, and any concomitant shoulder pathology. Prospective information on future NFL participation in regard to draft status, games played, and games started in the athlete's first NFL season after the Combine was compared between athletes with a history of labral repair with and without recurrent tearing versus all other athletes participating in the Combine. RESULTS: A total of 132 (10.1%) athletes underwent 146 shoulder labral repair procedures before the NFL Combine, of whom 32% (n = 39 athletes, n = 46 shoulders) had recurrent labral tears on MRI. Athletes with recurrent tears were more likely to have undergone bilateral labral repairs (P = .048) and possess concomitant shoulder pathology (P < .001). Recurrent labral tearing was significantly more common in the posterior labrum in athletes with a history of posterior labral repairs (P = .032). Prospective participation in the NFL in terms of games played (P = .38) or started (P = .98) was not significantly reduced in athletes with a history of labral repair compared with those without repair. Participation was not diminished in athletes with recurrent labral tears compared with those with intact repairs or those with evidence of degenerative joint disease. CONCLUSIONS: Athletes invited to the NFL Scouting Combine with a history of bilateral repair, posterior labral repair, and concomitant shoulder pathology are at high risk of recurrent labral tearing on MRI. No significant reduction in NFL participation the year after the Combine was seen in athletes with a history of labral repair, recurrent labral tearing, or degenerative joint disease who were successfully drafted into the NFL. In athletes with a history of labral repair, assessment of labral integrity on MRI alone is not predictive of future short-term participation. LEVEL OF EVIDENCE: Level IV, prognostic study-case series.

Prevalence of Surgical Repair for Athletic Pubalgia and Impact on Performance in Football Athletes Participating in the National Football League Combine.

PURPOSE: To examine the prevalence and impact of athletic pubalgia (AP) surgery in elite American football athletes participating in the National Football League (NFL) Combine. METHODS: Results from 1,311 athletes participating in the Combine from 2012 to 2015 were evaluated. Athletes with a history of AP repair were identified using the NFL Combine Database. Athlete history and available imaging was reviewed. NFL performance based on draft status, games played, games started, and current status in the NFL was gathered using publicly available databases. Statistical analysis was performed to detect for significant associations between athlete history and NFL performance in the presence of AP repair and pelvic pathology on postsurgical magnetic resonance imaging (MRI). RESULTS: AP repair was identified in 4.2% (n = 55) of athletes. MRI was performed in 35% (n = 19 of 55) with AP repair, of which 53% (n = 10 of 19) had positive pathology. Athletes with repair were not at risk of playing (P = .87) or starting (P = .45) fewer regular season games, going undrafted (P = .27), or not being on an active NFL roster (P = .51). Compared with athletes with negative imaging findings, positive pathology on MRI did not have a significant impact on games played (P = .74), games started (P = .48), draft status (P = .26), or being on an active roster (P = .74). Offensive linemen (P = .005) and athletes with a history of repair within 1 year of the Combine (P = .03) had a significantly higher risk of possessing positive pathology on MRI. CONCLUSIONS: Athletes with a history of successful AP surgery invited to the NFL Combine and those with persistent pathology on MRI are not at increased risk for diminished performance in the NFL. Offensive linemen and athletes less than 1 year out from surgery have a higher risk for positive MRI findings at the pubic symphysis. LEVEL OF EVIDENCE: Level IV, prognostic study-case series.

National Incidence of Patient Safety Indicators in the Total Hip Arthroplasty Population.

BACKGROUND: The Centers for Medicare & Medicaid Services use the incidence of patient safety indicators (PSIs) to determine health care value and hospital reimbursement. The national incidence of PSI has not been quantified in the total hip arthroplasty (THA) population, and it is unknown if patient insurance status is associated with PSI incidence after THA. METHODS: All patients in the Nationwide Inpatient Sample (NIS) who underwent THA in 2013 were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. The incidence of PSI was determined using the International Classification of Diseases, Ninth Revision, diagnosis code algorithms published by the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality. The association of insurance status and the incidence of PSI during the inpatient episode was determined by comparing privately insured and Medicare patients with Medicaid/self-pay patients using a logistic regression model that controlled for patient demographics, patient comorbidities, and hospital characteristics. RESULTS: In 2013, the NIS included 68,644 hospitalizations with primary THA performed during the inpatient episode. During this period, 429 surgically relevant PSI were recorded in the NIS. The estimated national incidence rate of PSI after primary THA was 0.63%. In our secondary analysis, the privately insured cohort had significantly lower odds of experiencing one or more PSIs relative to the Medicaid/self-pay cohort (odds ratio, 0.47; 95% confidence interval, 0.29-0.76). CONCLUSION: The national incidence of PSI among THA patients is relatively low. However, primary insurance status is associated with the incidence of one or more PSIs after THA. As value-based payment becomes more widely adopted in the United States, quality benchmarks and penalty thresholds need to account for these differences in risk-adjustment models to promote and maintain access to care in the underinsured population.

National Incidence of Reportable Quality Metrics in the Knee Arthroplasty Population.

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) characterizes adverse quality events in the inpatient setting as patient safety indicators (PSI). The incidence of PSI has not been quantified in the total knee arthroplasty (TKA) population. METHODS: All patients in the Nationwide Inpatient Sample who underwent primary TKA during an inpatient episode in 2013 were identified using International Classification of Disease, Ninth Revision, Clinical Modification codes. The incidence of PSI was determined using the International Classification of Disease, Ninth Revision diagnosis code algorithms used by CMS. Multivariable logistic regression was used to determine significant associations between patient level covariates (demographics, comorbidities, and hospital characteristics) and the risk of experiencing one or more PSI after TKA. RESULTS: We identified 132,453 primary TKA patients in the Nationwide Inpatient Sample in 2013. We estimated the national incidence rate of experiencing one or more PSI as 0.98%. After adjusting for patient demographics and hospital characteristics, we found that relative to Medicaid/self-pay patients, neither Medicare nor privately insured patients faced significantly different risk of experiencing one or more PSI after TKA. However, alcohol abuse, deficiency anemia, congestive heart failure, coagulopathy, and electrolyte imbalance were associated with increased risk of experiencing one or more PSI after TKA. CONCLUSION: The national incidence of PSI among TKA patients was lower than has been reported in other surgical populations. CMS uses the incidence of adverse quality events (measured using PSI) in part to determine hospital reimbursement. As value-based payment becomes more widely adopted in the United States, initiatives designed to eliminate and reduce PSI incidence can benefit vulnerable patient populations, physicians, and hospital systems.

Decompression surgery for spinal metastases: a systematic review.

OBJECTIVE The aim of this study was to systematically review the literature on reported outcomes following decompression surgery for spinal metastases. METHODS The authors conducted MEDLINE, Scopus, and Web of Science database searches for studies reporting clinical outcomes and complications associated with decompression surgery for metastatic spinal tumors. Both retrospective and prospective studies were included. After meeting inclusion criteria, articles were categorized based on the following reported outcomes: survival, ambulation, surgical technique, neurological function, primary tumor histology, and miscellaneous outcomes. RESULTS Of the 4148 articles retrieved from databases, 36 met inclusion criteria. Of those included, 8 were prospective studies and 28 were retrospective studies. The year of publication ranged from 1992 to 2015. Study size ranged from 21 to 711 patients. Three studies found that good preoperative Karnofsky Performance Status (KPS ≥ 80%) was a significant predictor of survival. No study reported a significant effect of time-to-surgery following the onset of spinal cord compression symptoms on survival. Three studies reported improvement in neurological function following surgery. The most commonly cited complication was wound infection or dehiscence (22 studies). Eight studies reported that preoperative ambulatory or preoperative motor status was a significant predictor of postoperative ambulatory status. A wide variety of surgical techniques were reported: posterior decompression and stabilization, posterior decompression without stabilization, and posterior decompression with total or subtotal tumor resection. Although a wide range of functional scales were used to assess neurological outcomes, four studies used the American Spinal Injury Association (ASIA) Impairment Scale to assess neurological function. Four studies reported the effects of radiation therapy and local disease control for spinal metastases. Two studies reported that the type of treatment was not significantly associated with the rate of local control. The most commonly reported primary tumor types included lung cancer, prostate cancer, breast cancer, renal cancer, and gastrointestinal cancer. CONCLUSIONS This study reports a systematic review of the literature on decompression surgery for spinal metastases. The results of this study can help educate surgeons on the previously published predictors of outcomes following decompression surgery for metastatic spinal disease. However, the authors also identify significant gaps in the literature and the need for future studies investigating the optimal practice with regard to decompression surgery for spinal metastases.

Does Running Increase the Risk of Hip and Knee Arthritis? A Survey of 3804 Marathon Runners.

BACKGROUND: Long-distance running is a popular form of cardiovascular exercise with many well-described health benefits, from improving heart health to the management of obesity, diabetes, and mental illness. The impact of long-distance running on joint health in recreational runners, however, remains inconclusive. HYPOTHESIS: The prevalence of osteoarthritis in runners is not associated with an athlete's running-related history, including the number of marathons completed, cumulative years of running, average weekly mileage, and average running pace. STUDY DESIGN: Prospective cohort study. LEVEL OF EVIDENCE: Level 3. METHODS: A survey was distributed to all participants registered for the 2019 or 2021 Chicago marathon (n = 37,917). Surveys collected runner demographics and assessed for hip/knee pain, osteoarthritis, family history, surgical history, and running-related history. Running history included the number of marathons run, number of years running, average running pace, and average weekly mileage. The overall prevalence of osteoarthritis was identified, and a multivariable logistic regression model was used to identify variables associated with the presence of hip and/or knee osteoarthritis. RESULTS: Surveys were completed by 3804 participants (response rate of 10.0%). The mean age was 43.9 years (range, 18-83 years) and participants had completed on average 9.5 marathons (median, 5 marathons; range, 1-664 marathons). The prevalence of hip and/or knee arthritis was 7.3%. A history of hip/knee injuries or surgery, advancing age, family history, and body mass index (BMI) were risk factors for arthritis. Cumulative number of years running, number of marathons completed, weekly mileage, and mean running pace were not significant predictors for arthritis. The majority (94.2%) of runners planned to run another marathon, despite 24.2% of all participants being told by a physician to do otherwise. CONCLUSION: From this largest surveyed group of marathon runners, the most significant risk factors for developing hip or knee arthritis were age, BMI, previous injury or surgery, and family history. There was no identified association between cumulative running history and the risk for arthritis.

Injury Rates at an NCAA Division I Institution After the COVID-19 Lockdown: A Descriptive Epidemiological Study.

Background: The coronavirus 2019 (COVID-19) pandemic led to frequent schedule changes, abbreviated seasons, and disrupted training at all levels of organized sports. Purpose/Hypothesis: The purpose of this study was to investigate the epidemiology of sports-related injuries at a single National Collegiate Athletic Association (NCAA) Division I institution during the 2020 COVID lockdown season when compared with pre-COVID seasons. It was hypothesized that there would be an increase in the overall injury rate and an increase in the number of days missed because of injury during the 2020 season when compared with the previous seasons. Study Design: Descriptive epidemiology study. Methods: The injury surveillance database at a single NCAA Division I institution was queried for injuries that resulted in time loss (missed game or practice) for a student-athlete or for injuries that persisted >3 days. Injuries were categorized by anatomic area. Days unavailable because of injury were recorded as total days that a student-athlete was listed as "out of activity." Injury incidence and days unavailable, per 1000 athlete-exposures (AEs), were calculated for 3 pre-COVID seasons (2017-2019) and the 2020 season. The authors calculated the injury rate ratio (IRR) and its associated 95% CI of the 2020 season in comparison with those for the pre-COVID seasons. Results: Compared with the pre-COVID seasons, the total injury incidence increased by 10.5% in the 2020 season (68.45 vs 75.65 injuries/1000 AEs; IRR, 1.11 [95% CI, 1.08-1.13]). Total days unavailable decreased by 20.7% in the 2020 season (1374 vs 1089 days/1000 AEs; IRR, 0.79 [95% CI, 0.77-2.26]). Compared with women's teams, men's teams had a larger increase in total injury incidence (16.4% vs 6.5%) and larger decrease in days unavailable (23.7% vs 10.75%). There were no clear trends to changes in anatomic distribution of injuries, either by sport or between the sexes. Conclusion: Compared with the pre-COVID seasons, the injury incidence was higher and the number of days missed because of injury lower among collegiate student-athletes at a single NCAA Division I school in the season immediately after the COVID-19 lockdown.

Increase in Deltoid Compartment Pressures Immediately After Arthroscopic Rotator Cuff Repair Does Not Significantly Affect Postoperative Opioid Consumption.

Purpose: To investigate the association between changes in individual (anterior, lateral, and posterior) and overall deltoid compartment pressures and postoperative opioid consumption up to 14 days after primary double-row arthroscopic rotator cuff repair (ARCR). Methods: In 113 consecutive patients undergoing primary double-row ARCR, anterior, lateral, and posterior deltoid compartment pressures were measured prior to incision and immediately after closure with a manometer. Postoperatively, all patients were provided with an identical rehabilitation protocol, quantity and dose of opioid tablets, and pain journal in which to record daily opioid consumption and visual analog scale pain scores for 14 days after surgery. The pain journals were collected at the first postoperative visit, and opioid consumption was calculated based on morphine equivalents. Statistical analysis was performed to determine the association between deltoid compartment pressures and opioid consumption postoperatively. Results: Sixty-nine percent of patients who met the inclusion criteria (74 of 107) returned the pain journals. The mean age at the time of surgery was 57.4 ± 8.8 years (range, 30-75 years), with female patients being significantly older (P = .03). The mean length of surgery was 71.7 ± 16.3 minutes. No significant association between increase in individual (anterior, lateral, or posterior) or mean overall compartment pressures and morphine equivalents of opioid consumption was appreciated on any postoperative day. Conclusions: No significant correlation between increase in individual or overall deltoid compartment pressures after ARCR and postoperative opioid consumption in the immediate postoperative period was found in this study. Level of Evidence: Level II, prospective cohort study.

Trends in Orthopedic Device Innovation: An Analysis of 510(k) Clearances and Premarket Approvals From 2000 to 2019.

The objective of this study was to characterize recent trends in orthopedic device development across different subspecialty areas. Orthopedic 510(k) clearances, premarket approvals (PMAs; together, "authorizations"), and new market entrants from 2000 to 2019 were analyzed as markers of research and development activity. Data were extracted from the US Food and Drug Administration website and stratified into one of 9 "subspecialty" groups: spine, trauma, hip arthroplasty, knee arthroplasty, shoulder, hand/elbow, foot/ankle, cement/filler/graft, and other. Descriptive statistics were used to analyze the data. Growth rates were calculated from trailing 3-year averages. During the study period, there were 9906 orthopedic 510(k) clearances and 1409 PMAs, of which 61 were for original PMA submissions. The preponderance of 510(k) clearances were for devices used in spine (36%) and trauma (30%) surgery, followed by hip (11%) and knee (8%) arthroplasty. Annual 510(k) clearances for spine and trauma devices grew by 232% and 44%, respectively, whereas annual hip and knee arthroplasty clearances declined. Paralleling these findings, the influx of new manufacturers of orthopedic devices was greatest for the trauma surgery (438), spine surgery (383), and cement/filler/graft (181) markets. Spinal surgery and orthopedic trauma have become leading priorities in orthopedic product development during the past two decades. Meanwhile, hip and knee arthroplasty products have proportionally become a smaller category of new devices over time. These findings demonstrate changing priorities within orthopedic innovation. [Orthopedics. 2023;46(2):e98-e104.].

Evaluating the Chase Utley Rule: The Association Between a Rule Change and Collision-Related Injuries in Major League Baseball.

Background: Major League Baseball (MLB) adopted a rule change in 2016 to reduce the number of collisions that occur when a player slides into a base. The effect of rule 6.01(j) has not been quantified, and it remains unknown if this rule change has led to improved player safety. Hypothesis: Rule 6.01(j) would be associated with a reduction in the number of collision-related injuries at second base. Study Design: Cohort study; Level of evidence, 3. Methods: Using data from the MLB Health and Injury Tracking System, we quantified the number of collision-related injuries for defensive (ie, fielding) players in the infield at the major and minor league levels between the 2010 and 2019 seasons. We compared the median number of collision-related injuries for defensive players in the infield from before (2010-2015) to after (2016-2019) the implementation of rule 6.01(j) and also calculated the difference in location of the median from the seasons before versus after the rule change. An additional 3 analyses were performed to support or contradict a conclusion that any observed reduction in injuries at the start of the 2016 season was likely caused by the adoption of rule 6.01(j). Results: The median number of collision-related injuries for defensive players at second base decreased from 58.5 to 37.5 injuries per season after the rule change, which was a 36% decrease (difference in location, 19.5 [95% CI, 5.0 to 31.0]; P = .019). In contrast, the median number of collision-related injuries at first base decreased by only 14.1%, from 49.5 before to 42.5 after the rule change (difference in location, -9.0 [95% CI, -4.0 to 18.0]; P = .16), and the median number of collision-related injuries per season at third base was unchanged at 15 per season. Conclusion: This rule change was associated with a decrease in the number of collision-related injuries, with the largest effect observed at second base, as expected.

Unicompartmental Knee Arthroplasty in Octogenarians versus Younger Patients: A Comparison of 30-Day Outcomes.

As the United States' octogenarian population (persons 80-89 years of age) continues to grow, understanding the risk profile of surgical procedures in elderly patients becomes increasingly important. The purpose of this study was to compare 30-day outcomes following unicompartmental knee arthroplasty (UKA) in octogenarians with those in younger patients. The American College of Surgeons National Surgical Quality Improvement Program database was queried. All patients, aged 60 to 89 years, who underwent UKA from 2005 to 2016 were included. Patients were stratified by age: 60 to 69 (Group 1), 70 to 79 (Group 2), and 80 to 89 years (Group 3). Multivariate regression models were estimated for the outcomes of hospital length of stay (LOS), nonhome discharge, morbidity, reoperation, and readmission within 30 days following UKA. A total of 5,352 patients met inclusion criteria. Group 1 status was associated with a 0.41-day shorter average adjusted LOS (99.5% confidence interval [CI]: 0.67-0.16 days shorter, p < 0.001) relative to Group 3. Group 2 status was not associated with a significantly shorter LOS compared with Group 3. Both Group 1 (odds ratio [OR] = 0.15, 99.5% CI: 0.10-0.23) and Group 2 (OR = 0.33, 99.5% CI: 0.22-0.49) demonstrated significantly lower adjusted odds of nonhome discharge following UKA compared with Group 3. There was no significant difference in adjusted odds of 30-day morbidity, readmission, or reoperation when comparing Group 3 patients with Group 1 or Group 2. While differences in LOS and nonhome discharge were seen, octogenarian status was not associated with increased adjusted odds of 30-day morbidity, readmission, or reoperation. Factors other than age may better predict postoperative complications following UKA.

Risk factors for loss to follow up of pelvis and acetabular fractures.

INTRODUCTION: Pelvic and acetabular fracture incidence is increasing worldwide for more than four decades. There is currently no evidence examining risk factors for loss to follow up in patients with these injuries. METHODS: Patients presenting with pelvic and/or acetabular fractures at our institution between 2015 and 2020 were included. Demographic, injury, treatment, and follow up information was included. Excluded patients were those who sustained a pathologic fracture, has a course of treatment prior to transfer to our centre, or expired prior to discharge. RESULTS: 446 patients, 263 with a pelvic ring injury, 172 with an acetabular fracture, and 11 with combined injuries were identified. 271 (61%) of patients in our cohort followed up in Orthopaedic clinic (p = 0.016). With an odds ratio of 2.134, gunshot wound mechanism of injury was the largest risk factor for loss to follow up (p = 0.031) followed by male sex (OR= 1.859) and surgery with general trauma surgery (OR=1.841). The most protective risk factors for follow up with Orthopaedic surgery were operatively treated pelvic and acetabular fractures (OR=0.239) and Orthopaedic Surgery as the discharging service (OR=0.372). DISCUSSION: Numerous risk factors exist for loss to follow up including male sex, ballistic mechanism, and discharging service. Investigation into interventions to improve follow up in these patients are warranted.

The change in postoperative opioid prescribing after lumbar decompression surgery following state-level opioid prescribing reform.

OBJECTIVE: On August 31, 2017, the state of Ohio implemented legislation limiting the dosage and duration of opioid prescriptions. Despite the widespread adoption of such restrictions, few studies have investigated the effects of these reforms on opioid prescribing and patient outcomes. In the present study, the authors aimed to evaluate the effect of recent state-level reform on opioid prescribing, patient-reported outcomes (PROs), and postoperative emergency department (ED) visits and hospital readmissions after elective lumbar decompression surgery. METHODS: This study was a retrospective cohort study of patients who underwent elective lumbar laminectomy for degenerative disease at one of 5 hospitals within a single health system in the years prior to and after the implementation of the statewide reform (September 1, 2016-August 31, 2018). Patients were classified according to the timing of their surgery relative to implementation of the prescribing reform: before reform (September 1, 2016-August 31, 2017) or after reform (September 1, 2017- August 31, 2018). The outcomes of interest included total outpatient opioids prescribed in the 90 days following discharge from surgery as measured in morphine-equivalent doses (MEDs), total number of opioid refill prescriptions written, patient-reported pain at the first postoperative outpatient visit as measured by the Numeric Pain Rating Scale, improvement in patient-reported health-related quality of life as measured by the Patient-Reported Outcomes Measurement Information System-Global Health (PROMIS-GH) questionnaire, and ED visits or hospital readmissions within 90 days of surgery. RESULTS: A total of 1031 patients met the inclusion criteria for the study, with 469 and 562 in the before- and after-reform groups, respectively. After-reform patients received 26% (95% CI 19%-32%) fewer MEDs in the 90 days following discharge compared with the before-reform patients. No significant differences were observed in the overall number of opioid prescriptions written, PROs, or postoperative ED or hospital readmissions within 90 days in the year after the implementation of the prescribing reform. CONCLUSIONS: Patients undergoing surgery in the year after the implementation of a state-level opioid prescribing reform received significantly fewer MEDs while reporting no change in the total number of opioid prescriptions, PROs, or postoperative ED visits or hospital readmissions. These results demonstrate that state-level reforms placing reasonable limits on opioid prescriptions written for acute pain may decrease patient opioid exposure without negatively impacting patient outcomes after lumbar decompression surgery.

Epidemiology of Tibial Fractures in Professional American Football Athletes From 2013 to 2019.

BACKGROUND: Lower extremity injuries occur with high frequency in National Football League (NFL) athletes and cause high burden to players and teams. Tibial fractures are among the most severe lower extremity injuries sustained in athletes and are associated with prolonged time loss from sport. PURPOSE: To determine the number of tibial fractures in NFL athletes from the 2013 to 2019 NFL seasons and describe athlete demographics, fracture characteristics, and details of injury onset. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of the NFL injury database was performed to identify all NFL athletes sustaining tibial fractures over the 2013 to 2019 NFL seasons. Athlete characteristics, injury characteristics, days missed, and treatment (operative vs nonoperative) were examined. Descriptive statistics were used to calculate means, standard deviations, ranges, and percentages. RESULTS: A total of 64 tibial fractures were identified in 60 athletes, resulting in a median loss of 74 days. Defensive secondary athletes had the highest number of injuries (n = 10; 16%), followed by running backs (n = 9; 14%), while 61% of these injuries occurred during NFL regular-season games, primarily between weeks 13 and 17. The most commonly reported activity during injury was athletes being tackled, with a direct impact to the tibia being the most common mechanism of injury. Lateral tibial plateau fractures were the most frequently reported, while distal tibial fractures resulted in the greatest number of days lost. The median time lost for injuries requiring surgery was 232 days compared with 56 days for injuries treated using conservative management. CONCLUSION: The highest proportion of tibial fractures were injuries to defensive secondary athletes and athletes being tackled while sustaining a direct impact to the leg, primarily to the lateral tibial plateau. Tibial fracture injuries were commonly sustained during NFL regular-season games, primarily during the final 4 weeks of the NFL regular season. Further investigations examining performance and career longevity in athletes sustaining tibial fractures are warranted to help improve the health and safety of NFL athletes.

Epidemiology, Treatment, and Performance-Based Outcomes in American Professional Baseball Players With Symptomatic Spondylolysis and Isthmic Spondylolisthesis.

BACKGROUND: Repetitive lumbar hyperextension and rotation during athletic activity affect the structural integrity of the lumbar spine. While many sports have been associated with an increased risk of developing a pars defect, few previous studies have systematically investigated spondylolysis and spondylolisthesis in professional baseball players. PURPOSE: To characterize the epidemiology and treatment of symptomatic lumbar spondylolysis and isthmic spondylolisthesis in American professional baseball players. We also sought to report the return-to-play (RTP) and performance-based outcomes associated with the diagnosis of a pars defect in this elite athlete population. STUDY DESIGN: Descriptive epidemiology study. METHODS: A retrospective cohort study was conducted among all Major and Minor League Baseball (MLB and MiLB, respectively) players who had low back pain and underwent lumbar spine imaging between 2011 and 2016. Players with radiological evidence of a pars defect (with or without listhesis) were included. Analyses were conducted to assess the association between player-specific characteristics and RTP time. Baseball performance metrics were also compared before and after the injury episode to determine whether there was an association between the diagnosis of a pars defect and diminished player performance. RESULTS: During the study period of 6 MLB seasons, 272 professional baseball players had low back pain and underwent lumbar spine imaging. Overall, 75 of these athletes (27.6%) received a diagnosis of pars defect. All affected athletes except one (98.7%) successfully returned to professional baseball, with a median RTP time of 51 days. Players with spondylolisthesis returned to play faster than those with spondylolysis, MLB athletes returned faster than MiLB athletes, and position players returned faster than pitchers. Athletes with a diagnosed pars defect did not show a significant decline in performance after returning to competition after their injury episode. CONCLUSION: Lumbar pars defects were a common cause of low back pain in American professional baseball players. The vast majority of affected athletes were able to return to competition without demonstrating a significant decline in baseball performance.

Identifying a clinical decision tool to predict discharge disposition following operative treatment of hip fractures in the United States.

BACKGROUND: Post-discharge management following operative treatment of hip fractures continues to be performed on a case-by-case basis, with no uniform guidelines dictating management. Predicting discharge to post-acute care (PAC) facilities (i.e. skilled nursing facilities and inpatient rehabilitation facilities) can assist preoperative planning and potentially decrease length of stay secondary to disposition issues. The goal of this study was to develop a nomogram using easily identified variables to preoperatively predict discharge disposition following operative treatment of hip fractures. METHODS: Using the National Surgical Quality Improvement Program database, patients who underwent surgical intervention for hip fractures between 2012 and 2015 were identified. A multivariable logistic regression model was used to identify risk factors for discharge to a PAC facility, and a predictive nomogram was created based on these results. RESULTS: From 2012 to 2015, 33,371 hip fractures were identified: 13,336 (40%) femoral neck fractures, and 20,035 (60%) intertrochanteric femur fractures. Of the patients identified, 26,082 (78.2%) were discharged to a PAC while the remainder were discharged home with or without home health. 70% of patients were female and 92.4% were Caucasian. When accounting for comorbidities, using the American Society of Anesthesiologists (ASA) classification system, 6,122 patients (18.4%) had 'Mild Systemic Disease' (ASA 2), 20,872 (62.6%) patients had 'Severe Systemic Disease' (ASA 3), and 6,006 (18.1%) had 'Life Threatening Disease' (ASA 4/5). The majority of patients were brought in from a 'Home' setting, while 10.4% of patients were admitted from a 'Long-Term Care' setting. After controlling for confounding variables, older age and increasing ASA class were predictive of an increased risk of discharge to a PAC. Diabetes, dyspnea, congestive heart failure, and chronic obstructive pulmonary disease were not associated with an increased risk of discharge to a PAC. DISCUSSION: Discharge disposition following operative treatment of hip fractures can be reliably predicted using a nomogram with commonly identified preoperative variables. LEVEL OF EVIDENCE: Level III, Retrospective Cohort Design, Observational Study.

Early Complications Following Articular Calcaneus Fracture Repair: Evaluation of Open Versus Percutaneous Techniques.

OBJECTIVES: To assess complications and secondary operations in patients treated with either open reduction and internal fixation (ORIF) versus percutaneous fixation of displaced intra-articular calcaneus fractures. DESIGN: Retrospective comparative study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Ninety-three adult patients with 111 fractures treated by a single orthopaedic traumatologist between 2001 and 2014. INTERVENTION: ORIF through an extensile lateral approach or percutaneous reduction and internal fixation. MAIN OUTCOME MEASUREMENTS: Wound-healing complications, infections, posttraumatic arthrosis (PTOA), and secondary procedures. RESULTS: Fifty patients with 58 fractures underwent ORIF, and 43 patients with 53 fractures had percutaneous fixation. Mean age was 43 years, and 80% were male. Open fractures and two-part fractures were more often treated percutaneously (26% vs 8%, P = 0.03) and (49% vs 31%, P = 0.02), respectively. Patients undergoing percutaneous fixation were more often tobacco users (58% vs 36%, P = 0.04) and with history of alcohol and other substance abuse. Twenty-seven patients (29%) had 28 complications, including 21% with PTOA, with no differences based on type of treatment. Six patients had secondary procedures, with no difference based on type of treatment. Patients with open fractures (P = 0.001) or tobacco abuse (P = 0.005) were more likely to experience complications. CONCLUSIONS: No differences in complication rates were found for ORIF versus percutaneous fixation. Regardless of fixation technique, patients with open fractures or history of tobacco abuse were more likely to develop complications. Percutaneous reduction and fixation represents an alternative to extensile ORIF in terms of similar early and late complications, particularly in high risk patients. LEVEL OF EVIDENCE: Therapeutic Level III.