BACKGROUND:The purpose of this study was to identify the incidence and risk factors associated with surgical site infection (SSI) after open reduction and internal fixation of bimalleolar ankle fractures. Bimalleolar ankle fractures are one of the most common subtypes of ankle fractures, accounting for 15% to 20% of all ankle fractures. Recent studies have shown that 4.37% of patients undergoing ORIF of ankle fractures develop an SSI postoperatively. The literature detailing the risk factors for the development of SSI after open reduction and internal fixation (ORIF) of bimalleolar ankle fractures is sparse. Therefore, the purpose of this study was to determine the risk factors that predispose patients to SSI after the index procedure. METHODS:Patients who underwent bimalleolar ankle fracture repair between January 1, 2010, and December 31, 2021, were identified using the PearlDiver Mariner Database. Demographics and comorbidities between SSI and non-SSI cohorts were compared through chi-square analysis. Multivariate logistic regression was used to analyze risk factors for SSIs. A P value less than 0.001 was determined to be statistically significant. RESULTS:The incidence of SSI after ORIF of bimalleolar ankle fractures was 3.1%. Age, sex, and a higher total Elixhauser Comorbidity Index were associated with an increased incidence of SSI ( P < 0.0001). Risk factors for the development of SSI included male sex (OR = 1.17; P < 0.0001), chronic kidney disease (odds ratio [OR] = 1.233; P < 0.001), diabetes (OR = 1.27; P < 0.0001), drug abuse (OR = 1.22; P < 0.0001), fluid and electrolyte disorders (OR = 1.42; P < 0.0001), hypertension (OR = 1.29; P < 0.0001), peripheral vascular disease (OR = 1.62; P < 0.0001), tobacco use (OR = 1.25; P < 0.0001), and weight loss (OR = 1.25; P < 0.0001). Peripheral vascular disease was the most highly correlated risk factor for the development of SSIs in this study. CONCLUSIONS:These findings underscore the importance of preoperative risk stratification and optimization to minimize SSIs in this population. This is the first study to delineate the risk factors for the development of SSI in patients undergoing ORIF for bimalleolar ankle fractures. Physicians can use these results to counsel patients before undergoing the index procedure to minimize postoperative infections. LEVELS OF EVIDENCE:IV.

BACKGROUND: Vertebral compression fractures (VCFs) are typically treated nonoperatively but can be treated with either kyphoplasty or vertebroplasty when indicated. The decision to treat patients with/without surgical intervention is dependent on the severity of deformity and patient risk profile. The aims of this study were to: 1) compare baseline patient demographics, 2) identify risk factors of patients undergoing operative vs. nonoperative management, and 3) identify patient-specific risk factors associated with postoperative readmissions METHODS: This retrospective database study used patient information from January 1st, 2010, to October 31st, 2021. Cohorts were identified by patients diagnosed with VCFs through International Classification of Disease, Ninth Revision (ICD-9), ICD-10 codes, identifying those undergoing kyphoplasty/vertebroplasty via Current Procedural Terminology codes. The 2 research domains utilized in this investigation were baseline demographic profiles of patients who underwent kyphoplasty or vertebroplasty for treatment of VCFs, and those who underwent nonoperative management served as the control cohort. RESULTS: Of the 703,499 patients diagnosed with VCFs, 76,126 patients (10.8%) underwent kyphoplasty or vertebroplasty within 90 days of diagnosis of a VCF. Univariate analysis demonstrated female sex was associated with increased risk of undergoing surgical management for VCF (P < 0.0001). Several comorbidities were significantly associated with increased rates of readmission including hypertension, tobacco use, coronary artery disease, and chronic obstructive pulmonary disease (P < 0.0001 for all). CONCLUSIONS: This study highlights specific comorbidities that are significantly associated with higher rates of kyphoplasty or vertebroplasty for the treatment of thoracolumbar wedge compression fractures and increased risk for 90-day postoperative hospital readmission.

CASE:We describe 2 case studies, involving a 10-year-old girl with an aneurysmal bone cyst and a 12-year-old adolescent boy with Ewing sarcoma. The patient with Ewing sarcoma was previously managed with wide surgical excision and fibular graft reconstruction and subsequently experienced significant graft resorption, hardware failure, and fracture 24 months after operation. A revision limb salvage attempt was undertaken. In both cases, fibular strut grafts were harvested and fixed with intramedullary k-wires to recreate the medial and lateral columns of the distal humeral triangle. CONCLUSION:The technique achieved complete osseous integration, structural support, and functional restoration of the elbow in both cases, with good functional outcomes.

The purpose of this study was to determine if short-term outcomes differed for pediatric patients with suspected musculoskeletal infection with or without a preoperative MRI. This was a multicenter, retrospective review of patients aged 0–16 years who presented with atraumatic extremity pain, underwent irrigation and debridement (I&D), and received at least one preoperative or postoperative MRI over a 10-year period. Primary outcomes were time to OR, total I&Ds, readmission rate, time from OR to discharge, and total number of MRIs. Secondary outcomes entailed the rate at which concurrent osteomyelitis was identified in patients with septic arthritis and the extent of the resulting surgical debridement. Of the 104 patients, 72.1% had a preoperative MRI. Patients with a preoperative MRI were significantly less likely to have surgery on the day of admission. No difference was found between groups regarding total I&Ds, readmission rate, time from OR to discharge, and total number of MRIs. Of the 57 patients diagnosed with septic arthritis, those with a preoperative MRI were significantly more likely to have concurrent osteomyelitis identified and to undergo bony debridement in addition to arthrotomy of the joint. In conclusion, patient outcomes are not adversely affected by obtaining a preoperative MRI despite the delay in time to OR. Although preoperative MRI can be beneficial in ruling out other pathologies and identifying the extent of concurrent osteomyelitis, the decision to obtain a preoperative MRI and timing of surgery should be left to the discretion of the treating surgeon.

Category: Trauma; Hindfoot Introduction/Purpose: The prevalence of depression is rising globally, and it has been noted in recent literature that the COVID-19 pandemic has exacerbated the increase in depressive disorders. Studies have suggested a strong association between depression and poor outcomes following various orthopedic surgeries, particularly joint arthroplasties. However, depression’s impact on complications following open reduction/internal fixation (ORIF) of Trimalleolar fractures has not been elucidated, despite the high complication rate of this procedure. Therefore, the aims of this study were to determine whether depression is associated with higher rates of 1) readmissions and 2) medical complications following ORIF of Trimalleolar fractures. Methods: Using the Mariner nationwide database from January 1, 2010, to March 31, 2021, a total of 50,154 adults aged 18 or older were identified as having undergone Trimalleolar ORIF using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD-9, ICD-10) coding. Patients with depression were matched 1:1 to controls without depression by age, sex, COPD, anxiety, diabetes, hypertension, obesity, and tobacco use. Primary endpoints compared 90-day all-cause readmissions and medical complications. Logistic regression was used to calculate odds-ratios (OR) of the effect of depression on readmissions and medical complications. A p-value of less than 0.05 was significant. Results: Patients with depression who underwent ORIF of Trimalleolar fractures had significantly higher odds of being readmitted within 90-days of the initial procedure (OR: 1.37; 95%CI: 1.27 – 1.48; p< 0.0001). 90-day odds of developing medical complications were significantly higher (OR: 4.61; 95%CI: 4.38 – 4.86; p< 0.0001) in patients with depression compared to patients within the control group. Conclusion: This study demonstrated that patients with depression undergoing Trimalleolar ORIF are at an increased risk of readmission and a multitude of postoperative complications. This information is crucial for orthopedic surgeons considering the already high burden of complications following ORIF of Trimalleolar fractures and increasing prevalence of depression worldwide.

Introduction Sleep Apnea (SA) is a common sleep disorder that increases postoperative morbidity. There is limited research on how SA influences outcomes following operative fixation of ankle fractures. Therefore, the aim of this study was to determine whether patients who undergo surgical fixation for bimalleolar ankle fractures have higher rates of medical complications and health care expenditures. Methods A retrospective review from January 1, 2005 to March 31, 2014 was conducted using the parts A and B Medicare Data from PearlDiver database. Patients with and without SA on the day of the primary open reduction and internal fixation (ORIF) of their bimalleolar ankle fractures were queried using the International Classification of Diseases, Ninth Revision codes. Welch’s t-tests were used to compare costs of care. A multivariate binomial logistic regression model was used to calculate the odds ratio (OR) of adverse events. A P-value <.001 was considered statistically significant. Results There were 20 560 patients (SA = 3150; comparison cohort = 17 410) who underwent ORIF for bimalleolar ankle fractures during the study period. Sleep apnea patients were found to have significantly higher rates and odds of 90-day medical complications (21.42% vs 7.47%, OR: 3.11, P < .0001) and 90-day costs of care ($7213.12 vs $5415.79, P < .0001). Conclusion This research demonstrates an increased risk of postoperative medical complications and health care costs among patients with SA undergoing ORIF for bimalleolar ankle fractures. Level of Evidence Therapeutic, Level IV: Retrospective

STUDY DESIGN:Level III evidence-retrospective cohort. OBJECTIVE:The purpose of this study was to (1) determine whether longer CDA operative time increases the risk of 30-day postoperative complications, (2) analyze the association between operative time and subsequent health care utilization, and (3) discharge disposition. BACKGROUND:Cervical disk arthroplasty (CDA) most commonly serves as an alternative to anterior cervical discectomy and fusion (ACDF) to treat cervical spine disease, however, with only 1600 CDAs performed annually relative to 132,000 ACDFs, it is a relatively novel procedure. METHODS:A retrospective query was performed identifying patients who underwent single-level CDA between January 2012 and December 2018 using a nationwide database. Differences in baseline patient demographics were identified through univariate analysis. Multivariate logistic regression was performed to identify associations between operative time (reference: 81-100 min), medical/surgical complications, and health care utilization. RESULTS:A total of 3681 cases were performed, with a mean patient age of 45.52 years and operative time of 107.72±49.6 minutes. Higher odds of length of stay were demonstrated starting with operative time category 101-120 minutes (odds ratio: 2.164, 95% CI: 1.247-3.754, P =0.006); however, not among discharge destination, 30-day unplanned readmission, or reoperation. Operative time <40 minutes was associated with 10.7x odds of nonhome discharge, while >240 minutes was associated with 4.4 times higher odds of LOS>2 days ( P <0.01). Increased operative time was not associated with higher odds of wound complication/infection, pulmonary embolism, deep venous thrombosis, or urinary tract infections. CONCLUSIONS:Prolonged CDA operative time above the reference 81-100 minutes is independently associated with increased length of stay, but not other significant health care utilization parameters, including discharge disposition, readmission, or reoperation. There was no association between prolonged operative time and 30-day medical/surgical complications, including wound complications, infections, pulmonary embolism, or urinary tract infection.

Study Design: Retrospective cohort study. Objectives: The study aimed to (1) compare baseline demographics of patients undergoing surgery for SEA who were/were not readmitted; (2) identify risk factors for 90-day readmissions; and (3) quantify 90-day episode-of-care health care costs. Background: Spinal epidural abscess (SEA), while rare, occurring ~2.5–5.1/10,000 admissions, may lead to permanent neurologic deficits and mortality. Definitive treatment often involves surgical intervention via decompression. Methods: A search of the PearlDiver database from 2010 to 2021 for patients undergoing decompression for SEA identified 4595 patients. Cohorts were identified through the International Classification of Disease, Ninth Revision (ICD-9), ICD-10, and Current Procedural Terminology codes. Baseline demographics of patients who were/were not readmitted within 90 days following decompression were aggregated/compared, identifying factors associated with readmission. Using Bonferroni correction, a P-value<0.001 was considered statistically significant. Results: Readmission within 90 days of surgical decompression occurred in 36.1% (1659/4595) of patients. While age/gender were not associated with readmission rate, alcohol use disorder, arrhythmia, chronic kidney disease, ischemic heart disease, and obesity were associated with readmission. Readmission risk factors included fluid/electrolyte abnormalities, obesity, paralysis, tobacco use, and pathologic weight loss (P<0.0001). Mean same-day total costs ($17,920 vs. $8204, P<0.001) and mean 90-day costs ($46,050 vs. $15,200, P<0.001) were significantly higher in the readmission group. Conclusion: A substantial proportion of patients (36.1%) are readmitted within 90 days following surgical decompression for SEA. The top 5 risk factors in descending order are fluid/electrolyte abnormalities, pathologic weight loss, tobacco use, pre-existing paralysis, and obesity. This study highlights areas for perioperative medical optimization that may reduce health care utilization.

Study Design: A retrospective cohort study was performed for patients undergoing 1–2-level lumbar fusion (1–2LF) from 2005 to 2014 using an administrative claims database. Objective: The objective of this study was to determine changes in: (1) annual charges; (2) annual reimbursement rates; and (3) annual difference (charges minus reimbursements) in patients undergoing 1–2LF. Summary of Background Data: With implementation of value-based care in orthopaedics, coupled with the rise in number of patients undergoing 1–2LF, understanding the discordance in hospital charges and reimbursements is needed. The difference in hospital charges to reimbursements specifically for 1–2LF for degenerative disc disease has not been studied. Materials and Methods: A Medicare administrative claims database was queried for patients undergoing primary lumbar fusion using ICD-9 procedural code 81.04–81.08. Patients specifically undergoing 1–2LF were filtered from this cohort using ICD-9 procedural code 81.62. The query yielded 547,067 patients who underwent primary 1–2LF. Primary outcomes analyzed included trends in charges, reimbursement rates, and net difference in cost over time and per annual basis. Linear regression evaluated the change in costs over time with a P -value less than 0.05 considered significant. Results: From 2005 to 2014, total charges increased from $6,085,838,407 to $19,621,979,956 and total reimbursements increased from $1,677,764,831 to $4,656,702,685 (all P <0.001). Per patient charges increased 92.10% from 2005 to 2014 for patients undergoing primary 1–2LF from $129,992 to $249,697 ( P <0.001). Similarly, an increase in reimbursement per patient of 65.35% from $35,836 to $59,258 ( P <0.001) was noted. The annual difference in charges to reimbursements increased 102.26% during the study interval from $94,155 to $190,439 ( P <0.001). Conclusions: Per patient charges and reimbursements both increased over the study period; however, charges increased 30% more than reimbursements. Further breakdown of hospital, surgeon, and anesthesiologist reimbursements for 1–2LF is needed. Level of Evidence: Level III.

The anterolateral ligament (ALL) was first described in 1879 in the context of Segond fractures, which correlate with a 75-100% chance of an anterior cruciate ligament (ACL) tear or a 66-75% chance of a meniscal tear. The purpose of this paper is to provide an updated comprehensive review on the anterolateral ligament complex of the knee focusing on the: (1) anatomy of the ALL/ALC; (2) associated biomechanics/function; and (3) important surgical considerations in contemporary anterior cruciate ligament (ACL) reconstruction and total knee arthroplasty (TKA). A systematic review of studies on ALL was conducted on Pubmed/MEDLINE and Cochrane databases (May 7th, 2020 to February 1st, 2022), with 20 studies meeting inclusion/exclusion criteria. Studies meeting inclusion criteria were anatomical/biomechanical studies assessing ALL function, cadaveric and computer simulations, and comparative studies on surgical outcomes of ALLR (concomitant with ACL reconstruction). Eight studies were included and graded by MINOR and Newcastle-Ottawa scale to identify potential biases. The anatomy of the ALL is part of the anterolateral ligament complex (ALC), which includes the superficial/deep iliotibial band (including the Kaplan fiber system), iliopatellar band, ALL, and anterolateral capsule. Multiple biomechanical studies have characterized the ALC as a secondary passive stabilizer in resisting tibial internal rotation. Given the role of the ALC in resisting internal tibial rotation, lateral extra-articular procedures including ALL augmentation may be considered for chronic ACL tears, ACL revisions, and a high-grade pivot shift test. In the context of TKA, in the event of injury to the ALC, a more constrained implant or soft-tissue reconstruction may be necessary to restore appropriate knee stability.

Contemporary studies evaluating utilization and trends of total ankle arthroplasty (TAA) and ankle fusion (AF) for tibiotalar osteoarthritis are sparse. Therefore, the purpose of this study was to utilize a nationwide administrative claims database from 2010 to 2019 to compare: (1) baseline demographics; (2) utilization, (3) in-hospital length of stay (LOS), and (4) costs of care. Using the PearlDiver database, a retrospective query from January 1st, 2010 to December 31st, 2019 was performed for all patients who underwent TAA and AF for tibiotalar osteoarthritis. Baseline demographics, comorbidities, and geographic utilization were compared using Pearson Chi-square analyses. Linear regression was used to compare differences in procedure utilization and in-hospital LOS during the study interval. Reimbursements between the two cohorts during the study interval were compared. A p value less than 0.05 was statistically significant. In total, 14,248 patients underwent primary TAA (n = 5544) or AF (n = 8704). Patients undergoing AF were generally younger (< 60) with greater comorbidity burden driven by hypertension, diabetes mellitus, obesity, and tobacco use compared to TAA patients (p < 0.0001). Over the study interval, TAA utilization remained constant (912 vs 909 procedures; p = 0.807), whereas AF utilization decreased by 42.5% (1737 vs 998 procedures; p = 0.0001). Mean in-hospital LOS for patients undergoing TAA decreased (2.5 days vs. 2.0 days, p = 0.0004), while AF LOS increased (2.6 days vs. 3.5 days, p = 0.0003). Reimbursements for both procedures significantly declined over the study interval (TAA: $4559–$2156, AF: $4729–$1721; p < 0.013). TAA utilization remained constant, while AF utilization declined by 42.5% from 2010 to 2019. There was divergence in the LOS for TAA versus AF patients. Both procedures significantly declined by over 50% in reimbursements over the study interval.

Case: A 17-year-old boy presented with an open talus fracture complicated by soot contamination after a chimney-related accident. Standard irrigation and debridement (I&D) methods were used, but complete removal of soot was not possible. At the latest follow-up, there was no evidence of infection, hardware failure, or avascular necrosis. Conclusion: There is a lack of well-established guidelines regarding I&D of traumatic wounds contaminated with fine particulates. A review of potential debridement methods is discussed. Orthoapedic surgeons should be aware of hydrosurgical debridement as a potential treatment approach in these unique scenarios.

Background: Knee osteonecrosis (ON) is rare, with an estimated incidence of 0.01-0.17 per 1,000 person years. Our study aimed to do the following: 1) quantify total operative procedures with rates normalized to the United States population; 2) compare arthroplasty versus joint-preserving procedural trends; and 3) determine rates of specific operative techniques/demographics in patients aged <50 versus >50 years. Methods: Using a nationwide database, 8,269 patients diagnosed with knee ON underwent surgical treatment from 2010 to 2020. Documented surgical procedures included total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA), and core decompression. Primary outcomes included procedural utilization with subanalyses comparing arthroplasty versus joint-preserving procedures, and age-stratified by under/over 50 years. Linear regressions were evaluated for trends in procedural volumes over time. Results: From 2010 to 2014, 0.54% of all knee procedures were to treat ON compared to 0.71% from 2015 to 2020 (P <.001). Overall rates of TKA (85.4%) and UKA (10.3%) far exceeded rates of joint preserving procedures (4.3%). Comparing 2010-2014 with 2015-2019, joint-preserving procedures proportionally increased (0.7 to 5.0%, P <.001). Patients <50 years had significantly more joint-preserving procedures (19.5 versus 2.7%). Overall, TKA was the most common procedure (7,062; 85.40%), following by UKA 853; 10.32%) and core decompression (354; 4.28%). Conclusion: To our knowledge, this is the first study to characterize surgical trends inmanagement of knee ON. Overall surgical volume for kneeONhas continued to increase, outpacing population growth. Patients who have knee ON are most commonly managed with arthroplasty procedures, specifically TKA. Younger aged patients (<50 years) are more likely to undergo joint-preserving procedures, namely core decompression. (c) 2023 Elsevier Inc. All rights reserved.

Case: A 17-year-old adolescent boy presented 2 months after initial intramedullary nail (IMN) fixation of a comminuted subtrochanteric fracture with refracture at the previous site and approximately 20° varus angulation of the nail. The bent femoral nail was successfully extracted using an open technique using Lohman bone-holding clamps and a broad plate. At the 1-year follow-up, fracture union was achieved. Conclusions: Removal of a deformed IMN is rare. No standardized protocol exists in guiding orthopaedic surgeons. A thorough review of techniques is discussed on this unusual complication.

Background: Well-powered studies analyzing the relationship and nature of emergency department (ED) visits following primary total hip arthroplasties (THAs) are limited. The aim of this study was to: 1) compare baseline demographics of patients with/without an ED visit; 2) determine leading causes of ED visits; 3) identify patient -related risk factors; and 4) quantify 90-day episode-of-care healthcare costs divided by final diagnosis.Methods: Patients undergoing primary THA between January 1, 2010 and October 1, 2020 who presented to the ED within 90-days postoperatively were identified using the Mariner dataset of PearlDiver, yielding 1,018,772 patients. This included 3.9% (n = 39,439) patients who did and 96.1% (n = 979,333) who did not have an ED visit. Baseline demographics between the control/study cohorts, ED visit causes, risk-factors, and subsequent costs-of-care were analyzed. Using Bonferroni-correction, a P-value less than 0.002 was considered statistically significant.Results: Patients who presented to the ED post-operatively were most often aged 65-74 years old (41.09%) or female sex (55.60%). Nonmusculoskeletal etiologies comprised 66.8% of all ED visits. Risk factors associated with increased ED visits included alcohol abuse, depressive disorders, congestive heart failure, coagulopathy, and electrolyte/fluid derangements (P < .001 for all). Pulmonary ($28,928.01) and cardiac ($28,574.69) visits attributed to the highest costs of care.Conclusion: Nonmusculoskeletal causes constituted the majority of ED visits. The top five risk factors associated with increased odds of ED visits were alcohol abuse, electrolyte/fluid derangements, congestive heart failure, coagulopathy, and depression. This study highlights potential areas of pre-operative medical optimization that may reduce ED visits following primary THA.(c) 2022 Elsevier Inc. All rights reserved.

Fractures involving the distal radius metaphyseal-diaphyseal junction (MDJ) present a unique challenge for pediatric orthopedic surgeons. These fractures are too proximal for percutaneous K -wire fixation and too distal for retrograde flexible nailing. The purpose of this study was to: (1) determine the safety of a described antegrade approach from the posterior interosseous nerve (PIN); (2) assess the efficacy of antegrade nailing in cases of distal MDJ fractures; and (3) describe a standardized lateral approach to the proximal radius. A cadaveric study was performed using 10 adult forearms. Anterograde flexinail was introduced at the proximal radius based on the described "safe zone". Distal MDJ fractures were created using osteotomes. We evaluated the distance between the entry point to the PIN in addition to the quality of the reduction for the fracture. The average distance between the entry point and piercing instrument to the PIN was 5.4 cm (range: 4.7 to 6.0 cm). When grouped based on sex, the average distance was significantly further for males (5.8 cm, range: 5.2 to 6.0 cm) versus females (4.9 cm, range: 4.7 to 5.2 cm), P =0.004. Fracture reduction was not maintained after the introduction of the antegrade flexible nail across the fracture site. For all specimens, >25% displacement was seen on the anterior-posterior imaging. Our modified lateral approach to the starting point in the proximal radius is safe as long as the entry point for antegrade flexible nailing stays proximal to the radial tuberosity during the lateral approach to the proximal radius while the elbow is flexed and the forearm pronated.

Introduction: Studies evaluating utilization and trends of total ankle arthroplasty (TAA) and ankle fusion (AF) are sparse. The purpose of this study was to use a nationwide administrative claims database to compare baseline demographics between TAA and ankle arthrodesis and to determine whether patients who had a TAA have increased rates of: (1) utilization, (2) in-hospital length of stay (LOS), and (3) costs of care. Methods: PearlDiver, a nationwide claims database was queried from 2005 to December 2013 for all patients who underwent primary TAA or AF for the treatment of osteoarthritis of the ankle and foot. Baseline demographics of age, sex, geographic distribution, and the prevalence of comorbidities comprising the Elixhauser comorbidity index (ECI) were compared between patients who had TAA and AF. Linear regression was used to compare differences in utilization and in-hospital LOS between the 2 cohorts during the study interval. Annual charges and reimbursement rates for TAA were assessed during the study period. A P value less than .05 was considered to be statistically significant. Results: A total of 21 433 patients undergoing primary TAA (n = 7126) and AF (n = 14 307) were included. Patients undergoing TAA had significantly greater ECI driven by arrythmias, congestive heart failure, diabetes mellitus, electrolyte/fluid disorders, iron deficiency anemia than patients undergoing AF (P < .001). From 2005 to 2013, TAA utilization increased from 21.5% to 49.4% of procedures (P < .0001). There was reduced in-hospital LOS over the time interval for patients with TAA compared with AF (2.15 days vs. 3.11 days, P < .0001). Total ankle arthroplasty reimbursements remained stable while charges per patient increased significantly from $40 203.48 in 2005 to doubling by the end of 2013 to $86 208.59 (P < .0001). Conclusion: This study demonstrated increased use of TAA compared to AF showing decreased in-hospital LOS and increased cost of care with stagnant reimbursement rates.Level of Evidence: Level III.

Background: A recently proposed risk factor for periprosthetic joint infections (PJI) in men is benign prostatic hyperplasia (BPH). The objective was to explore the association of BPH on 1) 90-day complications, 2) length of stay (LOS), 3) readmission rates, and 4) healthcare expenditures following total shoulder arthroplasty (TSA).Methods: A retrospective query was performed using a nationwide claims database from January 2005 to March 2014 for male patients undergoing primary TSA. The study cohort included 5067 patients with BPH while 50,720 patients served as the comparison cohort. Logistic regression determined the association of BPH on complications and readmissions. A p value less than 0.001 was significant.Results: Patients with BPH had higher incidence and odds (36.8 vs. 6.2%; OR: 2.73, p < 0.0001) of all ninety-day medical complications including PJIs (0.49 vs. 0.32%; OR: 1.54, p < 0.001). BPH patients had longer in-hospital LOS (3- vs. 2-days, p < 0.0001). Study group patients had higher 90-day episode of care reimbursements ($13,653 vs. $12,688), p < 0.0001).Conclusions: BPH is associated with increased complications and healthcare expenditures following total shoulder arthroplasty. The investigation can be used to educate BPH patients of the possible adverse events which may occur within ninety-days following primary TSA for the treatment of glenohumeral osteoarthritis.

Background: The Elixhauser Comorbidity Index (ECI) is a stratification tool to predict adverse surgical outcomes. No studies have explored the relationship between ECI and outcomes following primary 1- to 2-level lumbar fusion (1-2LF). The purpose was to determine whether an ECI score greater than 1 correlated with (1) longer in-hospital length of stay (LOS) and (2) greater odds of developing 90-day medical complications. Methods: A retrospective review from 2004 to 2015 was performed using the Medicare Standard Analytical Files for patients undergoing primary LF. Patients with ECI scores from 2 to 5 served as the study cohorts (1 for each ECI score), and patients with an ECI score of 1 served as the control cohort. In-hospital LOS and 90-day medical complications were compared between cohorts. A P value of <0.001 was statistically significant. Results: A total of 105,120 patients were equally distributed between the 5 cohorts. Patients with an ECI score of 2 (6.00 +/- 4.51), ECI 3 (6.22 +/- 4.67), ECI 4 (7.35 +/- 5.05), or ECI 5 (8.99 +/- 5.67) had longer in-hospital LOS compared with patients with an ECI score of 1 (4.28 +/- 4.36) (all P < 0.001). Patients with an ECI score of 2 (OR: 1.17, 95% CI: 1.05-1.30, P = 0.003; 2.85% vs 2.45%), ECI 3 (OR: 1.22, 95% CI: 1.10-1.36, P < 0.001; 2.98% vs 2.45%), ECI 4 (OR: 1.26, 95% CI: 1.13-1.40, P < 0.001; 3.10% vs 2.45%), or ECI 5 (OR: 1.18, 95% CI: 1.06-1.31, P = 0.001; 2.89% vs 2.45%) had greater incidence and odds of 90-day medical complications such as pneumonia, deep vein thrombosis, cerebrovascular accidents, and myocardial infarctions than patients in the control group (all P < 0.0001). Conclusions: Increasing ECI score was associated with longer in-hospital LOS and increased 90-day medical complication rates following 1-2LF. This study is the first to establish a correlation between ECI score, in-hospital LOS, and complication rates following lumbar fusion. Clinical Relevance: ECI score may assist physicians in adjusting pre- and postoperative care for complex patients undergoing 1-2LF. Level of Evidence: 3.