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Objectives: To evaluate the risk of developing a new mental disorder diagnosis within 2 years of lower extremity fracture., Design: Retrospective cohort study., Setting: National insurance claims database., Patient Selection Criteria: Patients between 18 and 65 years with lower extremity, pelvis, and acetabular fractures without prior mental disorders as defined using International Classification of Diseases, 9th and 10th revision diagnosis codes were included. Mental disorders evaluated included alcohol use disorder, generalized anxiety disorder, bipolar disorder, major depressive disorder, drug use disorder, panic disorder, posttraumatic stress disorder, and suicide attempt., Outcome Measures and Comparisons: The individual lower extremity fracture cohorts were matched 1:4 with nonfracture controls. The specific groups of interest were pelvis fractures, acetabulum fractures, proximal femur fractures, femoral shaft fractures, distal femur fractures, patella fractures, tibia plateau fractures, tibia shaft fractures, ankle fractures, pilon fractures, calcaneus fractures, and Lisfranc fractures. Rates of mental disorders after primary lower extremity fractures within 2 years were compared using multivariable logistic regression., Results: Overall, the 263,988 patient-fracture group was 57.2% female with an average age of 46.6 years. Compared with controls with no fracture, patients who sustained pelvis, acetabulum, proximal femur, femoral shaft, distal femur, patella, tibia plateau, tibia shaft, pilon, calcaneus, or Lisfranc fracture had a statistically significantly increased risk of being diagnosed with a queried mental disorder within 2 years of fracture. When comparing all fracture patients by location, those suffering from fractures proximal to the knee joint, including pelvis fractures [OR: 1.51, 95% confidence interval (CI): 1.39-1.64] and proximal femur fractures [odds ratio (OR): 1.36, 95% CI: 1.26-1.47], demonstrated greater risk of developing any of the queried mental disorders compared with fractures distal to the knee, including ankle fractures (OR: 0.99, 95% CI: 0.95-1.03) and pilon fractures (OR: 1.05, 95% CI: 0.81-1.36). When comparing specific fracture patients with patients without fracture by mental disorder, patients demonstrated an increased risk of suicide attempt following fracture of the pelvis, acetabulum, femoral shaft, distal femur, and calcaneus, as well as patients sustaining a Lisfranc fracture., Conclusions: There is an increased risk of being diagnosed with a new mental disorder following lower extremity trauma in patients without prior mental disorder diagnosis compared with matched individuals without a lower extremity fracture. Among the fractures studied, those that were more proximal, such as pelvis and proximal femur fractures, carried greater risk compared with more distal fracture sites, including ankle and pilon fractures. Patients who experienced certain lower extremity fractures had a significantly higher rate of suicide attempt compared with patients without fracture. Physicians should consider increased mental health screening and potential referral for mental health evaluation for patients following lower extremity trauma., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: W.F. Sherman is a paid consultant for Stryker. K.C. Vemulapalli is a paid consultant for Skeletal Dynamics, Johnson & Johnson, and Smith & Nephew. All remaining authors have no conflicts of interest to declare., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Rotator cuff tears are common in middle-aged and elderly patients. Despite advances in the surgical repair of rotator cuff tears, the rates of recurrent tear remain high. This may be due to the complexity of the tendons of the rotator cuff, which contributes to an inherently hostile healing environment. During the past 20 years, there has been an increased interest in the use of biologics to complement the healing environment in the shoulder, in order to improve rotator cuff healing and reduce the rate of recurrent tears. The aim of this review is to provide a summary of the current evidence for the use of forms of biological augmentation when repairing rotator cuff tears., Competing Interests: None declared., (© 2024 The British Editorial Society of Bone & Joint Surgery.)

Background: Smoking is a known risk factor for complications after open tibia fractures, but it is unclear if smokeless tobacco confers a similar risk., Objective: The purpose of this study was to evaluate the rates of postoperative complications after surgical fixation of open tibia fractures in smokeless tobacco users as compared to matched tobacco naïve controls., Methods: A retrospective cohort study was conducted using the national PearlDiver database. For patients who had a unilateral open tibia fracture, smokeless tobacco users (n=121) and tobacco-naïve controls (n=242) were matched at a 1:2 ratio. Rates of bone complications within 1 year were compared using multivariable logistic regression., Results: Compared to controls, the smokeless tobacco user cohort demonstrated significantly higher rates of nonunion (OR: 3.42, 95% CI: 1.05 - 11.12), infection / inflammatory reaction of implant (OR: 12.45, 95% CI: 2.67 - 58.93), and osteomyelitis of the leg (OR: 6.15, 95% CI: 1.90 - 19.93) within 1 year of open tibia fracture. Compared to the most recent population figures, smokeless tobacco use was significantly under-reported in both males and females., Conclusions: Smokeless tobacco use confers an increased risk of fracture nonunion, infection or inflammatory response to implant, and osteomyelitis of the leg in patients with open tibia fractures. Surgeons should consider this risk when counseling patients and deciding on treatment plans for patients with tibia fractures., Competing Interests: Timothy L. Waters: None Julianna E. Winter: None Bela P. Delvadia: None William F. Sherman: Editorial board member for arthroplasty today, American Academy of Orthopaedic Surgery knee committee member, Paid consultant for Stryker, Associate editor for Orthopedic Reviews Olivia C. Lee: None

Introduction: Firearms are the leading cause of death in the pediatric population, and the incidence of firearm injury is on the rise in the United States. The purpose of this study was to examine the incidence of pediatric gunshot wounds (GSWs) in New Orleans from 2012 to 2023 and evaluate factors that contribute to mortality., Methods: A retrospective analysis of pediatric GSWs was conducted using the trauma database at a Level I trauma center in New Orleans, Louisiana. All patients aged 0 to 18 years with a GSW between January 1, 2012, and January 1, 2023, were evaluated. Demographic data, Injury Severity Score (ISS), hospital length of stay (LOS), discharge disposition, intent of injury, mortality, firearm type, orthopaedic injuries, and related surgical procedures were extracted from the database. Linear regression was used to assess the trend of GSWs over time, and logistic regression was used to identify variables that predicted mortality. Statistical significance was defined as α = 0.05. Geographic information system (GIS) mapping was conducted using the ZIP code location of injury to identify geographic areas with the greatest number of GSWs., Results: A significant increasing trend was observed in the number of pediatric GSWs when adjusted for changes in population ( P = 0.014), and the number of GSWs increased 43.2% over the duration of the study. Higher ISS, shorter length of stay, and self-inflicted intent of injury were notable predictors of mortality. Three hundred fifty-four patients (31.4%) had at least one orthopaedic injury, and of the survivors, 365 patients (35.6%) required at least one surgical procedure in the operating room during their admission., Discussion: The number of GSWs in the pediatric population in New Orleans presenting at a large level 1 trauma center demonstrated a statistically significant increasing trend over the past 11 years. ISS and self-inflicted intent were predictive of mortality within this pediatric patient population., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Background: The purpose of this study was to (1) evaluate the rates of postoperative complications following ankle or hindfoot arthrodesis among current smokeless tobacco users and people who smoke compared to matched controls, and (2) compare rates of postoperative complications in current smokeless tobacco users vs people who smoke tobacco cigarettes., Methods: A retrospective cohort study was conducted using a large national database. For patients who underwent ankle or hindfoot arthrodesis, smokeless tobacco users (n = 131) and people who smoke (n = 1948) were matched 1:4 with controls, and smokeless tobacco users (n = 131) were matched 1:4 with people who smoke tobacco cigarettes (n = 524). Orthopaedic complications within 90 days, 1 year, and 2 years were compared using multivariable logistic regressions., Results: Within 90 days of ankle or hindfoot arthrodesis, smokeless tobacco users demonstrated significantly higher rates of hardware removal (odds ratio [OR] 5.01, 95% CI 1.65-15.20), wound disruption or dehiscence (OR 3.00, 95% CI 1.21-7.44), and pooled complications (16.0% vs 5.9%, OR 2.84, 95% CI 1.50-5.38) compared with tobacco-naïve controls. The rates of hardware removal, wound disruption and dehiscence, and pooled complications remained significant in the smokeless tobacco cohort at 1 and 2 years. At 2 years following ankle or hindfoot arthrodesis, smokeless tobacco users additionally demonstrated significantly higher rates of infection (OR 6.08, 95% CI 1.15-32.05) and nonunion (OR 2.35, 95% CI 1.31-4.20) compared with tobacco-naïve controls. Within 90 days of ankle or hindfoot arthrodesis, smokeless tobacco users demonstrated significantly lower rates of malunion or nonunion than patients who smoke tobacco cigarettes (OR 0.34, 95% CI 0.12-0.97), whereas all other complications were not significantly different., Conclusion: Smokeless tobacco use is associated with higher rates of complications following ankle or hindfoot arthrodesis compared with tobacco-naïve controls, and physicians should screen for smokeless tobacco use specifically and encourage cessation before operating electively., Level of Evidence: Level III, retrospective cohort study., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

Background: Urinary incontinence has been linked to worse postoperative pain, decreased physical function, and reduced quality of life in patients following total joint arthroplasty. The purpose of this study was to analyze whether incontinence is associated with increased postoperative medical and joint complications following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA)., Methods: A retrospective cohort study was conducted using a national insurance database. Thirty-two thousand eight hundred eleven patients with incontinence who underwent primary THA were identified and matched 1:4 with 129,073 patients without incontinence. Ninety-one thousand nine hundred thirty-five patients with incontinence who underwent primary TKA were matched 1:4 with 367,285 patients without incontinence. Medical and joint complication rates at 90 days and 2 years, respectively, were then compared for patient cohorts using multivariable logistic regressions., Results: Patients who underwent primary THA with incontinence had statistically higher rates of dislocation, periprosthetic fracture, aseptic revisions, and overall joint complications compared to controls. Patients who underwent primary TKA with incontinence had higher rates of mechanical failure, aseptic revision, and all-cause revision compared to controls., Conclusions: This study demonstrated an association between patients with incontinence and higher rates of dislocation, periprosthetic fractures, aseptic revisions, and overall joint complications following primary THA compared to controls. Patients with incontinence experience higher rates of mechanical failure, aseptic revision, and all-cause revision following TKA compared to controls. As such, perioperative management of urinary incontinence may help mitigate the risk of postoperative complications., (© 2024 Published by Elsevier Inc. on behalf of The American Association of Hip and Knee Surgeons.)

Background: Studies have demonstrated increased complication risk after total hip arthroplasty (THA) in patients who smoke cigarettes. It is unclear if smokeless tobacco use confers a similar impact. The purpose of this study was to (1) evaluate rates of postoperative complications after THA in smokeless tobacco users and people who smoke compared to matched controls, and (2) compare rates of postoperative complications in smokeless tobacco users versus patients who smoke., Methods: A retrospective cohort study was conducted using a large national database. For patients who underwent primary THA, smokeless tobacco users (n = 950) and people who smoke (n = 21,585) were matched 1:4 with controls (n = 3,800 and 86,340, respectively), and smokeless tobacco users (n = 922) were matched 1:4 with people who smoke (n = 3,688). Joint complication rates within 2 years and medical complications within 90 days postoperatively were compared using multivariable logistic regressions., Results: Within 90 days of primary THA, smokeless tobacco users demonstrated significantly higher rates of wound disruption, pneumonia, deep vein thrombosis, acute kidney injury (AKI), cardiac arrest, transfusion, readmission and longer length of stay compared to tobacco naïve controls. Within 2 years, smokeless tobacco users demonstrated significantly higher rates of prosthetic joint dislocations and overall joint-related complications compared to tobacco naïve controls., Conclusion: Smokeless tobacco use is associated with higher rates of medical- and joint-related complications following primary THA. Smokeless tobacco use may be under-diagnosed in patients undergoing elective THA. Surgeons may consider delineating between smoking and smokeless tobacco use during preoperative counseling., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Orthopaedic surgeons who are fellowship-trained in adult reconstruction (AR) specialize specifically in total joint arthroplasty, including total knee arthroplasty (TKA). However, TKA procedures are not only performed by AR surgeons. The purpose of this study was to compare the patient demographics and postoperative outcomes of patients who had a TKA procedure performed by an AR surgeon vs a sports medicine (SM) surgeon., Methods: A retrospective cohort study was conducted using a national insurance database. Patients who underwent a primary elective TKA procedure by an AR surgeon (n = 56,570) and an SM surgeon (n = 72,888) were identified. Patient demographics, rates of joint complications within 2 years, and medical complications within 90 days postoperatively were compared using multivariable logistic regression., Results: Compared to the cohort of patients undergoing TKA by SM surgeons, the patient cohort of AR surgeons had a higher mean Elixhauser comorbidity index (4.2 vs 4.0, P < .001), and had significantly higher rates of several comorbidities. Within 90 days, patients of AR surgeons demonstrated significantly lower rates of acute kidney injury and transfusions. When compared to patients of SM surgeons, patients of AR surgeons demonstrated significantly lower rate of manipulation under anesthesia or lysis of adhesions within 2 years. Rates of all other joint-related complications were statistically comparable between the 2 cohorts., Conclusions: As a cohort, AR surgeons perform TKA on a higher-risk cohort of patients compared to sports medicine surgeons. Despite the higher-risk patient population, outcomes of TKA by AR surgeons appear equivalent compared to their SM colleagues., (© 2024 Published by Elsevier Inc. on behalf of The American Association of Hip and Knee Surgeons.)

Purpose: To compare postoperative complication rates between patients who underwent medial patellofemoral ligament reconstruction (MPFLR) and those who underwent MPFLR with tibial tubercle osteotomy (TTO) in a large-scale study. A secondary goal was to investigate demographic associations with outcomes., Methods: Patients who underwent MPFLR (n = 3,480) or MPFLR-TTO (n = 615) for patellar instability were identified in the PearlDiver database. Rates of surgery for infection, procedures for knee stiffness, patellar fracture, and revision MPFLR within 2 years postoperatively were compared using multivariable logistic regression. Demographic associations with outcomes were also investigated., Results: The MPFLR-TTO cohort exhibited a significantly lower rate of revision surgery at 2 years (0.8% vs 1.9%; odds ratio [OR], 0.33; 95% confidence interval [CI], 0.10-0.80; P = .036) when compared with the MPFLR group. Independent of index procedure, patients younger than 21 years had significantly lower rates of requiring procedures for knee stiffness (OR, 0.35; 95% CI, 0.22-0.54; P < .001) and any complication at 2 years (OR, 0.59; 95% CI, 0.45-0.78; P < .001) when compared with older patients. Male patients displayed a significantly lower rate of requiring procedures for knee stiffness at 2 years than female patients (OR, 0.46; 95% CI, 0.25-0.78; P = .007). Tobacco use was associated with a significantly higher rate of postoperative infection at 2 years (OR, 2.35; 95% CI, 1.00-5.38; P = .046)., Conclusions: The MPFLR cohort exhibited higher rates of revision surgery at 2 years compared with the MPFLR-TTO cohort. Patient age under 21 years was associated with lower rates of any complication and requiring procedures for knee stiffness, male sex was associated with a lower rate of requiring procedures for knee stiffness, and tobacco use was associated with a higher rate of surgery for postoperative infection. This information can assist surgeons when counseling patients before these procedures are performed., Level of Evidence: Level III, retrospective, comparative prognostic trial., (Copyright © 2023 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: With emerging evidence supporting functional rehabilitation for Achilles tendon ruptures (ATRs), this study sought to evaluate the treatment trends for patients sustaining an acute ATR and whether gender and age may influence the rates of operative repair., Methods: A retrospective database review identified ATRs from 2010 through 2019. Patients were then stratified into three cohorts based on age (18-30, 30-45, and 46 and older), separated by gender, and then assessed whether patients were treated operatively or not. Cochran-Armitage Trend test was performed to analyze the trends of operative management. Chi-square analyses were performed to assess whether the proportion of patients who received operative management in each age cohort differed from 2010 to 2019. Logistic regression analyses were performed to assess whether gender influenced treatment., Results: Over the previous decade, the total rates of operative treatment for ATR significantly decreased (18.3%-12.3%, P < .0001). Each individual age cohort experienced a proportional decrease in operative management when comparing 2010 with 2019 (all P < .0001). Within all age cohorts, males were significantly more likely to receive operative treatment for an ATR over the previous decade (odds ratios: 2.63-3.22). Conclusion. Overall rates of operative management for ATR decreased across all cohorts likely due to previous studies providing evidence of similar results between operative and nonoperative managements. Over the previous decade, males were demonstrated to be far more likely than females to undergo operative management. Why females are less likely to receive an operation for ATR is likely multi-factorial and requires further exploration., Level of Evidence: Level III: Retrospective comparative study.

Study Design: Retrospective Comparative Study., Objective: The purpose of this study was to characterize trends in surgical approach for single-level lumbar fusion over the past decade., Summary of Background Data: The number of elective lumbar fusion cases performed is increasing annually. Several different surgical approaches exist for lumbar spinal fusion including novel anterior approaches developed in recent years. With ongoing innovation, trends in the utilization of common surgical approaches in recent years are unclear., Materials and Methods: A retrospective cohort study was conducted using the PearlDiver database (Fort Wayne, IN). Patients undergoing single-level lumbar fusion between 2010 and 2019 were identified using Current Procedural Technology codes and divided into 4 mutually exclusive cohorts based on surgical approach: (1) anterior-only, (2) anterior approach with posterior instrumentation, (3) posterolateral, and (4) posterior-only interbody. Trend analyses of surgical approach utilization over the last decade were performed with the Cochran-Armitage test to evaluate the 2-tailed null hypothesis that utilization of each surgical approach for single-level lumbar fusion remained constant., Results: A total of 53,234 patients met inclusion criteria and were stratified into 4 cohorts: anterior-only (n=5104), anterior with posterior instrumentation (n=23,515), posterolateral (n=5525), and posterior-only interbody (n=19,090). Trend analysis revealed the utilization of a posterior-only interbody approach significantly decreased from 36.7% to 29.2% ( P <0.001), whereas the utilization of a combined anterior and posterior approach significantly increased from 45.8% to 50.4% ( P <0.001). The utilization of an anterior-only approach also significantly increased from 7.9% to 10.5% ( P <0.001)., Conclusions: Utilization of anterior-only and anterior with posterior instrumentation approaches for single-level lumbar fusion have been significantly increasing over the past decade while use of posterior-only interbody approach trended significantly downward. These data may be particularly useful for trainees and spine surgeons as new techniques and technology become available., Level of Evidence: Level III-retrospective cohort study., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The prevalence of gout is increasing along with the number of total knee arthroplasties (TKA) performed annually. The purpose of this study was to evaluate the incidence of gout following TKA in patients who had a previous history of gout and to determine if it is associated with an increased rate of postoperative joint complications., Methods: Patients who did and did not have a preoperative diagnosis of gout and underwent a primary TKA were identified from a national database. The gout patients were matched 1:1 to patients who did not have gout and rates of postoperative gout diagnoses within 2 years of surgery were compared. Complication rates at mean 1 and 2 years were then compared for both patient cohorts using multivariable logistic regressions. A total of 17,463 patients with a prior diagnosis of gout were matched with 17,463 controls., Results: There were 53.8% of patients who had previous gout and had a recurrence of gout within 2 years versus 3.6% of controls (Odds Ratios [OR]: 30.86). At mean 1-year, patients who had gout were significantly more likely to experience prosthetic joint infections (PJIs) and revision procedures. At mean 2 years, gout patients were at increased risk of prosthetic loosening, PJI, revision, and incision and debridement procedures., Conclusion: This study suggests that patients who had a prior diagnosis of gout are significantly more likely to experience recurrent episodes of gout after TKA. Gout attacks after TKA are associated with an increase in the rate of joint complications., Level of Evidence: Level III., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Study Design: Retrospective study., Objective: This study evaluated the impact of chewing tobacco on both medical and spine-related complication rates after spinal lumbar fusions in comparison to both a control cohort and a smoking cohort., Summary of Background Data: Smoking is a prevalent modifiable risk factor that has been demonstrated to be associated with increased complications after lumbar fusion. Although smoking rates have decreased in the United States, chewing tobacco use has not similarly reduced. Despite chewing tobacco delivering up to 4 times the dose of smoking, the impact of chewing tobacco is incompletely understood., Methods: A retrospective cohort study was conducted using the PearlDiver database. Patients who underwent lumbar spine fusion and used chewing tobacco were matched with a control cohort and a smoking cohort. Medical complications within 90 days after primary lumbar fusion were evaluated, including deep venous thrombosis, acute kidney injury, pulmonary embolism, transfusion, acute myocardial infarction, and inpatient readmission. Spine-related complications were evaluated at 2 years postoperatively, including pseudoarthrosis, incision and drainage (I&D), instrument failure, revision, and infection., Results: After primary lumbar fusion, the chewing tobacco cohort demonstrated significantly higher rates of pseudoarthrosis [odds ratio (OR): 1.41], revision (OR: 1.57), and any spine-related complication (OR: 1.32) compared with controls. The smoking cohort demonstrated significantly higher rates of pseudoarthrosis (OR: 1.88), I&D (OR: 1.27), instrument failure (OR: 1.39), revision (OR: 1.54), infection (OR: 1.34), and any spine-related complication (OR: 1.77) compared with controls. The chewing tobacco cohort demonstrated significantly lower rates of pseudoarthrosis (OR: 0.84), I&D (OR: 0.49), infection (OR: 0.70), and any spine-related complication (OR: 0.81) compared with the smoking cohort., Conclusions: This study demonstrated that chewing tobacco is associated with higher rates of both spine-related and medical complications after primary lumbar fusion. However, chewing tobacco use is associated with less risk of complications compared with smoking., Level of Evidence: Level III., Competing Interests: M.C. is a paid speaker for Medtronic, Stryker and ATEC. The remaining authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Smoking has been demonstrated to be a risk factor for nonunion of scaphoid fractures, but it is unclear if chewing tobacco confers similar risk. The purpose of this study was to evaluate rates of bone-related complications after nonsurgical management of scaphoid fractures in smokeless tobacco users compared with matched control subjects and compared with smokers., Methods: A retrospective cohort study was conducted using the PearlDiver database. For patients who underwent nonsurgical management of scaphoid fractures, 212 smokeless tobacco users and 6,048 smokers were matched 1:4 with control subjects (n = 848 and 24,192, respectively) and 212 smokeless tobacco users were matched 1:4 with 848 smokers. Rates of bone-related complications within 2 years of initial injury were compared using multivariable logistic regression., Results: From weeks 12 through 104 after initial injury, compared with control subjects who do not use tobacco, the smokeless tobacco cohort demonstrated markedly higher rates of nonunion (5.7% vs 2.7%, OR: 2.07). Compared with control subjects who do not use tobacco, the smoking cohort demonstrated markedly higher rates of nonunion (4.3% vs 2.6%, OR: 1.91), repair of nonunion (1.5% vs 0.9%, OR: 1.87), and four corner fusion and proximal row carpectomy (0.3% vs 0.1%, OR: 3.17). Smokeless tobacco use was markedly underdiagnosed in the adult male cohort of unilateral scaphoid fractures with 2 years of follow-up found in the database (372 of 25,704, 1.45%) relative to Centers for Disease Control estimates for adult male smokeless tobacco use (4.5%) ( P < 0.001)., Conclusion: Given the higher rates of nonunion diagnoses after nonsurgical management in this cohort, surgeons should consider asking all patients with scaphoid fractures if they use smokeless tobacco or smoke and consider adding this to the patient's intake history to further identify patients at risk for nonunions. Tobacco cessation counseling is indicated for all tobacco users, including smokeless with scaphoid fractures., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Background: Studies have demonstrated increased complication risk after total knee arthroplasty (TKA) in patients who smoke cigarettes, but it is unclear if smokeless tobacco use confers a similar impact. The purpose of this study was to (1) evaluate rates of postoperative complications after TKA in smokeless tobacco users and smokers as compared to matched controls, and (2) compare rates of postoperative complications in smokeless tobacco users versus smokers to determine if one is associated with significantly higher rates of postoperative complications., Methods: A retrospective cohort study was conducted using a national database. For patients who underwent primary TKA, smokeless tobacco users (n = 1,535) and smokers (n = 28,953) were matched at a 1:4 with controls (n = 6,140 and 115,812, respectively), and smokeless tobacco users (n = 1,481) were matched at a 1:4 with smokers (n = 5,924). Rates of joint complications within 2 years and medical complications within 90 days postoperatively were compared using multivariable logistic regressions., Results: After primary TKA, compared to controls, smokeless tobacco users demonstrated significantly higher rates of aseptic loosening/mechanical failure within 2 years, longer lengths of stay, and higher rates of urinary tract infection, pneumonia, deep vein thrombosis, and acute kidney injury within 90 days. Compared to smokers, smokeless tobacco users demonstrated significantly lower rates of aseptic revision and lower rates of wound disruption., Conclusion: Smokeless tobacco use is associated with higher rates of both medical and joint complications following primary TKA. However, smoking is associated with higher risk for complications than smokeless tobacco use., Level of Evidence: Level III., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: Arthroscopic shoulder surgery has been identified as a potential risk factor for carpal tunnel syndrome (CTS). The purposes of this study were as follows: to (1) examine the percentage of patients who underwent arthroscopic shoulder procedures and later developed ipsilateral CTS within 1 year of the procedure, (2) determine the percentage of those patients with CTS who subsequently underwent an injection or release, and (3) examine comorbidities associated with developing CTS after surgery., Methods: Patients who underwent arthroscopic rotator cuff repair (RCR), labral repair, or biceps tenodesis were retrospectively identified in a national database. Within 1 year, we compared the rates of ipsilateral CTS diagnoses versus the contralateral side. The rates of comorbidities between those who did and did not develop CTS were also compared., Results: Within 1 year, arthroscopic RCR patients (1.47% vs 1.00%; odds ratio [OR], 1.48; P < .001) and arthroscopic labral repair patients (0.76% vs 0.52%; OR, 1.47; P < .001) had a significantly higher rate of ipsilateral carpal tunnel diagnosis versus contralateral side diagnosis. Arthroscopic RCR patients were also significantly more likely to have ipsilateral carpal tunnel injection (0.16% vs 0.11%; OR, 1.45; P < .001) and release (0.46% vs 0.37%; OR, 1.24; P < .001). Patients who had an ipsilateral carpal tunnel diagnosis following arthroscopic RCR and labral repair were both significantly older (both P < .001), a higher percentage of women (both P <.001), and more likely to have had a preoperative nerve block (both P < .05). Both cohorts had significantly higher mean Elixhauser comorbidity Index ( P < .001) and more comorbidities., Conclusions: This study demonstrated a significantly higher incidence of operative side CTS within 1 year following arthroscopic RCR and labral repairs. Arthroscopic RCR was also demonstrated to result in significantly higher rates of injections and carpal tunnel release. The cohort that developed ipsilateral CTS was older, had higher percentage of women, and had more comorbidities., Type of Study/level of Evidence: Prognostic III., (© 2023 The Authors.)

Purpose: To assess clinical outcomes of patients who have undergone surgical repair of radial meniscal tears with reinforced suture bar (rebar) technique augmented with bone marrow aspirate concentrate., Methods: This is a retrospective study of a single fellowship-trained sports medicine surgeon's experience on all patients who underwent a reinforced repair (rebar) of a radial meniscus tear from November 2016 to 2018, with a minimum of 12-month follow-up. Lysholm scores, IKDC (International Knee Documentation Committee) Subjective Knee Form scores, and Tegner scale were collected postoperatively at periods for at least 1 year and retrospectively studied., Results: Patients were followed for an average of 36.3 ± 25.0 months [range: 12.0-69.0 months]. Pain scores improved from 6.1 ± 2.1 to 0.4 ± 1.4 at 1 year ( P < .001). IKDC Subjective Knee Form scores improved from 63 ± 26 to 90 ± 13 ( P  = .021). Lysholm scores improved from 64 ± 28 to 94 ± 9 ( P  = .025). Based on a calculated minimal clinical important difference (MCID) of 1.5, 100% of patients had improvement above the MCID. In addition, 88% of patients had a 1-year IKDC Subjective Knee Form score above the patient acceptable symptomatic state. Preoperative Tegner activity scale improved from 3 ± 1.5 to 8 ± 2.6 ( P  = .007). Patients returned to their preinjury activity with little difference in the Tegner activity scale when we compared preinjury and 1-year postoperative (8.1 ± 1.3 vs 8.0 ± 2.6 respectively, P  = .317)., Conclusions: The rebar repair technique for radial meniscus tears, with bone marrow aspirate concentrate augmentation, showed improved outcomes in both pain and function at minimum follow-up of 12 months. Patients were able to return to a high preinjury activity level by 1 year, and 100% of patients had improvement above the MCID and 88% met patient acceptable symptomatic state., Level of Evidence: Level IV, therapeutic case series., (© 2023 The Authors.)

Purpose: Over the past 40 years, advances in the development of anchors and sutures have contributed to the improvement in surgical outcomes for treatment of shoulder instability. Important choices in surgery when treating instability include the use of knotless versus knotted suture anchors, and bony versus soft tissue reconstruction techniques., Methods: A literature review was conducted to evaluate the history of instability of the shoulder and the results of specific fixation techniques including bony and soft tissue reconstructions as well as knotted and knotless suture anchors., Results: As knotless suture anchors have continued to grow in popularity since their development in 2001, many studies have compared this newer technique to that of the standard knotted suture anchors. In general, these studies have demonstrated no difference in patient-reported outcome measures between the two options. Additionally, the choice of bony versus soft tissue reconstructions is patient specific as it depends on the specific pathology or combination of injuries., Conclusion: In each surgery performed for shoulder instability, it is vitally important that we try to restore normal anatomy. The normal anatomy is best established by knotted mattress sutures. However, loop laxity and tear through by the sutures in the capsule can eliminate this restoration, increasing risk of failure. Knotless anchors may allow better soft tissue fixation of the labrum and capsule to the glenoid, but without complete restoration of normal anatomy., (© 2023. The Author(s).)

Background: Many regularly prescribed classes of drugs are known to negatively impact bone health. However, it is unclear if perioperative use of these drugs impacts total shoulder arthroplasty (TSA) outcomes. The purpose of this study was to analyze the impact of perioperative use of 10 drug classes with known negative effects on bone health on prosthesis-related outcomes of TSA., Methods: Patients who underwent primary TSA were retrospectively identified in the PearlDiver database. Within this population, patients prescribed proton pump inhibitors (PPIs), thiazolidinediones (TZDs), loop diuretics, glucocorticoids, aromatase inhibitors, calcineurin inhibitors, selective serotonin reuptake inhibitors (SSRIs), antiepileptic drugs (AEDs), first-generation antipsychotics (FGAs), and second-generation antipsychotics (SGAs) within 6 months before or 6 months after primary TSA were identified (n = 23,748). These patients were propensity score matched 1:1 with controls (n = 23,748) on age, sex, and several comorbidities. After matching, patients with perioperative drug exposure were divided into 10 subgroups (ie, 1 for each drug class). Rates of prosthesis-related complications among patients taking each medication class vs. controls were compared with multivariable logistic regression., Results: Relative to controls, SGA exposure was associated with significantly higher rates of all-cause revision (odds ratio [OR] 1.68) and aseptic revision (OR 1.57). Loop diuretic exposure was associated with significantly higher rates of all-cause revision (OR 1.44) and aseptic revision (OR 1.43). Glucocorticoid exposure was associated with significantly higher rates of all-cause revision (OR 1.32) and aseptic revision (OR 1.30). SSRI exposure was associated with significantly higher rates of all-cause revision (OR 1.27) and aseptic revision (OR 1.24). Periprosthetic fracture, aseptic loosening, and septic revision was comparable for all drug cohorts compared to matched controls (all P > .05). Patients with perioperative exposure to PPIs, TZDs, FGAs, AEDs, aromatase inhibitors, and calcineurin inhibitors displayed comparable rates of all queried complications compared with controls (all P > .05)., Conclusion: Compared with matched controls, patients with perioperative exposure to SGAs, loop diuretics, glucocorticoids and SSRIs exhibited significantly higher rates of all-cause and aseptic revisions following primary TSA. Several other medications that are risk factors for osteoporosis and fragility fractures did not demonstrate significant associations with any complications, including periprosthetic fracture. These results highlight the need for a thorough review of patients' medical history and current medication usage prior to preoperative risk counseling for patients seeking TSA., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Aging causes a reduction in testosterone and estrogen, which is linked to diminished bone mineral density. Hormone replacement therapy and its effect on the outcome of joint arthroplasties is unclear. The purpose of this study was to analyze the impact of testosterone replacement therapy (TRT) and estrogen replacement therapy (ERT) on the medical and joint outcomes of total hip (THA) and total knee arthroplasties (TKA). A retrospective cohort study was conducted using the PearlDiver database. Patients who received TRT or ERT perioperatively were matched to controls. Rates of 90-day medical complications and 2-year joint complications were queried. Patients who received TRT had an increased risk of revision, periprosthetic joint infection, and pooled joint complications within 2 years following a THA and increased rates of septic and aseptic revisions, and aseptic loosening after TKA compared to the control cohort. Patients receiving ERT had increased rates of aseptic loosening and pooled joint complications within 2 years following THA and increased rates of all-cause revisions and pooled joint complications after TKA. Patients who received TRT demonstrated significantly higher rates of revision rates and PJI. Patients who received perioperative ERT were significantly more likely to have increased risks of revision rates and joint infections.

Background: After failed nonoperative treatment, unicompartmental osteoarthritis can be treated surgically by either unicompartmental knee arthroplasty (UKA) or high tibial osteotomy (HTO). The purpose of this retrospective study is to analyze utilization and demographic trends of UKA and HTO relative to total knee arthroplasty (TKA) over the past decade., Methods: A retrospective review was conducted using the PearlDiver database. Patients that received a UKA or HTO were identified. Trend analyses of surgical procedure utilization were performed with the Mann-Kendall trend test. Demographic data and the rates of various comorbidities were also queried., Results: A total of 103,465 UKAs, 2183 HTOs, and 1,413,425 TKAs, between 2010 and 2021 quarter 1, were analyzed. Trend analyses revealed that relative to TKA utilization, UKA utilization significantly increased ( P < .001) while HTO utilization significantly decreased ( P < .001). The compound annual growth rate of UKA utilization relative to TKA was +5.16% from 2010 to 2017 but was -10.61% from 2018 to 2021, while that of HTO relative to TKA was -9.69% from 2010 to 2021. Demographic analyses demonstrated the UKA cohort (63.1) was significantly older than the HTO cohort (46.5) ( P < .001). Additionally, there were significantly more female patients who underwent UKA than HTO ( P < .001)., Conclusions: The present study demonstrated that relative to TKA, UKA utilization increased from 2010 to 2017, with a subsequent decrease afterward, whereas HTO utilization decreased since 2010. Demographic differences exist between the 2 operations, with HTOs more commonly performed in younger male patients, and UKAs in older female patients., Level of Evidence: Level III., (© 2023 The Authors.)

Background: It is unclear if hepatitis C virus (HCV) negatively impacts outcomes of revision total hip arthroplasty (rTHA). The purpose of this study is to trend recent rTHA utilization in patients who have HCV and compare postoperative complication rates versus a matched cohort., Methods: All patients who underwent rTHA were retrospectively identified in a national database. Patients who had HCV (n = 1,746) were matched 1:3 with a matching group (n = 5,238) for age, gender, and several comorbidities. Cochran-Armitage tests were used to analyze trends in the annual proportion of rTHA performed in patients who had HCV from 2010 to 2019. Rates of 90-day medical and prosthesis-related complications within 2 years postoperatively were compared with multivariable logistic regressions., Results: The annual proportion of rTHA performed in patients who had HCV significantly increased from 2010 to 2019 (P < .001). Patients who had HCV exhibited significantly higher rates of acute kidney injuries (7.6% versus 4.4%; odds ratio [OR] 1.50), transfusions (20.6% versus 14.6%; OR 1.38), and re-revisions for prosthetic joint infection (10.9% versus 6.5%; OR 1.73). In subgroup analyses, rates of re-revision for prosthetic joint infection after initial aseptic rTHA (7.1% versus 3.8%; OR 1.82) and periprosthetic fracture after initial septic rTHA (4.5% versus 1.6%; OR 2.77) were significantly higher in the HCV cohort., Conclusion: Similar to primary THA, patients who have HCV exhibit significantly increased complication rates after rTHA. With growing utilization in recent years, these data suggest that this population will comprise an increasingly larger proportion of rTHA procedures performed in the coming years., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The association between tendon damage and fluoroquinolone (FQ) antibiotics has been well documented. However, there is limited data evaluating the impact of postoperative FQ use on outcomes of primary tendon repairs. The purpose of this study was to compare rates of reoperation for patients with FQ exposure after primary tendon repair versus controls., Methods: A retrospective cohort study was conducted using the PearlDiver database. All patients who underwent primary repair of distal biceps ruptures, Achilles tendon ruptures, and rotator cuff tears were identified. For each tendon, patients who were prescribed FQs within 90 days postoperatively were propensity score matched at a 1:3 ratio with controls without postoperative FQ prescriptions across age, sex, and several comorbidities. Rates of reoperation were compared at two years postoperatively with multivariable logistic regression., Results: A total of 124,322 patients who underwent primary tendon procedures were identified, including 3,982 (3.2%) patients with FQ prescriptions within 90 days postoperatively: 448 with distal biceps repair, 2,538 with rotator cuff repair, and 996 with Achilles tendon repair. These cohorts were matched with 1,344, 7,614, and 2,988 controls, respectively. Patients with postoperative FQ prescriptions exhibited significantly higher rates of revision surgery after primary repair of distal biceps ruptures (3.6% vs. 1.7%; OR 2.13; 95% CI, 1.09-4.04), rotator cuff tears (7.1% vs. 4.1%; OR 1.77; 95% CI, 1.48-2.15), and Achilles tendon ruptures (3.8% vs. 1.8%; OR 2.15; 95% CI, 1.40-3.27)., Conclusion: Patients with FQ prescriptions within 90 days after primary tendon repair demonstrated significantly higher rates of reoperations for distal biceps, rotator cuff, and Achilles tendon repair at two years postoperatively. To achieve optimal outcomes and avoid complications in patients following primary tendon repair procedures, physicians should consider prescribing alternative non-FQ antibiotics and counsel patients on the risk of reoperation associated with postoperative FQ use., Competing Interests: All authors report no disclosures or conflicts of interest.

Background: From 1999 to 2011, studies demonstrated an increasing trend toward surgical management of adolescent clavicle fractures. The purpose of this study was to examine more recent trends of surgical management of closed clavicle fractures in adolescent patients over the past decade., Methods: A retrospective cohort study was conducted using the PearlDiver database. Patients with clavicle fractures from 2011 to 2021 were identified and stratified by age, sex, and year of their fracture. Categorical variables were compared with a chi square test, and continuous variables were compared with the Welch t test or Mann-Whitney U test., Results: Overall, there was a significant increase in the percentage of patients surgically treated by open reduction and internal fixation from 2016 to 2021 compared with 2011 to 2015 (8.58% vs. 7.34%, P < 0.001). When stratified by age, both the 10 to 14-year group (3.80% vs. 3.10%, P < 0.001) and the 15 to 18-year group (15.41% vs. 12.84%, P < 0.001) demonstrated significant increases in the percentage of patients surgically treated., Conclusion: Despite increasing literature demonstrating high revision surgery rates for surgical treatment of adolescent clavicle fractures with no difference in functional outcomes, this study demonstrated a notable increase in the rate of surgical treatment of adolescent clavicle fractures from 2011 to 2021 in the United States., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background: It is unclear how epilepsy may affect total joint arthroplasty outcomes. The purpose of this study is to analyze the impact of epilepsy on prosthesis-related complications following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA)., Methods: A retrospective cohort study was conducted using a national database. Patients who have epilepsy underwent a primary THA (n = 6,981) and TKA (n = 4,987) and were matched 1:4 (THA, n = 27,924; TKA, n = 19,948). Rates of low-energy falls and prosthesis-related complications within 2 years postoperatively were compared for patients who did and did not have epilepsy with multivariable logistic regression., Results: After primary TKA, patients who have epilepsy exhibited significantly higher rates of aseptic revision (4.3% versus 3.5%, odds ratio [OR] 1.21, P = .017) and revision for prosthetic joint infection (1.8% versus 1.3%, OR 1.29, P = .041). THA patients who have epilepsy exhibited significantly higher rates of prosthetic dislocation (3.2% versus 1.9%, OR 1.54, P < .001), periprosthetic fracture (2.2% versus 0.8%, OR 2.39, P < .001), and aseptic loosening (1.7% versus 1.1%, OR 1.40, P = .002). Rates of low-energy falls within 2 years after TKA (14.1% versus 6.4%, OR 2.19, P < .001) and THA (33.6% versus 7.5%, OR 5.95, P < .001) were also significantly higher for patients who have epilepsy., Conclusion: Epilepsy was associated with significantly higher rates of falls (P < .001) and prosthesis-related complications after primary THA (P < .05) and TKA (P < .05). Precautions should be implemented in this population during intraoperative and perioperative decision-making to reduce complication risk., Level of Evidence: Level III., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: The purpose of this study was to examine whether previous lumbar spinal fusion (LSF) was an independent risk factor for complications in patients undergoing total hip arthroplasty (THA) or hemiarthroplasty for displaced femoral neck fractures., Methods and Materials: An administrative database was queried from 2010 to Q2 of 2019 to analyze and compare complications in patients undergoing either THA or hemiarthroplasty for femoral neck fracture with a history of LSF versus no history of LSF. Joint complications including periprosthetic fracture, prosthetic joint infection (PJI), prosthetic joint dislocation (PJD), aseptic loosening, and prosthetic revision were examined at 90 days and 1 year post-operatively., Results: In the THA cohort, patients with prior LSF had significantly higher likelihood of aseptic loosening at 90 days and 1 year post-operatively in comparison to those without prior LSF (90-day: OR 2.22; 1-year: OR 1.95). Patients in the hemiarthroplasty cohort with prior LSF had significantly higher likelihood of PJI (90-day: OR 2.18; 1-year: OR 2.37), aseptic loosening (90-day: OR 3.42; 1-year: OR 4.68), and prosthetic revision (90-day: OR 2.27; 1-year: OR 2.25) in both the 90-day and 1-year postoperative period in comparison to those without prior LSF. Additionally, for the same cohort, periprosthetic fracture (1-year: OR 2.32) and PJD (1-year: OR 2.31) were significantly higher at 1-year postoperative., Conclusion: Presence of LSF was found to be an independent risk factor for increased joint complications in patients undergoing either a THA or hemiarthroplasty for displaced femoral neck fractures., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Aims: This studied aimed to compare rates of reoperation for patients who received primary ankle arthrodesis (AA) versus total ankle replacement (TAR) for posttraumatic indications between 2010 and 2016 Q2 using a nationwide claims database., Methods: A retrospective cohort study analyzing patients who received primary AA or TAR for posttraumatic indications was performed using PearlDiver. Reoperations assessed included prosthetic joint infection (PJI), hardware removal, adjacent joint fusion, and local open reduction internal fixation (ORIF). Multivariable logistic regression was used to compare rates of reoperations at 1 and 2 years postdischarge., Results: A total of 862 (74%) patients received AA and 318 (26%) patients underwent TAR for a posttraumatic indication. At 1 year, 305 (35.4%) AA patients had at least 1 reoperation compared with 55 (17.3%) TAR patients (OR 2.32; 95% CI, 1.68-3.26). At 2 years, 364 (42.2%) AA patients and 66 (20.8%) TAR patients had at least 1 reoperation (OR 2.51; 95% CI, 1.84-3.45). ORIF, hardware removal, and adjacent joint fusions were more likely for AA patients at both time intervals (all P s < .05)., Conclusion: Patients who received primary AA for posttraumatic indications exhibited higher rates of major reoperations in the short to medium term compared with patients who underwent TAR., Levels of Evidence: Level III: Retrospective cohort study.

Background: It was estimated that up to 30,000 primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures would be cancelled each week during the moratorium on elective surgeries in the United States. The purpose of this study was to analyze the impact of the COVID-19 pandemic on elective total joint arthroplasty utilization in the United States., Methods: A retrospective study was conducted using the PearlDiver database. Patients who underwent primary elective THAs and TKAs were identified and filtered by state and month from January through September of both 2019 and 2020. The volume of these procedures immediately following the moratorium on elective surgeries was compared to that of the same months the previous year., Results: For THA, overall, there was a 27.39% reduction in volume from 2019 to 2020 in March and an 88.94% reduction in April. For TKA, overall, there was a 31.28% reduction in volume in March and a 96.61% reduction in April. When the states were separated into 2 cohorts by the 2020 presidential election vote, there was a significantly larger decrease in THA and TKA volume observed in the 25 states and Washington DC that voted democrat than that in the 25 states that voted republican in both March ( P < .05) and April ( P < .05). Both THA (118.29%) and TKA (101.02%) volume returned to prepandemic levels by June., Conclusions: Overall, this study demonstrated that elective total joint arthroplasty utilization did reduce as anticipated following the CMS moratorium on elective surgeries but quickly returned to prepandemic levels by June., Level of Evidence: Level III., (© 2022 Published by Elsevier Inc. on behalf of The American Association of Hip and Knee Surgeons.)

Ligamentous Lisfranc injuries, which mimic a surgical transection are rare. Left untreated or missed, these injuries may result in severe complications including long-term disability. The present case describes a unique mechanism of injury via a sharp object puncture through the plantar surface of the midfoot. It highlights the utility of planning staged procedures to remove a large foreign body object, reports notable intraoperative techniques, and provides a decision management guide for treating this type of injury. Extensive surgical planning may be required when encountering similar cases and knowledge of this may be useful to providers., Competing Interests: All conflicts of interest have been identified, and there has been no significant financial support or funding for this work that could have influenced its outcome.

Case: Pseudogout in a total joint arthroplasty is rare and can be difficult to distinguish from a prosthetic joint infection (PJI). In this unique case, we present a patient who developed her first episode of pseudogout 17 years after her primary total knee arthroplasty at age 75., Conclusion: With similar clinical and laboratory findings, it is important to distinguish the presence of PJI and inflammatory arthropathy. The use of diagnostic tools available, consideration of patient co-morbidities, and timing of symptoms can help guide surgeons' treatment.

Introduction: The 2015 change in the American College of Rheumatology (ACR) guidelines narrowed indications for initiating treatment with biologic disease-modifying antirheumatic drugs (bDMARDs) in patients with rheumatoid arthritis (RA). This study sought to evaluate trends in total joint arthroplasty (TJA) in patients with RA and to characterize the effect of bDMARDs on arthroplasty risk in this population after the change in ACR treatment guidelines., Methods: A retrospective review was conducted using the PearlDiver database. TJA procedures included total shoulder arthroplasty, total elbow arthroplasty, total hip arthroplasty, and total knee arthroplasty. The Cochran-Armitage Trend Test was used to evaluate trends in the volume of TJA procedures conducted in patients with RA between 2010 and 2019. Logistic regression was used to compare 2-year arthroplasty risk after an initial joint-specific RA International Classification of Diseases 10th Revision diagnosis for RA patients with versus without bDMARD exposure., Results: A total of 2,942,360 patients with RA were identified, and 80,744 (2.74%) underwent TJA between 2010 and 2019. Rates of TJA procedures trended significantly upward over the decade (2.6% versus 5.1%, P < 0.001) with a sharp increase between 2015 and 2016 (2.1% versus 4.9%, P < 0.001). Among the 16,736 identified patients with an initial International Classification of Diseases 10th Revision joint-specific RA diagnosis, 3362 patients (20.09%) were treated with bDMARDs and 13,374 (79.91%) were not. Untreated patients exhibited significantly lower risk of any TJA (5.92% versus 7.73%; odds ratio [OR]: 0.72; 95% confidence interval [CI]: 0.64 to 0.82), total hip arthroplasty (OR: 0.69, 95% CI: 0.50 to 0.95), and total knee arthroplasty (OR: 0.63, 95% CI: 0.52 to 0.75) compared with treated patients., Discussion: The volume of TJA procedures conducted in patients with RA has trended markedly upward over the past decade, with a sharp increase after 2015. bDMARD treatment was associated with markedly increased risk of TJA, likely because of initiation of bDMARDs in only those patients with advanced disease per ACR guidelines., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background: The United States has been facing a worsening opioid epidemic over the past two decades. The veteran population represents a large and vulnerable group with a higher burden of mental health comorbidities. The purpose of this study was to analyze the impact of lumbar spine surgery on postoperative opioid usage in the United States veteran population., Methods: A retrospective cohort study was conducted using the Veterans Affairs Informatics and Computing Infrastructure database. Patients who underwent lumbar spine surgery were stratified into three groups by their preoperative opioid claims within 365 days of surgery. Postoperative cumulative morphine milligram equivalents (MME) were tracked for each group and the paired Wilcoxon signed rank test was used to compare cumulative preoperative MME (days -365-0) to cumulative postoperative MME (days 91-455)., Results: At one year, 30.6% of patients in the high preoperative opioid group and 73.1% of patients in the low preoperative opioid group were no longer using opioids. In the opioid naive cohort, 10.0% of patients were still using opioids at one year. Among all patients, median cumulative postoperative MME was significantly less than median cumulative preoperative MME (P<0.001). High preoperative opioid usage of more than 3 claims was most significantly associated with continued postoperative opioid usage (odds ratio 12.55, P<0.001). From 2010 to 2020 the proportion of patients with preoperative opioid claims decreased (58.8% to 34.8%)., Conclusions: In the veteran population, lumbar spine surgery was effective in getting 50% of patients who were on opioids preoperatively to discontinue opioids postoperatively. Even minimal exposure to opioids preoperatively resulted in a 2.69-time increase in risk of being on opioids at one year versus opioid naive patients. This study affirms that despite being a high-risk population, the veteran population has a similar response to lumbar spine surgery as the general population in regards to opioid dependence., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-22-50/coif). MC is a paid speaker for Medtronic, Stryker and ATEC. The other authors have no conflicts of interest to declare., (2022 Journal of Spine Surgery. All rights reserved.)

Objective: The sequalae of mild concussions continue to emerge with increased awareness in sports-related injuries. This study aimed to quantify the number of patients who are affected by a mental illness within 3 yrs of a concussion and identify whether demographic differences exist that may influence a mental illness diagnosis., Design: Using a nationwide database, data were queried for a diagnosis of concussion, capturing patients aged 18-45 yrs with no previous mental illness, and then identified if these patients were diagnosed with a mental illness within 3 yrs of their concussion. The mental illnesses specifically chosen for this study included depression, anxiety, panic disorder, posttraumatic stress disorder, bipolar, and schizophrenia., Results: Within 3 yrs after a concussion, 48% of patients were later diagnosed with a mental illness. All of the mental illnesses this study chose to evaluate were present in a higher proportion of patients after a concussion than the general population., Conclusions: The mechanism between concussions and mental illness remains unclear. A large proportion of patients who experience a concussion are later diagnosed with a mental illness within 3 yrs. Patients with a history of a previous concussion may benefit from screening for the development of a mental illness., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Surgeons are familiar with the complication rates and risks of knee arthroscopy, but comparative data between hip arthroscopy and knee arthroscopy are lacking., Purpose: To compare complications in knee arthroscopy, the most common arthroscopic procedure, with those in hip arthroscopy., Study Design: Cohort study; Level of evidence, 3., Methods: A retrospective matched-cohort study analyzing patients who received a primary hip or knee arthroscopy was performed using the PearlDiver database. A total of 19,735 patients were identified for each cohort. Systemic complications and readmissions were assessed at 3 months postoperatively. Local complications and reoperations were assessed at 6 months, 12 months, and 24 months postoperatively. All categorical variables were compared using chi-square analysis., Results: Hip arthroscopy had significantly higher rates of nerve injury, stiffness, heterotopic ossification, and avascular necrosis (all P < .001) than knee arthroscopy at all observed time periods postoperatively. Hip arthroscopy also had a greater rate of all local joint complications than knee arthroscopy (16.79% vs 11.80%; P < .001). Knee arthroscopy was found to have higher incidences of deep vein thrombosis (0.98% vs 0.66%; P < .001) and myocardial infarction (0.06% vs 0.00%; P < .001) as well as a higher overall systemic complication rate (3.93% vs 3.44%; P = .013). Hip arthroscopy was found to have higher rates of subsequent arthroscopy, arthroplasty, and overall reoperation when compared with knee arthroscopy (11.99% vs 14.99%; P < .001) at all time periods up to 24 months postoperatively., Conclusion: Although the systemic complication rate was higher in knee arthroscopy, local joint complications, reoperation, and total complication rates were higher for hip arthroscopy. Surgeons should be aware of these potential differences to best discuss and mitigate risks with this expanding patient population., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: W.F.S. has received honoraria from Encore Medical. W.M.R.H. has received hospitality payments from Smith & Nephew. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2022.)

Background: It is unclear if hepatitis C (HCV) negatively impacts outcomes of revision total knee arthroplasty (rTKA). The purpose of this study was to compare complication rates after rTKA for patients with HCV vs matched controls., Methods: A retrospective cohort study was conducted using the PearlDiver database (PearlDiver Inc., Colorado Springs, CO). Patients with HCV who underwent rTKA (n = 1448) were matched 1:4 with controls (n = 5792) on age, sex, and several comorbidities. Rates of medical complications within 90 days and prothesis-related complications within 2 years postoperatively were compared with logistic regression for (1) patients with vs without HCV and (2) HCV patients who underwent aseptic vs septic rTKA., Results: Relative to controls, patients with HCV exhibited significantly higher rates of medical complications (27.7% vs 20.9%; odds ratio [OR] 1.47), periprosthetic fractures (2.3% vs 1.1%; OR 2.20), all-cause repeat rTKA (11.7% vs 9.4%; OR 1.29), and repeat rTKA for prosthetic joint infection (PJI) (6.7% vs 3.6%; OR 1.92). Within the HCV cohort, HCV patients with initial septic rTKA exhibited significantly higher rates of medical complications (41.7% vs 22.7%; OR 2.39), all-cause subsequent rTKA (15.9% vs 10.2%; OR 1.67), and repeat rTKA for PJI (15.9% vs 3.4%; OR 5.39). Conversely, HCV patients with initial aseptic rTKA exhibited significantly higher rates of aseptic loosening (2.6% vs 7.4%; OR 0.33)., Conclusions: Patients with HCV exhibited significantly higher rates of medical and prosthesis-related complications after rTKA than controls. Among patients with HCV, initial septic rTKA was associated with significantly higher rates of medical complications, repeat rTKA, and PJI., (© 2022 The Authors.)

Background: Non-compete clauses (NCC) are commonly required for physicians practicing in an employed model. With growing pressures driving surgeons to practice in an employed model instead of physician-led practices, the purpose of this survey was to determine the impact of NCCs on orthopaedic surgeons and their patients in Louisiana., Methods: A voluntary, single-mode online survey containing 23 questions was created using the Qualtrics XM Platform (Qualtrics, Provo, UT) and distributed to 259 orthopaedic surgeons who are members of the Louisiana Orthopaedic Association. Survey questions assessed the prevalence and details of existing NCCs and perceptions of their impact on surgeons' practice, patients, and personal life., Results: 117 members responded (response rate: 45.2%), of which 91 (77.8%) finished the survey. Nearly half (44%) of respondents had an expired or active NCC in their contract. Most (84.3%) believed NCCs give employers unfair leverage during contract negotiations. NCCs have deterred or would deter 71.4% of respondents from accepting another job offer. Respondents believed NCCs negatively impact patients, including forcing patients to drive long distances to maintain continuity of care (64.4%) and forcing surgeons to abandon their patients if they seek new employment (76.7%). Many respondents reported NCCs also exert significant detrimental effects on their personal life, including mandatory relocation of their family (67.0%). Nearly all (97.8%) believed such clauses have become unreasonable over the last decade with the rise of large hospital conglomerates. Most surgeons (83.7%) believed that removal of NCCs from all orthopaedic surgeons' contracts would improve the overall healthcare of orthopaedic patients in Louisiana., Conclusion: Perceptions of NCCs were overwhelmingly negative among orthopaedic surgeons in Louisiana. Such clauses give employers an unfair advantage during contract negotiations and exert a significant detrimental impact on surgeons and their patients. While NCCs may be reasonable in the business sector and other professions, it is unclear how such clauses benefit surgeons or improve patient care and may be detrimental to both., Study Design: Cross-sectional Survey., Competing Interests: All conflicts of interest have been identified, and there has been no significant financial support or funding for this work that could have influenced its outcome.

Background: Hip arthroscopy (HA) procedures have increased exponentially in recent years. Their effect on outcomes after subsequent total hip arthroplasty (THA) remains unclear., Purpose: To compare rates of complications and opioid claims after elective THA among patients with prior HA versus controls., Study Design: Cohort study; Level of evidence, 3., Methods: Patients who underwent THA were identified in the PearlDiver database. Arthroplasty performed for hip fractures and hip avascular necrosis were excluded. Within this population, patients with HA before arthroplasty (n = 3156) were propensity score matched 1:1 with controls on age, sex, US region, and several comorbidities. Rates of medical complications within 90 days and prosthesis-related complications within 2 years were queried. The number of patients with an opioid claim within 0 to 30 days and subsequent opioid claim(s) during the 90-day global period were obtained to assess rates of prolonged opioid use after arthroplasty. Rates of postoperative complications and opioid claims were compared using logistic regression., Results: Patients with prior HA exhibited significantly lower rates of readmission (5.6% vs 7.3%; odds ratio [OR], 0.72), pulmonary embolism (0.2% vs 0.6%; OR, 0.45), urinary tract infection (3.1% vs 4.0%; OR, 0.75), and blood transfusion (3.6% vs 6.1%; OR, 0.55). The prior HA cohort also exhibited a significantly lower rate of prosthetic joint infection at 1 year postoperatively (0.6% vs 1.3%; OR, 0.50). Rates of dislocation, periprosthetic fracture, mechanical complications, and aseptic revision arthroplasty were statistically comparable between the cohorts within 2 years. The prior HA cohort was significantly less likely to file persistent opioid claims after 30 days postoperatively, including between 31 and 60 days (27.2% vs 33.1%; OR, 0.74) and 61 to 90 days (16.2% vs 20.9%; OR, 0.71)., Conclusion: After elective THA, patients with prior HA exhibited significantly lower rates of medical complications and prolonged opioid claims within 90 days and prosthetic joint infection at 1 year. Rates of all other prosthesis-related complications within 2 years were statistically comparable., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: A.A.M. has received education payments from Medinc and hospitality payments from Organogenesis and Stryker. W.F.S. has received honoraria from Encore Medical. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2022.)

Background: While many studies have demonstrated increased complication risk after total joint arthroplasty in patients with inflammatory bowel disease, it is unclear if celiac disease is associated with similarly increased risk. The purpose of this study was to analyze if celiac disease is associated with increased postoperative complications following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA)., Methods: A retrospective cohort study was conducted using the PearlDiver database. Patients with celiac disease who underwent THA (n = 1701) and TKA (n = 3515) were matched 1:3 with controls (THA, n = 5103; TKA, n = 10,545) on age, sex, year of arthroplasty, diabetes mellitus, tobacco use, and obesity. Rates of medical complications within 90 days and joint complications including revision arthroplasty, prosthetic joint infection, periprosthetic fracture, and aseptic loosening within 2 years postoperatively were queried. Complication rates were compared for patients with celiac disease vs controls with multivariable logistic regression., Results: After primary THA, patients with celiac disease exhibited significantly higher rates of acute myocardial infarction within 90 days (2.7% vs 1.9%; odds ratio 1.45; 95% confidence interval 1.01-2.07) and periprosthetic fractures at 2 years postoperatively (1.1% vs 0.5%; odds ratio 2.09; 95% confidence interval 1.14-3.79) than controls. Following primary TKA, patients with celiac disease exhibited higher but statistically comparable complication rates than controls (all P > .05)., Conclusions: Celiac disease was associated with significantly higher rates of acute myocardial infarction and periprosthetic fracture after primary THA. Complication rates after primary TKA were similar between the cohorts., Level of Evidence: Level III., (© 2022 The Authors.)

This study highlights the persistent osteoporosis treatment gap following fragility fractures. Patients with multiple sclerosis sustained more primary hip fractures than controls and exhibited significantly higher rates of falls within three years post-fracture. However, multiple sclerosis (MS) patients were significantly more likely to be diagnosed with osteoporosis and treated with medications., Introduction: The purpose of this study was to compare rates of osteoporosis management, falls, and secondary fractures following primary fragility fractures among patients with MS versus matched controls., Materials and Methods: A retrospective matched cohort study was conducted using the PearlDiver database. Patients aged ≥ 50 years with primary fragility fractures were identified (n = 120,368). Within this population, patients with MS were matched 1:10 with controls across age, sex, and US region. Rates of osteoporosis diagnoses and pharmacologic treatment, low-energy falls, and secondary fragility fractures were compared at three years post-fracture via logistic regression., Results: A total of 1,232 patients with MS (mean age, 65.7 years) with primary fragility fractures were matched with 12,320 controls (mean age, 65.8 years). Primary hip fractures were significantly more common in the MS cohort (47.4% vs. 34.2%, p < 0.001). After the initial fracture, patients with MS were significantly more likely to receive a formal osteoporosis diagnosis (12.9% vs. 9.7%; OR 1.35; 95% CI, 1.13-1.61) and osteoporosis pharmacotherapy (14.4% vs. 11.9%; OR 1.24; 95% CI, 1.04-1.46). The MS cohort also exhibited significantly higher rates of falls (27.8% vs 22.7%; OR 1.15; 95% CI, 1.01-1.32). Rates of secondary fractures were comparable (6.3% vs. 5.0%; OR 1.10; 95% CI, 0.85-1.40)., Conclusion: Primary hip fragility fractures were significantly more common in patients with MS compared to matched controls. Following an initial fracture, patients with MS exhibited a significantly higher rate of falls but were more likely to be diagnosed with osteoporosis and treated with medications., (© 2022. International Osteoporosis Foundation and National Osteoporosis Foundation.)

Morbidity and mortality related to opioid use has generated a public health crisis in the United States. Total knee arthroplasty (TKA) is an increasingly common procedure and is often accompanied by post-operative opioid utilization. Unfortunately, post-operative opioid usage after TKA has been shown to lead to higher rates of complications, longer hospital stays, increased costs, and more frequent need for revision surgery. Pre-operative opioid utilization has been shown to be one of the most important predictors of post-operative opioid usage. Additional risk factors for continued post-operative opioid utilization after TKA include pre-operative substance and tobacco use as well as higher post-operative prescription dosages, younger age, female gender, and Medicaid insurance. One method for mitigating excessive post-operative opioid utilization are Enhanced Recovery After Surgery (ERAS) protocols, which include a multidisciplinary approach that focuses on perioperative factors to optimize patient recovery and function after surgery. Additional strategies include multimodal pain regimens with epidural anesthetics, extended duration local anesthetics and adjuvants, and ultrasound guided peripheral nerve blocks. In recent years, opioid prescribing duration limitations have also been put into place by state and federal government, hospital systems, and ambulatory surgery centers making effective acute pain management imperative for all stakeholders. In this regard, as rates of TKA continue to increase across the United States, multidisciplinary efforts by all stakeholders are needed to ensure adequate pain control while preventing the negative sequalae of opioid medications., Competing Interests: No relevant disclosures

Femoroacetabular impingement (FAI) is a chronic hip condition caused by femoral head and acetabular malformations resulting in abnormal contact across the joint. FAI often leads to labral, cartilaginous, and tissue damage that predispose this patient population to early osteoarthritis (OA). There are a variety of factors that increase the risk for FAI including younger age, Caucasian background, familial FAIS morphology, and competing in high-intensity sports during adolescence. Slow-onset, persistent groin pain is the most frequent initial presenting symptom. On physical examination, patients will typically have a positive FADIR test (flexion, adduction, internal rotation), also known as a positive impingement sign. FAI syndrome can be organized into three classifications; cam, pincer, or mixed. This classification refers to the characteristic morphological changes of the bony structures. The primary imaging modality for diagnosing FAI is a plain radiograph of the pelvis, which can be used to measure the alpha angle and the lateral center edge angle used to quantify severity. Conservative treatment is typically considered first-line treatment for mild to moderate FAI syndrome; however, the outcomes following postoperative surgical intervention have demonstrated excellent results. The most common surgical treatment option for FAI is done arthroscopically.

Background: Hepatitis C virus (HCV) is associated with increased complications of risk after arthroplasty. The purpose of this study was to examine the impact of HCV and a pre-arthroplasty antiviral treatment on complications following total shoulder arthroplasty (TSA)., Methods: A retrospective matched cohort study was conducted using an administrative claims database. Patients who underwent TSA were identified with Current Procedural Terminology -23472 and International Classification of Diseases procedural codes. A total of 1244 HCV patients were matched 1:3 with 3732 noninfected controls across age, sex, diabetes mellitus, tobacco use, and obesity. The HCV patients with treatment before TSA were identified by claims containing antiviral drug codes. Multivariable logistic regression was used to compare rates of 90-day medical complications and prosthesis-related complications within 2 years postoperatively for (1) HCV patients vs. controls, (2) antiviral-treated HCV patients vs. controls, and (3) antiviral-treated HCV patients vs. untreated HCV patients., Results: Patients with HCV exhibited significantly higher rates of blood transfusion (OR 2.12), acute kidney injuries (OR 1.86), inpatient readmission (OR 2.06), revision TSA (OR 1.48), dislocation (OR 1.92), mechanical complications (OR 1.39), and prosthetic joint infection (OR 1.53) compared to controls. Antiviral-treated HCV patients exhibited a significantly lower rate of myocardial infarction (OR 0.27) and comparable rates of all other complications relative to controls (all P  > .05). Compared to untreated HCV patients, antiviral-treated HCV patients exhibited significantly lower rates of 90-day medical complications (OR 0.57) and prosthetic joint infection (OR 0.36)., Conclusions: HCV is associated with significantly increased complication rates after TSA. Antiviral treatment before TSA may reduce the risk of postoperative complications., (© 2022 The Author(s).)

Objective: With the use of anterior cervical discectomy and fusion (ACDF) expected to rise by 13.3% from 2020 to 2040, the increased usage of interbody cages with integral anterior fixation prompted a Centers for Medicare & Medicaid Services (CMS) review, which resulted in coding changes affecting anterior instrumentation documentation. CMS determined that Current Procedural Terminology (CPT) code 22845 should not be used to report integrated instrumentation (plate) with an interbody device, and if additional anterior instrumentation (e.g., plates and screws) is placed with an integrated interbody device, then a 59 modifier should be used. There is sparse literature examining the trends of ACDF without and with additional anterior instrumentation after the 2015 CMS audit. Therefore, this study aimed to evaluate the trends of single-level subaxial ACDF utilization from 2011 to 2019 to determine whether the 2015 CMS audit influenced the documented usage of additional anterior instrumentation., Methods: A retrospective cohort study was performed using the commercially available database PearlDiver. Patient records were queried from 2011 to 2019 for single-level subaxial ACDF without (CPT code 22551) and with (CPT codes 22551 + 22845) instrumentation. Cochran-Armitage trend analyses were performed to evaluate the hypothesis that ACDF with additional anterior instrumentation decreased over the given time period., Results: Between 2011 and 2019, the total number of single-level ACDFs decreased from 6202 to 4402. From 2011 to 2015, an average of 6240 patients per year underwent single-level subaxial ACDF; of those, 950 patients (15.2%) had ACDF without instrumentation and 5290 patients (84.8%) had ACDF with instrumentation. In 2016, the total number of single-level subaxial ACDFs decreased to 5525, with 1006 patients (18.2%) receiving no instrumentation and 4519 patients (81.8%) receiving instrumentation. From 2017 to 2019, an average of 4283 patients per year underwent a single-level subaxial ACDF; of these, 1280 (29.9%) had no instrumentation and 3003 (70.1%) had instrumentation (all p < 0.0001)., Conclusions: From 2015 to 2019, single-level ACDF without instrumentation significantly increased by 91.5% and ACDF with anterior instrumentation significantly decreased by 18.1%. The 2015 CMS audit of interbody cages and anterior instrumentation coding (CPT code 22845) may account for the decreased documentation of anterior instrumentation in the 9-year period. Understanding CMS auditing could help surgeons perceive changes in practice patterns that may lead to a more thorough evaluation of patient outcomes, cost, and overall value.