Jennifer Kurowicki

Trends in total elbow arthroplasty in the Medicare population: a nationwide study of records from 2005 to 2012

BACKGROUNDnUtilization of total elbow arthroplasty (TEA) has reportedly increased in recent years. Since the introduction of disease-modifying antirheumatic drugs, there has been a reported decline in its use among rheumatoid patients; yet, the shift in indications for TEA remains unclear. This study evaluated trends in TEA utilization from 2005 to 2012 by analyzing the most common indications within the population of Medicare patients.nnnMETHODSnWe performed a retrospective review of a comprehensive Medicare patient population database using the PearlDiver supercomputer (Warsaw, IN, USA) for TEA utilization in rheumatoid arthritis (RA), osteoarthritis (OA), distal humerus fracture (DHF), post-traumatic arthritis (PTA), and distal humerus nonunion (DHNU). Total reported incidence of office visits and TEA utilization for each indication was reviewed.nnnRESULTSnUtilization of TEA remained unchanged (Pu2009=u2009.9530) despite a growing Medicare population (Pu2009=u2009.0201). There was a significant decline in annual TEA utilization for RA (Pu2009=u2009.002) and DHNU (Pu2009=u2009.003). No significant change was found in TEA use for DHF, OA, and PTA. A significant increase was noted in total visits coded for OA, RA, and DHNU (Pu2009<u2009.001). A significant, strong negative correlation was found for office visit coding and TEA use in RA (ru2009=u2009-0.850; Pu2009=u2009.008) and DHNU (ru2009=u2009-0.902; Pu2009=u2009.002).nnnCONCLUSIONnFrom 2005 to 2012, utilization rates of TEA in the Medicare population remained constant. Despite increases in office visits, TEA use for RA and DHNU has declined, likely secondary to improved medical management with disease-modifying antirheumatic drugs and the surgeons comfort with improved fracture fixation options.

Trends in surgical management of proximal humeral fractures in the Medicare population: A nationwide study of records from 2009 to 2012

BACKGROUNDnSurgical management of proximal humeral fractures has reportedly increased in recent years. Much of this growth relates to a growing elderly population, together with the introduction of modern implants, such as locking plates and, recently, introduction of reverse shoulder arthroplasty (RSA). This study evaluated trends in surgical management of proximal humeral fractures from 2009 to 2012 by analyzing the use of hemiarthroplasty (HA), RSA, and osteosynthesis (open reduction with internal fixation [ORIF]) within the Medicare patient population.nnnMETHODSnWe retrospectively reviewed a comprehensive Medicare patient population database within the PearlDiver supercomputer (Warsaw, IN, USA) for proximal humeral fractures treated with HA, RSA, or ORIF. Total use, annual utilization rates, age, and gender were investigated.nnnRESULTSnWithin the study period, 32,150 proximal humeral fractures were treated operatively, with no significant change in annual volume (Pxa0=xa0.119). The percentage of fractures treated surgically decreased significantly from 16.2% to 13.9% (Pxa0<xa0.001). The utilization rate decreased significantly for HA from 52% to 39% (Pxa0<xa0.001), increased significantly for RSA from 11% to 28% (Pxa0<xa0.001), and did not change significantly for ORIF (Pxa0=xa0.164). The utilization rate of RSA nearly tripled for patients older than 65 years (11% to 29%) and doubled for patients younger than 65 (6% to 12%).nnnCONCLUSIONnFrom 2009 to 2012, utilization rates of ORIF remained fairly constant. HA remains the most commonly used surgical treatment for proximal humeral fractures in the Medicare population, but its use has declined significantly. This decline has been offset by a corresponding increase in RSA.

Outcomes and radiographic findings of anatomic press-fit radial head arthroplasty

BACKGROUNDnRadial head arthroplasty (RHA) is a popular method of treatment for complex fractures of the radial head. The purpose of this study was to investigate patient outcomes and radiographic findings associated with a single anatomic monopolar press-fit radial head system commonly used for the treatment of radial head fractures.nnnMETHODSnA retrospective review of prospectively collected data was performed for a consecutive series of patients treated with a press-fit anatomically designed RHA between November 2007 and April 2014. The most recent radiographs were evaluated for loosening, stress shielding, and instability. Postoperative motion and outcomes were reported at most recent follow-up.nnnRESULTSnAt an average follow-up of 30 months, 6 of the 15 patients (40%) demonstrated radiographic loosening. Six of the 9 patients (67%) without loosening demonstrated stress shielding (average, 6u2009mm). Functional outcome scores included a mean American Shoulder and Elbow Surgeons score of 70, Mayo Elbow Performance Score of 85, visual analog scale score for pain of 2, visual analog scale score for function of 7, and Single Assessment Numeric Evaluation score of 75. Average flexion-extension arc was 14° to 138°, and average pronation-supination was 75° to 74°. All 6 of the patients with radiographic loosening had undergone RHA with an associated ligamentous injury repair. Satisfaction among patients was high as no patient reported an unsatisfactory outcome.nnnCONCLUSIONSnThe use of an anatomic, press-fit monopolar RHA in the management of acute complex radial head fractures has yielded excellent clinical outcomes despite high rates of radiographic loosening and stress shielding. Press-fit RHA in the setting of ligamentous injury warrants further investigation because of a high rate of implant loosening observed.

Reverse shoulder prosthesis in the treatment of locked anterior shoulders: a comparison with classic reverse shoulder indications

BACKGROUNDnLocked anterior shoulder (LAS) with static instability and anterior glenoid bone loss is challenging in the elderly population. Reverse shoulder arthroplasty (RSA) has been employed in treating these patients. No study has compared RSA for LAS with classically indicated RSA.nnnMETHODSnA retrospective case-control study of patients treated with RSA for LAS with glenoid bone loss and static instability was performed using matched controls treated with primary RSA for classic indications. Twenty-four cases and 48 controls were evaluated. Average follow-up was 25.5 months, and median age was 76 years. Motion, outcome assessments, and postoperative radiographs were compared.nnnRESULTSnPreoperatively, LAS had significantly less rotation and lower baseline outcome scores. Glenoid bone grafting was more common (Pu2009=u2009.05) in the control group (26%) than in the LAS group (6.3%). Larger glenospheres were used more often (Pu2009=u2009.001) in the LAS group (75%) than in the control group (29%). Both groups demonstrated significant improvements in pain, function, and outcome scores. Postoperatively, the control group had significantly better elevation and functional outcome scores. With the exception of flexion and Simple Shoulder Test score, effectiveness of treatment was similar between groups. Postoperative acromion stress fractures were seen in 21% of LAS patients and 9% of controls (Pu2009=u2009.023) with a predominance of type 3 fractures in LAS. Two LAS patients remained dislocated.nnnCONCLUSIONnPatients with LAS treated with RSA can anticipate improvements in pain and function by use of larger glenospheres, often without the need for glenoid bone grafting. Worse postoperative motion and function and a higher incidence of acromion stress fracture may be expected.

Speed of recovery after arthroscopic rotator cuff repair

BACKGROUNDnThe purpose of this study was to delineate the time taken to achieve maximum improvement (plateau of recovery) and the degree of recovery observed at various time points (speed of recovery) for pain and function after arthroscopic rotator cuff repair.nnnMETHODSnAn institutional shoulder surgery registry query identified 627 patients who underwent arthroscopic rotator cuff repair between 2006 and 2015. Measured range of motion, patient satisfaction, and patient-reported outcome measures were analyzed for preoperative, 3-month, 6-month, 1-year, and 2-year intervals. Subgroup analysis was performed on the basis of tear size by retraction grade and number of anchors used.nnnRESULTSnAs an entire group, the plateau of maximum recovery for pain, function, and motion occurred at 1 year. Satisfaction with surgery wasu2009>96% at all time points. At 3 months, 74% of improvement in pain and 45% to 58% of functional improvement were realized. However, only 22% of elevation improvement was achieved (Pu2009<u2009.001). At 6 months, 89% of improvement in pain, 81% to 88% of functional improvement, and 78% of elevation improvement were achieved (Pu2009<u2009.001). Larger tears had a slower speed of recovery for Single Assessment Numeric Evaluation scores, forward elevation, and external rotation. Smaller tears had higher motion and functional scores across all time points. Tear size did not influence pain levels.nnnCONCLUSIONnThe plateau of maximum recovery after rotator cuff repair occurred at 1 year with high satisfaction rates at all time points. At 3 months, approximately 75% of pain relief and 50% of functional recovery can be expected. Larger tears have a slower speed of recovery.

Trends in Management of Radial Head and Olecranon Fractures

Background: Advancement in surgical techniques and implants has improved the ability to manage radial head and olecranon fractures. However, trends in management of these fractures are largely unstudied. Objective: This purpose of this study is to evaluate management trends for these common fractures. Methods: A retrospective review of a comprehensive Humana database was performed using Pearl Diver supercomputer (Warsaw, IN, USA) for radial head and neck (RHNF) and olecranon fractures (OF) between 2007 and 2014. Treatment methods including open reduction internal fixation (ORIF), radial head arthroplasty (RHA), and non-operative treatment were reviewed. Total reported incidence of office visits and utilization of each treatment modality were investigated. Sub-analysis with stratification by age 15-74 and greater than 75-years was performed for OF. Results: A total of 10,609 OF and 20,400 RHNF were identified between 2007 and 2014. A significant trend increase in the annual incidence of RHNF (266 cases/year, p<0.001) and OF (133.9 cases/year, p=0.001) was observed. A significant trend increase in annual percent utilization of RHA (0.22% per year, p=0.011) and a significant trend decrease in the annual percent utilization of ORIF (-1.0% per year, p=0.004) and non-operative management (-0.53% per year, p=0.046) was observed for RHNF. A significant trend increase was observed in percent utilization (0.40% per year, p=0.022) for OF non-operative management, especially in patients over 75 years (66% per year, p=0.034). Conclusion: The percentage of patients being treated with RHA is increasing. Non-operative management of OF has increased, specifically in the patients who are over 75 years.

Effect of Hypoglycemia on the Incidence of Revision in Total Knee Arthroplasty

BACKGROUNDnIt is well established that diabetic patients undergoing total knee arthroplasty (TKA) are more susceptible to infection, problematic wound healing, and overall higher complication rates. However, a paucity in current literature exists. The purpose of this study was to determine the effect of hypoglycemia on TKA revision (rTKA) incidence by analyzing a national private payer database for procedures performed between 2007 and 2015 Q1 Q2.nnnMETHODSnA retrospective review of a national private payer database within the PearlDiver Supercomputer application for patients undergoing TKA with blood glucose levels from 20 to 219 mg/mL, in 10-mg/mL increments, was conducted. Patients who underwent TKA were identified by Current Procedural Terminology (CPT) and International Classification of Disease (ICD) codes. Glucose ranges were identified by filtering for Logical Observation Identifiers Names and Codes within the PearlDiver database. Patients with diagnosed diabetes mellitus type I or II were excluded by using ICD-9 codes 250.00-250.03, 250.10-250.13, and 250.20-250.21. rTKA causes including mechanical loosening, failure/break, periprosthetic fracture, osteolysis, infection, pain, arthrofibrosis, instability, and trauma were identified with CPT and ICD-9 codes. Statistical analysis was primarily descriptive.nnnRESULTSnOur query returned 264,824 TKAs, of which 12,852 (4.9%) were revised. Most TKAs were performed with a glucose of 70-99 mg/mL (26.1%), followed by 100-109 mg/mL (18.5%). Patients with TKAs performed with glucose 20-29 mg/mL had the highest rate of revision (17.2%; P < .001). Infection was the most common cause of revision among all glucose ranges (P < .001).nnnCONCLUSIONnInfection remains one of the most common causes of rTKA irrespective of glucose level. Our results suggest that hypoglycemia may increase revision rates among TKA patients. Tight glycemic control before and during surgery may be warranted.

Treatment of Periprosthetic Humerus Fractures With Open Reduction and Internal Fixation.

Summary: Periprosthetic humerus fractures are relatively uncommon occurrence that can be difficult to manage nonoperatively. Locking plate technology has enhanced the surgical management of these fractures. However, adequate fixation around the stem remains of some concern. We describe an osteosynthesis technique using a locking plate utilizing eccentrically placed screw holes to place “skive screws” in the proximal end of the plate to achieve fixation around the stem of the implant. A clinical series of 5 consecutive patients treated with this technique is presented with an average follow-up of 29 months (range, 12–48). Two additional patients had less than 1-year follow-up. All patients demonstrated fracture healing. Functional outcomes were limited with only 1 patient achieving forward elevation above 90 degree, and the average American Shoulder and Elbow Surgeons Function score was 28. Pain relief was nearly uniform with an average visual analog scale pain score of 0.5.

Effect of opioid dependence or abuse on opioid utilization after shoulder arthroplasty

AIM To examine whether opioid dependence or abuse has an effect on opioid utilization after anatomic or reverse total shoulder arthroplasty (TSA). METHODS All anatomic TSA (ICD-9 81.80) and reverse shoulder arthroplasty (RSA) (ICD-9 81.88) procedures from 2007 to 2015 were queried from within the Humana claims database utilizing the PearlDiver supercomputer (Colorado Springs, CO). Study groups were formed based on the presence or absence of a previous history of opioid dependence (ICD-9 304.00 and 304.03) or abuse (ICD-9 305.50 and 305.53). Opioid utilization among the groups was tracked monthly up to 1 year post-operatively utilizing National Drug Codes. A secondary analysis was performed to determine risk factors for pre-operative opioid dependence or abuse. RESULTS Two percent of TSA (157 out of 7838) and 3% of RSA (206 out of 6920) patients had a history of opioid dependence or abuse. For both TSA and RSA, opioid utilization was significantly higher in opioid dependent patients at all post-operative intervals (P < 0.01) although the incidence of opioid use among groups was similar within the first post-operative month. After TSA, opioid dependent patients were over twice as likely to fill opioid prescriptions during the post-operative months 1-12. Following RSA, opioid dependent patients were over 3 times as likely to utilize opioids from months 3-12. Age less than 65 years, history of mood disorder, and history of chronic pain were significant risk factors for pre-operative opioid dependence/abuse in patients who underwent TSA or RSA. CONCLUSION Following shoulder arthroplasty, opioid use between opioid-dependent and non-dependent patients is similar within the first post-operative month but is greater among opioid-dependent patients from months 2-12.

Racial Disparities in Revision Total Knee Arthroplasty: Analysis of 125,901 Patients in National US Private Payer Database

IntroductionThere is a relative paucity of studies that characterized racial disparities in revision total knee arthroplasty (TKA). Therefore, this study was specifically conducted to evaluate the following: (1) incidence; (2) annual burden; (3) causes; and (4) age group distribution of revision TKA among different racial groups in the US sample population.MethodsThe PearlDiver database was utilized to identify patients with knee osteoarthritis (OA) who underwent primary then subsequent revision TKA from January 2007 to December 2014. Patients were stratified by race, and subset stratification by age was also performed. In each racial cohort, the overall incidence of revision TKA, annual revision burdens, and causes of revisions were calculated and compared. Additionally, a sub-analysis for the incidence of revision TKA stratified by age, in each cohort, was performed. Statistical analysis was performed to demonstrate revision incidence, burden, causes, and age distribution.ResultsRevision incidence and burden were the highest in the African-American cohort (12.4%, 11.1%), (pu2009<u20090.001) and was lowest in the Asian cohort (3.4%, 3.3%) (pu2009<u20090.001). Across all cohorts, mechanical complications of the joint prosthesis were the most common cause of revision followed by periprosthetic joint infection, while contracture was the least common (pu2009<u20090.001). Subset analysis by age revealed that the highest incidence of revision TKA was in patients less than 40xa0years old in the Caucasian cohort (27.1%). The African-American (17.8%), other races (7.9%), and Hispanic (16.5%) cohorts had the highest incidence of revision in the 40 to 64xa0years age range. Among the Asian (4.1%) and Native American (9.7%) cohorts, revision incidence was highest in patients older than 65xa0years.ConclusionThe present study demonstrated that racial disparities, highlighted by previous studies mainly in primary TKA, extend to influence revision TKA. Among the studied racial cohorts, race may affect outcomes and our results will help expand the current literature particularly on its role in revision TKA.