Utilization of reverse shoulder arthroplasty for the treatment of glenohumeral arthritis among American Board of Orthopaedic Surgery (ABOS) Part II candidates, 2008-2019

BackgroundDespite advances in shoulder arthroplasty, treatment options for advanced glenohumeral osteoarthritis (GHOA) remain limited. Surgical management includes total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (RSA), and hemiarthroplasty. The rates of TSA and RSA for the treatment of GHOA in the United States has increased in recent years. Trends in shoulder arthroplasty in recently trained surgeons have not been explored. The purpose of the study was to examine the trends in arthroplasty use (TSA, RSA, and hemiarthroplasty) for primary GHOA among American Board of Orthopedic Surgeons (ABOS) Part II examinees, and to identify patterns based on geographic region or fellowship training.MethodsABOS Part II examinees with at least 1 shoulder arthroplasty in the examination years 2008-2019 were collected. Hemiarthroplasty, TSA, and RSA performed from 2007-2018 for a diagnosis of primary GHOA were included. Arthroplasty for primary or secondary diagnoses of fracture, infection, tumor, rotator cuff arthropathy or tear, revision, and non-arthroplasty procedures were excluded. Proportion and volume of cases were evaluated, with sub-analyses of geographic region and fellowship training. Univariate logistic regression determined statistical significance (P< .05).ResultsA total of 946,946 cases from 8609 ABOS Part II examinees were submitted, with 8733 shoulder arthroplasties performed. Overall, 3923 arthroplasties for primary GHOA were included (44.9% of all shoulder arthroplasties). TSA was used in 50.9% of cases. The proportion of RSA performed for primary GHOA has increased over the past 11 years, with RSA surpassing TSA as the most common procedure for primary GHOA over the last 4 years (P< .001). Hemiarthroplasty is less commonly. TSA and RSA were performed in similar proportions across regions, with the largest volume in the Midwest. Most procedures (91.5%) were completed by surgeons in sports medicine, shoulder and elbow, and those completing multiple fellowships. From 2008-2019 the number of RSA procedures performed for primary GHOA by sports medicine and shoulder and elbow surgeons has increased approximately 1100% and 800%, respectively (P< .001).ConclusionUtilization of RSA for treatment of primary GHOA by ABOS Part II examinees has increased significantly over the past twelve years. Among ABOS Part II examinees, RSA has recently surpassed TSA as the most common arthroplasty utilized for treatment of primary GHOA. Examination of early-career surgical practice allows for consideration of training influence in treatment of GHOA. As volume of shoulder arthroplasty continues to increase, trends and procedure volume have implications for clinical practice and patient outcomes.Level of EvidenceLevel IV; Case-series Database Study     

Prior surgical fixation of proximal humerus fractures is associated with increased complications following subsequent reverse shoulder arthroplasty

BackgroundThe objective of this study was to compare complication rates between patients undergoing reverse shoulder arthroplasty (RSA) after a prior open reduction and internal fixation (ORIF) for proximal humerus fracture (PHF) to those undergoing RSA as a primary treatment for PHFs, glenohumeral osteoarthritis, or rotator cuff tear arthropathy (CTA).MethodsPatients who underwent RSA between 2015 and 2020 were identified in the Mariner database. Patients were separated into 3 mutually exclusive groups: (1) RSA for osteoarthritis, rotator cuff tear, or CTA (Control-RSA); (2) RSA as a primary treatment for PHF (PHF-RSA); and (3) RSA for patients with prior ORIF of PHFs (ORIF-RSA). Ninety-day medical and 2-year postoperative surgical complications were identified. In addition, patients in the PHF-RSA group were subdivided into those undergoing RSA for PHF within 3 months of the fracture (acute) vs. those treated greater than 3 months from diagnosis (delayed). Multivariate regression was performed to control for differences in comorbidities and demographics.ResultsA total of 30,824 patients underwent primary RSA for arthritis or CTA, 5389 patients underwent RSA as a primary treatment for a PHF, and 361 patients underwent RSA after ORIF of a PHF. ORIF before RSA was associated with an increased risk of overall revision (odds ratio [OR] 2.45, P = .002), infection (OR 2.40, P < .001), instability (OR 2.43, P < .001), fracture (OR 3.24, P = .001), minor medical complications (OR 1.59, P = .008), and readmission (OR 2.55, P = .001) compared with the Control-RSA cohort. RSA as a primary treatment for PHF was associated with an increased risk of 2-year revision (OR 1.60, P < .001), infection (OR 1.51, P < .001), instability (OR 2.84, P < .001), and fracture (OR 2.54, P < .001) in addition to major medical complications (OR 2.02, P < .001), minor medical complications (OR 1.92, P < .001), 90-day emergency department visits (OR 1.26, P < .001) and 90-day readmission (OR 2.03, P < .001) compared with the Control-RSA cohort. The ORIF-RSA group had an increased risk of periprosthetic infection (OR 1.94, P = .002) when compared with the PHF-RSA cohort. There were no differences in medical or surgical complications in the RSA-PHF cohort between patients treated in an acute or delayed fashion.ConclusionRSA following ORIF of a PHF is associated with increased complications compared with patients undergoing RSA for nonfracture indications. Prior ORIF of a PHF is also an independent risk factor for postoperative infection after RSA compared with patients who undergo RSA as a primary operation for fracture. The timing of RSA as a primary operation for PHF does not appear to impact the rates of postoperative medical and surgical complications.     

Revision of failed reverse shoulder arthroplasty to revision reverse shoulder arthroplasty leads to significant clinical and functional improvement

BackgroundReverse shoulder arthroplasty (RSA) is rapidly growing in the United States. As the number of procedures increases, the number of complications and need for additional surgeries correspondingly continues to grow. The purpose of this study was to describe clinical and functional outcomes of revision of RSA to RSA.MethodsA retrospective review of 29 patients from 2 centers who underwent revision surgery following RSA to RSA from 2007 to 2017 was conducted. The reasons for revision were recorded. Clinical outcome measures including shoulder range of motion, American Shoulder and Elbow Surgeons score, Single Assessment Numerical Evaluation score, simple shoulder test and Visual analog scale scores were collected for all patients at an average follow-up of 29 months. Postoperative complications were also recorded.ResultsA total of 29 patients were identified. The average time between index RSA and revision was 2.3 years (30 days – 7 years). Mean follow-up duration for clinical outcome measures was 29.1 months (12-114 months). The most common indication for revision surgery was aseptic loosening (13/29, 44.8%), followed by instability (7/29, 24.1%), fracture (5/29, 17.2%), and infection (4/29, 13.7%). The average Visual analog scale decreased from 7 to 3 (P< .001). American Shoulder and Elbow Surgeons score scores improved from a mean of 30 to 58 (P < .001). Single Assessment Numerical Evaluation score scores improved from 26 to 54 (P < .001), and Simple shoulder test improved from 2 to 6 (P = .001). Range of motion in both forward elevation from 76° to 131° (P < .001) and external rotation from 26 to 42 (P = .001). Complications were seen in 10 of 29 patients (34.5%).ConclusionA failed RSA can be managed with revision RSA with acceptable clinical outcomes although outcome is inferior to primary RSA with a high rate of complications.Level of EvidenceLevel IV; Retrospective Case Series     

Gastrointestinal Complications Following Total Joint Arthroplasty Are Rare but Have Severe Consequences

BackgroundGastrointestinal (GI) complications following total joint arthroplasty (TJA) are rare, but can result in substantial morbidity and mortality, especially when intervention is required. The purpose of this study is to identify modifiable risk factors for the development of GI complications and determine their impact on short-term outcomes following TJA.MethodsWe queried patients who underwent primary TJA at a single academic center from 2009 through 2018 and collected data on demographics, comorbidities, operative and perioperative details, and short-term outcomes. Patients who suffered at least one GI complication during the same hospitalization as their TJA were identified. The type of GI complication and intervention performed, if necessary, was recorded. Variables that independently affected the risk of GI complication were identified. Multivariate regression was performed to determine the effect suffering a GI complication had on outcomes.ResultsOf 17,402 patients, 106 (0.6%) suffered a GI complication. Constipation/obstruction, followed by diarrhea/malabsorption, hemorrhage, and Clostridium difficile were the most commonly reported complications. Patients suffering a GI complication were significantly older (68.5 vs 63.7, P < .001), less likely to use alcohol (49% vs 65%, P = .008), and had higher incidences of 8 of the 16 comorbidities analyzed (all P < .05). Patients with GI complications had greater lengths of stay (13.2 vs 2.3 days, P < .001), discharge to facility rates (58% vs 16%, P < .001), and in-hospital mortality rates (1.9% vs 0.1%, P = .002).ConclusionPatients suffering a GI complication following TJA require longer hospital stays and greater post-acute care resources and have a substantially higher risk of mortality.     

Conditional cumulative incidence of postoperative complications stratified by complexity classification for laparoscopic liver resection: Optimization of in-hospital observation

BackgroundThe optimal in-hospital observation periods associated with minimal risks of complications and unplanned readmission after laparoscopic liver resection are unknown. The purpose of this study was to assess changes in the risks of postoperative complications over time.MethodsSurgical complexity of laparoscopic liver resection was stratified into grades I (low complexity), II (intermediate), and III (high) using our 3-level complexity classification. The cumulative incidence rate and conditional probability of postoperative complication and risk factors for complication Clavien-Dindo grade ≥II (defined as treatment-requiring complications) were assessed.ResultsThe cumulative incidence of treatment-requiring complications was higher in patients undergoing grade III resection than in patients undergoing grade I resection (32.3% vs 10.4%, P < .001) and grade II resection (32.3% vs 20.7%, P = .019). The conditional probability of postoperative complication stratified by our complexity classification decreased over time and was <10% for patients undergoing grade I resection on postoperative day 1, grade II resection on postoperative day 4, and grade III resection on postoperative day 10.ConclusionThe conditional cumulative incidence of treatment-requiring complications for patients undergoing laparoscopic liver resection is well stratified based on the 3-level complexity classification. Conditional complication risk analysis stratified by the 3 complexity grades may be useful for optimizing in-hospital observation after laparoscopic liver resection.     

Predictive factors of complications in revisional gastric bypass surgery: results from the Scandinavian Obesity Surgery Registry

BackgroundRoux-en-Y gastric bypass is the most common procedure for revisional bariatric surgery. This study is an analysis of revisional gastric bypass operations (rGBP) compared with primary gastric bypass (pGBP) performed in Sweden between 2007 and 2016.ObjectiveThe aim was to compare the incidence of adverse events in primary and revisional gastric bypass surgery and to identify predictive factors of intraoperative, early, and late complications in revisional gastric bypass surgery.SettingForty-four hospitals.MethodsRegistered study from the Scandinavian Obesity Surgery Registry. The study group (rGBP) comprised 1795 patients, and the control group (pGBP) comprised 46,055 patients.ResultsMedian follow-up time was 28 months. The rate of open procedures was significantly higher in the rGBP group (39.1% versus 2.4%; P < .001) decreasing from 70.8% in 2007 to 8.5% in 2016. Intraoperative complications (15.5% versus 3.0%, P < .001), early complications (24.6% versus 8.7%; P < .001), and late complications (17.7% versus 8.7%; P < .001) occurred more often in the rGBP group. Open access in revisional surgery was an independent risk factor for intraoperative complications (odds ratio 3.87; 95% confidence interval: 2.69–5.57, P < .001), early complications (odds ratio 2.08; 95% confidence interval: 1.53–2.83, P < .001), and late complications (odds ratio 1.91; 95% confidence interval: 1.31–2.78, P = .001). Indication for revision or type of index operation were not associated with complications.ConclusionRGBP was associated with a higher incidence of intraoperative, early, and late complications compared with pGBP. Open access in revisional surgery was predictive of complications regardless of the index operation or indication for revision.     

Revision to reverse total shoulder arthroplasty: do short stem and stemless implants reduce the operative burden compared to convertible stems?

BackgroundRevision of prior hemiarthroplasty (HA) or total shoulder arthroplasty (TSA) to reverse shoulder arthroplasty (RSA) is a technically challenging procedure with high complication rates. The purpose of this study was to compare intraoperative complications between convertible humeral stems and nonconvertible humeral stems stratified by stem length for conversion of TSA or HA to RSA.Materials and methodsA multicenter retrospective analysis of patients undergoing revision of a primary TSA or HA to RSA was conducted. Patients were divided into 2 groups based on convertible or nonconvertible humeral stem design from the index surgery. The primary outcome measures were the following intraoperative variables and complications: total operative time, blood loss, intraoperative fracture, overall complication rate, and blood transfusions. Rates were compared between groups and analyzed according to primary stem length for the nonconvertible group.ResultsA total of 279 patients were included in the study, 70 with convertible stems and 209 with nonconvertible stems. About 70% of convertible stems were successfully retained. Operative time was similar between the 2 groups overall. Patients with nonconvertible stems had higher intraoperative blood loss (P = .0001), higher overall complication rate (P = .009), and greater risk of intraoperative fracture (P = .002). Revising stemless and short stems to RSA had significantly reduced operative time compared to standard length stems (97 and 116 minutes vs. 141 minutes, P < .0001 and P = .035, respectively). When revising stemless implants, there was a significantly lower rate of intraoperative fracture (3.6%) compared to short stems (24%, P = .004) and standard stems (23.4%, P = .001). When revising stemless implants to RSA, there was shorter operative time (P= .0001) and similarly low rate of intraoperative fracture (P= .820) compared to convertible stems.ConclusionIn revision of anatomic TSA to RSA, convertible stems lead to lower blood loss and intraoperative fracture rate compared to nonconvertible stems when broadly including all stem types. However, differences appear to be based on stem type. Among nonconvertible stems, revision of short stem and stemless implants are associated with reduced operative time compared to standard length stems. Revision of stemless implants to RSA is associated with the shortest operative time of all implant types as well as a similar rate of intraoperative fracture compared to convertible stems.Level of EvidenceLevel III; Retrospective Cohort Comparative Study     

Risk factors and reasons for revision after reverse total shoulder arthroplasty

BackgroundAs the indications for reverse shoulder arthroplasty (RSA) continue to expand, the need for revision surgery after RSA will become more frequent. The objective of this study was to characterize patient-related risk factors for revision RSA and to compare reasons for early vs. late revision after RSA.MethodsPatients who underwent primary and revision RSA from 2015 to 2019 were identified in a national insurance database. Subgroups of early revision (defined as revision within 1 year postoperatively) and late revision (more than 1 year postoperatively) were also identified. The primary outcome of interest was patient-related risk factors for revision RSA. Secondary outcomes of interest were patient-related risk factors for early vs. late revision RSA and to compare surgical diagnoses for early vs. late revision RSA. Univariate analysis using chi-square tests was performed to analyze any differences in reasons for revision. Multivariate regression was subsequently utilized to control for any confounding variables when identifying risk factors for revision.ResultsA total of 28,880 patients were identified who underwent RSA, with 553 (1.9%) patients undergoing revision RSA. Three hundred eighty-five patients (69.6%) were classified as early revision (within one year), while 141 (30.4%) underwent late revision more than a year postoperatively. Risk factors for overall revisions included age <65 years (odds ratio [OR] = 1.23, P = .032), male sex (OR = 2.21, P < .001), type I diabetes mellitus (OR = 1.44, P = .039), congestive heart failure (CHF) (OR = 1.79, P < .001), and depression (OR = 1.33, P = .002) in addition to RSAs performed for fracture (OR = 1.63, P < .001) and glenohumeral instability (OR = 2.25, P < .001) compared to RSA performed for arthritis. Risk factors for early revision RSA included male sex (OR = 2.54, P < .001) and CHF (OR = 1.81, P < .001) in addition to RSAs performed for fracture (OR = 1.84, P < .001) and glenohumeral instability (OR = 2.44, P < .001). Risk factors for late revision RSA included male sex (OR = 1.62, P = .004), CHF (OR = 1.83, P = .005), steroid use (OR = 1.79, P = .036), human immunodeficiency virus (OR = 3.50, P = .038), and RSA performed for glenohumeral instability (OR = 1.92, P = .004). Early revision RSA was more commonly performed for instability (63.1% vs. 25.0%, P < .001) and stiffness (5.5% vs. 1.2%, P = .021) than late revisions.ConclusionRevision RSA is uncommon at early follow-up. Overall patient-related risk factors for revision include male sex, age <65 years, type I diabetes mellitus, CHF, and depression in addition to RSAs performed for fracture and glenohumeral instability. Instability and stiffness were more common indications for early compared to late revision. Instability remained the most common reason for overall revision followed by periprosthetic infection.     

How does gout impact outcomes following primary shoulder arthroplasty?: Gout and shoulder arthroplasty

IntroductionStudies have shown that the overall prevalence of gout has increased. Data shows that patients with gout have worse outcomes following total joint arthroplasty, however studies investigating the effects of gout following primary total shoulder (TSA) and reverse shoulder arthroplasty (RSA) are limited. The purpose of this study was to compare outcomes of patients with and without gout undergoing primary shoulder arthroplasty, evaluating (1) in-hospital length of stay (LOS); (2) medical complications; (3) cost of care.MethodsA retrospective query using a nationwide administrative claims database was performed from January 2005 to March 2014 for all patients who underwent primary TSA and RSA for the treatment of glenohumeral osteoarthritis, yielding a total of 11,414 patients to be included. For the TSA cohort, 7702 patients were identified within the study (n = 1,185) and control (n = 6417) cohorts. Similarly, 3712 patients were identified within the RSA cohorts (gout n = 621 and control n = 3,091). Primary endpoints were in-hospital LOS, 90-day medical complications, and total global 90-day episode of care (EOC) costs. Multivariate logistic regression analyses were used to calculate the odds (OR) of medical complications, whereas Welch's t-tests were used to compare LOS and costs of care. A P value less than .05 was considered statistically significant.ResultsPatients with gout undergoing primary TSA (3- vs. 2-days, P < .0001) and RSA (3- vs. 2-days, P < .0001) had significantly longer in-hospital LOS. Gout patients undergoing either TSA (41.2 vs. 11.3%; OR: 3.30, P < .0001) or RSA had significantly higher incidence and odds (50.6 vs. 17.9%; OR: 2.10, P < .0001) of developing 90-day medical complications compared to their counterparts. Study group patients incurred significantly higher total global 90-day episode of care costs following both TSA ($15,007.84 vs. $13,447.06, P < .0001) and RSA ($19,659.27 vs. $16,783.70, P< .0001).ConclusionThis study demonstrates that patients with gout undergoing primary shoulder arthroplasty have longer in-hospital LOS, in addition to higher rates of complications, and increased costs of care. The study can be used by orthopedic surgeons to educate patients who have gout on complications which may occur following their surgical procedure.Level of EvidenceLevel III, retrospective comparative study.     

Hospital Frailty Risk Score Predicts Adverse Events in Primary Total Hip and Knee Arthroplasty

BackgroundThe Hospital Frailty Risk Score (HFRS) is a validated geriatric comorbidity measure derived from routinely collected administrative data. The purpose of this study is to evaluate the utility of the HFRS as a predictor for postoperative adverse events after primary total hip (THA) and knee (TKA) arthroplasty.MethodsIn a retrospective analysis of 8250 patients who had undergone THA or TKA between 2011 and 2019, the HFRS was calculated for each patient. Reoperation rates, readmission rates, complication rates, and transfusion rates were compared between patients with low and intermediate or high frailty risk. Multivariate logistic regression models were used to assess the relationship between the HFRS and postoperative adverse events.ResultsPatients with intermediate or high frailty risk showed a higher rate of reoperation (10.6% vs 4.1%, P < .001), readmission (9.6% vs 4.3%, P < .001), surgical complications (9.1% vs 1.8%, P < .001), internal complications (7.3% vs 1.1%, P < .001), other complications (24.4% vs 2.0%, P < .001), Clavien-Dindo grade IV complications (4.1% vs 1.5%, P < .001), and transfusion (10.4% vs 1.3%, P < .001). Multivariate logistic regression analyses revealed a high HFRS as independent risk factor for reoperation (odds ratio [OR] = 2.1; 95% confidence interval [CI], 1.46-3.09; P < .001), readmission (OR = 1.78; 95% CI, 1.21-2.61; P = .003), internal complications (OR = 3.72; 95% CI, 2.28-6.08; P < .001), surgical complications (OR = 3.74; 95% CI, 2.41-5.82; P < .001), and other complications (OR = 9.00; 95% CI, 6.58-12.32; P < .001).ConclusionThe HFRS predicts adverse events after THA and TKA. As it derives from routinely collected data, the HFRS enables hospitals to identify at-risk patients without extra effort or expense.Level of EvidenceLevel III–retrospective cohort study.     

Recurrent incisional hernia repairs at a tertiary hernia center: Are outcomes really inferior to initial repairs?

BackgroundRecurrent ventral hernia repairs are reported to have higher recurrence and complication rates than initial ventral hernia repairs. This is the largest analysis of outcomes for initial versus recurrent open ventral hernia repairs reported in the literature.MethodsA prospective, institutional database at a tertiary hernia center was queried for patients undergoing open ventral hernia repairs with complete fascial closure and synthetic mesh placement.ResultsA total of 1,694 open ventral hernia repairs patients were identified, including 896 (52.9%) initial ventral hernia repairs and 798 (47.1%)recurrent ventral hernia repairs. Recurrent ventral hernia repair patients were more complex: older (P = .003), higher body mass index (P < .001), higher American Society of Anesthesiologists class (P < .001), incidence of diabetics (P = .003), comorbidities (P < .001), and larger hernia defects (133.3 ± 171.9 vs 220.2 ± 210.0; P < .001). Recurrent ventral hernia repairs also had longer operative times (161.6 ± 82.4 vs 188.2 ± 68.9 minutes; P < .001), increased use of preoperative botulinum toxin A injection (4.3% vs 10.1%; P = .01), components separation (19.2% vs 39.5%; P < .001), and panniculectomy (20.3% vs 35.8%; P < .001). The overall hernia recurrence rate was 4.4% at a mean follow-up of 36.6 ± 45.5 months. Between the initial ventral hernia repairs and recurrent ventral hernia repairs, the hernia recurrence rates were equivalent (4.2% vs 4.7%, P = .63). Rates of wound infection, seromas, hematomas, mesh infections, and wound related reoperations (P > .05) were nonsignificant.ConclusionAt a tertiary hernia center, despite higher-risk patients, larger hernia defects, and increased components separation in recurrent ventral hernia repairs, early recurrence rates, wound complications, and reoperations are similar to initial ventral hernia repairs.     

Cruciate-Retaining vs Posterior-Stabilized Antibiotic Cement Articulating Spacers for Two-Stage Revision of Prosthetic Knee Infection: A Retrospective Cohort Study

BackgroundAntibiotic cement articulating spacers are recommended during 2-stage revision for prosthetic knee infection because of increased range of motion (ROM) and improved function; however, spacer mechanical complications have been reported. We aimed to determine the association between different constraints of articulating spacers and the rate of complications and infection eradication, functional outcomes, and ROM.MethodsA retrospective study of prosthetic knee infection using cruciate-retaining (CR) or posterior-stabilized (PS) spacers was conducted between 2011 and 2018. The rate of spacer mechanical complications, infection eradication after reimplantation and reoperation, Hospital of Special Surgery (HSS) knee score, and ROM during the interim stage were analyzed. All patients were regularly followed up for 2 years.ResultsOne hundred forty-one patients were included, with 66 CR and 75 PS spacers. Overall mechanical complication rate was lower in PS (9.3%) than in CR spacers (45.5%) (P < .001), especially in joint dislocation (1.3% vs 30.3%, respectively, P < .001). Overall reoperation rate was lower in PS (16.0%) than in CR spacers (36.4%) (P < .001), especially for mechanical complications (1.3% vs 24.2%, respectively, P < .001). HSS knee score was higher in PS (72.3) than in CR spacers (63.8) (P < .001). ROM was greater in PS (90.3°) than in CR spacers (80.6°) (P = .005), especially at maximum flexion (102.4° vs 89.6°, respectively, P = .003). Infection eradication was comparable between the spacers.ConclusionBoth spacers can control infection; however, PS spacers had a lower rate of mechanical complications and reoperation, better HSS knee scores, and greater ROM than CR spacers.     

Pathologic Versus Native Hip Fractures: Comparing 30-day Mortality and Short-term Complication Profiles

BackgroundA large body of research on native hip fractures has resulted in several evidence-based guidelines aimed at improving postsurgical care for these patients. In contrast, there is a paucity of data on pathologic hip fractures, and whether native hip fracture protocols are generalizable to this population is unknown. The purpose of this study was to compare mortality rates and complication profiles between patients with pathologic and native hip fractures.MethodsUsing the American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) database, we identified patients who underwent surgical treatment for pathologic and native hip fractures from 2007 to 2017 and 2601 matched pairs were identified using propensity scoring. Baseline covariates were controlled for, and rates of 30-day postoperative complications and mortality were compared using McNemar’s test.ResultsPathologic hip fracture patients experienced significantly higher rates of death (6.3% vs 4.3%, P < .001), serious adverse events (17.3% vs 13.5%, P < .001), minor complications (34.3% vs 29.1%, P < .001), extended postoperative lengths of stay (30.2% vs 25.9%, P < .001), readmissions (11.9% vs 8.4%, P < .001), thromboembolic complications (3.0% vs 1.6%, P < .001), and perioperative transfusions (31.5% vs 26.4%, P < .001) compared to native hip fracture patients.ConclusionPathologic hip fractures result in significantly higher complication rates than native hip fractures after surgical treatment, suggesting that guidelines for native hip fractures may not be generalizable for pathologic hip fractures. Orthopedic surgeons should closely monitor these patients for deep vein thrombosis, utilize blood sparing techniques, and employ a multidisciplinary approach to help manage and prevent a more heterogenous profile of postsurgical complications.     

Is There an Association Between Study Materials and Scores on the American Board of Orthopaedic Surgeons Part 1 Examination?

BackgroundPrevious studies have shown that certain orthopaedic in-training examination scores can be used to identify which residents may be at risk for failing the American Board of Orthopaedic Surgeons (ABOS) Part 1 examination. However, no studies have examined how study resources may affect residents’ ABOS Part 1 scores. The goal of this study is to determine which review sources or review courses, if any, are associated with improved ABOS Part 1 scores.MethodsA survey was sent to 221 of the 865 examinees who took the ABOS Part 1 examination in 2012. The questions inquired the respondents how well they performed on previous orthopaedic in-training examinations and ABOS Part 1, along with the study sources they most commonly used, review courses they attended, and resources they would recommended if they were to retake ABOS Part 1 examination.ResultsOverall, 118 of the 221 (53%) survey recipients completed the survey. Six (5%) of the respondents failed ABOS Part 1 examination. Orthobullets and the American Academy of Orthopaedic Surgeons self-assessment examinations were recommended as the primary study source significantly more (p < 0.01) than most other resources, but there was no significant association between study source and passing ABOS Part 1 or scoring in a certain percentile on ABOS Part 1. Similarly, there were no associations between attending a review course and either passing or scoring in a certain percentile for ABOS Part 1. Half of the respondents who failed ABOS Part 1 attended multiple review courses.ConclusionsThere does not appear to be an association between improved ABOS Part 1 scores and orthopedic study materials or review courses. Further research into the value of certain educational modalities should be conducted to determine the best ways to educate orthopedic residents and determine the value of some of these commonly used orthopedic review modalities.     

Preoperative Anemia Independently Predicts Significantly Increased Odds of Short-Term Complications Following Aseptic Revision Hip and Knee Arthroplasty

BackgroundPreoperative anemia is an important risk factor for developing complications following revision hip (rTHA) and knee (rTKA) arthroplasty. We aim to determine the effect of anemia severity on 30-day postoperative complications following revision hip and knee arthroplasty.MethodsA retrospective cohort study was conducted using the American College of Surgeons National Quality Improvement Program Database. All patients who underwent revision joint arthroplasty (rTJA) between 2006 to 2017 were identified and grouped based upon the hematocrit (Hct) level. Anemia was defined as Hct <36% for women and <39% for men, and further stratified into mild anemia (Hct 33% to 36% for women, Hct 33% to 39% for men), and moderate to severe anemia (Hct <33% for both men and women). Univariate and multivariate analysis were used to evaluate the incidence of multiple adverse events within 30 days after TJA.ResultsA total of 8932 patients undergoing rTHA and 13,313 patients undergoing rTKA were included for analysis. On multivariate adjustment, patients undergoing rTHA with moderate to severe anemia had an increased odds of 5.437 (95% Confidence Interval (CI) 4.604 to 6.421; P < .001) of developing any postoperative complication. On multivariate adjustment, patients undergoing rTKA with moderate to severe anemia had increased odds of 6.731 (95% Confidence Interval (CI) 5.540 to 8.179; P < .001) of developing any postoperative complication.ConclusionThe increasing severity of anemia was associated with an increasing risk of developing any postoperative complication and death following revision hip and knee arthroplasty. There is a significant trend between diminishing preoperative hematocrit levels and increasing odds of postoperative complication.     

Utilization Patterns,Efficacy, and Complications of Venous Thromboembolism Prophylaxis Strategies in Revision Hip and Knee Arthroplasty as Reported by American Board of Orthopaedic Surgery Part II Candidates

BackgroundThe optimum venous thromboembolism (VTE) prophylaxis strategy to minimize risk of VTE and bleeding complications following revision total hip and knee arthroplasty (rTHA/rTKA) is controversial. The purpose of this study is to describe current VTE prophylaxis patterns following revision arthroplasty procedures to determine efficacy, complication rates, and prescribing patterns for different prophylactic strategies.MethodsThe American Board of Orthopaedic Surgery Part II (oral) examination case list database was analyzed. Current Procedural Terminology codes for rTHA/rTKA were queried and geographic region, VTE prophylaxis strategy, and complications were obtained. Less aggressive prophylaxis patterns were defined if only aspirin and/or sequential compression devises were utilized. More aggressive VTE prophylaxis patterns were considered if any of low-molecular-weight heparin (enoxaparin), warfarin, rivaroxaban, fondaparinux, or other strategies were used.ResultsIn total, 6387 revision arthroplasties were included. The national rate of less aggressive VTE prophylaxis strategies was 35.3% and more aggressive in 64.7%. Use of less aggressive prophylaxis strategy was significantly associated with patients having no complications (89.8% vs 81.9%, P < .001). Use of more aggressive prophylaxis patterns was associated with higher likelihood of mild thrombotic (1.2% vs 0.3%, P < .001), mild bleeding (1.7% vs 0.6%, P < .001), moderate thrombotic (2.6% vs 0.4%, P < .001), moderate bleeding (6.2% vs 4.0%, P < .001), severe bleeding events (4.4% vs 2.4%, P < .001), infections (6.4% vs 3.8%, P < .001), and death within 90 days (3.1% vs 1.3%, P < .001). There were no significant differences in rates of fatal pulmonary embolism (0.1% vs 0.04%, P = .474). Subgroup analysis of rTHA and rTKA patients showed similar results.ConclusionThe individual rationale for using a more aggressive VTE prophylaxis strategy was unknown; however, more aggressive strategies were associated with higher rates of bleeding and thrombotic complications. Less aggressive strategies were not associated with a higher rate of thrombosis.Level of EvidenceTherapeutic Level III.     

The effects of metabolic surgery on microvascular complications in obese patients with type 2 diabetes: a meta-analysis

BackgroundMetabolic surgery is a standard treatment for obesity with type 2 diabetes (T2D), although the effects of metabolic surgery on the incidence rate of microvascular complications remain controversial.ObjectivesWe aimed to evaluate the effect of metabolic surgery versus nonsurgical treatments on the incidence rate of microvascular complications in obesity with T2D.SettingA meta-analysis of published studies.MethodsWe searched PubMed, Web of Science, and the Cochrane Library to identify clinical studies assessing the effect of metabolic surgery on the incidence rate of microvascular diabetic complications compared with that of nonsurgical treatments. We extracted the primary outcomes, including the incidence rate of microvascular complications after metabolic surgery.ResultsA total of 32,756 participants from 12 studies were identified. Metabolic surgery reduced the incidence rate of microvascular complications (odds ratios [OR], .34; 95% confidence intervals [CI], .30–.39; P < .001) compared with that of nonsurgical treatments in obesity with T2D. Moreover, metabolic surgery also reduced the incidence of diabetic nephropathy (OR, .39; 95% CI, .30–.50; P < .001), diabetic retinopathy (OR, .52; 95% CI, .42–.65; P < .001) and diabetic neuropathy (OR, .27; 95% CI, .22–.34; P < .001) compared with nonsurgical treatments in obesity with T2D.ConclusionMetabolic surgery was superior to nonsurgical treatments in reducing the incidence of microvascular complications in obesity with T2D. Prospective studies, preferably randomized controlled trials, with evaluations of different types of metabolic surgery are warranted to provide guidelines for treatment preferences in obesity with T2D.     

Use of preoperative advanced imaging for reverse total shoulder arthroplasty

BackgroundIn order to avoid implant related complications related to glenosphere malposition, there has been an increased interest in the use of advanced imaging, including computed tomography (CT) and magnetic resonance imaging (MRI) for preoperative planning and patient-specific instrumentation for reverse shoulder arthroplasty (RSA). While recent literature has demonstrated improved component position when this technology is applied, the clinical benefits remain largely hypothetical and unproven. Thus, the goals of the current study were to utilize a national database to describe current trends in the use of preoperative advanced imaging and investigate the relationship between such imaging and postoperative complications compared to matched controls without any preoperative imaging.MethodsPatients undergoing RSA for non-fracture indications were identified within the Mariner dataset within the PearlDiver database from 2010 to 2018Q2. Patients who underwent preoperative advanced imaging (MRI and/or CT) within a year prior to surgery were then identified as study cohorts. A matched cohort undergoing RSA without preoperative advanced imaging was created for comparison purposes. The incidence of imaging over time and rates of loosening/osteolysis, periprosthetic fracture, prosthetic dislocation, and revision shoulder arthroplasty of all groups were compared using a regression analysis.ResultsThe percentage of patients who underwent preoperative CT (141% increase, P < .0001), and either MRI or CT (107% increase, P = .002) increased significantly during the study period, while there was no significant increase in MRI utilization (P = .122). Patients who underwent preoperative CT experienced significantly lower rates of revision shoulder arthroplasty (2.4% vs. 3.3%, OR = 0.72, P = .004) and periprosthetic dislocation (2.8% vs. 3.3%, OR 0.80, P = .039) within 2 years of RSA compared to patients who did not undergo preoperative CT, while preoperative MRI was associated with significantly lower rates of periprosthetic fracture (0.2% vs. 0.4%, OR 0.44, P = .005), revision shoulder arthroplasty (2.1% vs. 2.6%, OR = 0.75, P = .006), and periprosthetic dislocation (2.5% vs. 3.2%, OR 0.78, P = .003) within 2 years of RSA compared to patients without an MRI.ConclusionThere has been a significant increase in the utilization of preoperative CT as compared to MRI for RSA during the time period studied. The utilization of preoperative advanced imaging may be associated with a statistically significant reduction in multiple implant related complications following RSA for non-fracture indications, although these findings are of unclear clinical significance given limitations of the database and low percentage difference in complication rates.Level of Evidence: Level III     

Effect of obesity on perioperative and 180-day outcomes following anatomic and reverse total shoulder arthroplasty

BackgroundAn increasing number of anatomic and reverse total shoulder arthroplasties (aTSA and rTSA, respectively) are being performed on obese patients. Current literature shows highly variable results regarding the relationship between obesity and TSA outcomes. The purpose of this study is to more clearly define the effect of obesity on complication rates and outcomes following TSA using large, national databases.MethodsThe Nationwide Inpatient Sample (NIS) database and Nationwide Readmission Database (NRD) were queried from 2011 to 2017 to identify all cases of aTSA and rTSA. These groups were further stratified into non-obese, obese, and morbidly obese cohorts. The NIS database was used to perform a demographic, hospital characteristic analysis, and peri‑operative complication analysis (n = 433,111). The NRD was then used to analyze 180-day rates of complications, revisions, mortality, extended hospital stays, non-home discharges, and overall total cost (n = 303,755).ResultsThe most obese individuals were significantly more likely to be younger, female, black, and have higher comorbidity scores (all P < .001). In the peri‑operative setting, morbid obesity was predictive of higher complication rates compared to non-obese patients following both aTSA and rTSA (both P< .001). Obesity was predictive of increased perioperative complication rates following aTSA (P = .002), but fewer complications following rTSA (P < .001). Morbid obesity was predictive of higher frequencies of 180-day complication rates, extended hospital stays, and non-home discharge following aTSA and rTSA, as well as higher rates of 180-day revision rates following rTSA (all P < .05) compared to non-obese individuals. While obesity was predictive of higher 180-day revision rates following rTSA (P < .001), it was predictive of lower rates of extended hospital stays following aTSA and rTSA (all P < .001), lower non-home discharge rates following rTSA (P = .009), lower 180-day revision rates following aTSA (P < .001), and lower 180-day complication and revision rates following rTSA (both P < .001).ConclusionsWhile obesity was predictive of higher rates of peri‑operative complications following aTSA and 180-day revision rates following rTSA, it otherwise appears to be a safe procedure in the obese population. Morbid obesity, however, appears to be predictive of increased peri‑operative and 180-day complication rates, longer hospital stays, and more frequent non-home discharge rates following TSA. Patients should be counseled appropriately on this information when considering surgery in order to facilitate shared decision making, and surgeons should take particular care when performing TSA in the morbidly obese population.Level of EvidenceLevel III; Retrospective Cohort; Treatment Study     

Bariatric surgery outcomes in oxygen-dependent patients: analysis of the MBSAQIP database

BackgroundThe number of bariatric procedures performed on complex, oxygen-dependent patients has increased. These patients often have other medical co-morbidities that can be improved after bariatric surgery; however, questions remain regarding their perioperative risk.ObjectiveTo assess the safety of bariatric surgery among oxygen-dependent patients, and to compare outcomes in this patient group after laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy.SettingUniversity and private hospitals enrolled in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry.MethodsThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data from 2015 to 2017 was analyzed. A multivariable regression analysis was performed looking at 30-day serious complications for oxygen-dependent patients, with a secondary propensity-matched analysis performed comparing patients undergoing laparoscopic sleeve gastrectomy versus laparoscopic Roux-en-Y gastric bypass.ResultsIn total, 430,396 patients were analyzed, 3034 (0.7%) of whom were oxygen dependent. The absolute 30-day complication rate among oxygen-dependent patients was more than twice as high (8.24% versus 3.46%, P < .001). The postoperative leak (.69% versus .41%, P = .017), bleed (2.08% versus .91%, P < .001), cardiac event (.16% versus .07%, P = .034), and pneumonia rate (.89% versus .19%, P < .001) were all significantly higher. Mortality was significantly higher among oxygen-dependent patients (.49% versus .09%, P < .001). On multivariable analysis, oxygen dependency was an independent predictor of adverse outcomes (odds ratio 1.30 [1.22–1.50], P < .001). Laparoscopic Roux-en-Y gastric bypass was associated with a statistically significant higher complication rate compared with laparoscopic sleeve gastrectomy (13.23% versus 5.16%, P < .001).ConclusionOxygen-dependent patients undergoing bariatric surgery are at a higher risk of both morbidity and mortality postoperatively.