The Impact of the COVID-19 Pandemic on Racial Disparities in Patients Undergoing Total Shoulder Arthroplasty in the United States

INTRODUCTION: The purpose of this study was to assess racial disparities in total shoulder arthroplasty (TSA) in the US and to determine whether these disparities were affected by the COVID-19 pandemic. METHODS: Centers for Medicare and Medicaid Services (CMS) 100% sample was used to examine primary TSA volume from April-December from 2019-2020. Utilization was assessed for White/Black/Hispanic/Asian populations to determine if COVID-19 affected these groups differently. A regression model adjusted for age/sex/CMS-Hierarchical Condition Categories (HCC) score, dual enrollment (proxy for socioeconomic status), time fixed effects, and Core-based Statistical Area (CBSA) fixed effects was used to study difference across groups. RESULTS: In 2019, TSA volume/1000 beneficiaries was 1.51 for White and 0.57 for non-White, a 2.6-fold difference. In 2020, the rate of TSA in White patients (1.30/1000) was 2.9 times higher than non-White (0.45/1000) during the COVID-19 pandemic (P\u3c0.01). There was an overall 14% decrease in TSA volume/1000 Medicare beneficiaries in 2020; non-White patients had a larger percentage decrease in TSA volume than White (21% vs. 14%, estimated difference;8.7%,p = 0.02). Black patients experienced the most pronounced disparity with estimated difference of 10.1%,p = 0.05, compared with White patients. Similar disparities were observed when categorizing procedures into anatomic and reverse TSA, but not proximal humerus fracture. CONCLUSIONS: During the COVID-19 pandemic, overall TSA utilization decreased by 14% with White patients experiencing a decrease of 14%, and non-White patients experiencing a decrease of 21%. This trend was observed for elective TSA while disparities were less apparent for proximal humerus fracture

Five-Year Mortality Rates Following Elective Shoulder Arthroplasty and Shoulder Arthroplasty for Fracture in Patients Over Age 65.

BACKGROUND: To effectively counsel patients prior to shoulder arthroplasty, surgeons should understand the overall life trajectory and life expectancy of patients in the context of the patient\u27s shoulder pathology and medical comorbidities. Such an understanding can influence both operative and nonoperative decision-making and implant choices. This study evaluated 5-year mortality following shoulder arthroplasty in patients ≥65 years old and identified associated risk factors. METHODS: We utilized Centers for Medicare & Medicaid Services Fee-for-Service inpatient and outpatient claims data to investigate the 5-year mortality rate following shoulder arthroplasty procedures performed from 2014 to 2016. The impact of patient demographics, including fracture diagnosis, year fixed effects, and state fixed effects; patient comorbidities; and hospital-level characteristics on 5-year mortality rates were assessed with use of a Cox proportional hazards regression model. A p value of RESULTS: A total of 108,667 shoulder arthroplasty cases (96,104 nonfracture and 12,563 fracture) were examined. The cohort was 62.7% female and 5.8% non-White and had a mean age at surgery of 74.3 years. The mean 5-year mortality rate was 16.6% across all shoulder arthroplasty cases, 14.9% for nonfracture cases, and 29.9% for fracture cases. The trend toward higher mortality in the fracture group compared with the nonfracture group was sustained throughout the 5-year postoperative period, with a fracture diagnosis being associated with a hazard ratio of 1.63 for mortality (p \u3c 0.001). Medical comorbidities were associated with an increased risk of mortality, with liver disease bearing the highest hazard ratio (3.07; p \u3c 0.001), followed by chronic kidney disease (2.59; p \u3c 0.001), chronic obstructive pulmonary disease (1.92; p \u3c 0.001), and congestive heart failure (1.90; p \u3c 0.001). CONCLUSIONS: The mean 5-year mortality following shoulder arthroplasty was 16.6%. Patients with a fracture diagnosis had a significantly higher 5-year mortality risk (29.9%) than those with a nonfracture diagnosis (14.9%). Medical comorbidities had the greatest impact on mortality risk, with chronic liver and kidney disease being the most noteworthy. This novel longer-term data can help with patient education and risk stratification prior to undergoing shoulder replacement. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence

Impact of COVID-19 on cardiovascular testing in the United States versus the rest of the world

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P &lt; 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Management of Complications After Revision Shoulder Arthroplasty

Complications after revision shoulder arthroplasty are similar to those in the primary setting which include instability, fracture, bone loss, infection, nerve injury, and loosening. Unlike in the primary setting, however, the rate of complications for revisions is significantly greater and the management is more complex because of overlapping complications and limited treatment options. Furthermore, there is a paucity of evidence-based literature to direct the management options in these patients. The purposes of this review are to broadly outline the major complications that are seen in revision shoulder arthroplasty and to provide general principles on how to recognize and approach these complex cases

Predictors of unsatisfactory patient outcomes in primary reverse total shoulder arthroplasty

© 2019 Journal of Shoulder and Elbow Surgery Board of Trustees Background: Despite favorable clinical and functional results for reverse total shoulder arthroplasty (RSA), there remains a group of patients without postoperative complications who demonstrate poor improvement and overall outcome. Methods: Using a single surgeon shoulder arthroplasty registry, we identified patients who underwent RSA from 2013 to 2016 with minimum of 2-year postoperative follow-up. Patients with intra- and postoperative complications were excluded. Poor postoperative clinical outcome was defined as those patients within the bottom 30th percentile for American Shoulder and Elbow Surgeons (ASES) score. Poor postoperative improvement was defined as the bottom 30th percentile of ASES improvement, measured preoperatively to the 2-year postoperative mark. Multivariate logistic regression modeling was used to determine preoperative characteristics (e.g., demographics, comorbidities, preoperative ASES score) associated with poor outcome. Results: A total of 137 patients met the inclusion and exclusion criteria. Multivariable logistic regression modeling found that prior shoulder surgery, the majority (75%) of which were arthroscopic, was the only independent factor associated with both poor improvement (adjusted odds ratio, 2.46 [1.03-5.83]) and outcome (adjusted odds ratio, 4.92 [1.74-14.96]). Preoperative opioid use was associated with poor outcomes only, whereas the high preoperative ASES score was associated with poor postoperative improvement. Conclusions: Prior ipsilateral shoulder surgery was strongly associated with poor clinical improvement and outcome after RSA. No other factors correlated with both poor improvement and outcome. This association is important to decision making for any shoulder surgery, given the long-term implications

Critical shoulder angle is associated with full-thickness rotator cuff tears in patients with glenohumeral osteoarthritis.

BACKGROUND: Higher critical shoulder angle (CSA) is correlated with rotator cuff tears (RCTs), whereas lower CSA is associated with glenohumeral osteoarthritis (OA). Our goal was to investigate whether patients with concurrent glenohumeral OA and full-thickness RCTs demonstrate a higher CSA than patients with OA alone. METHODS: Using a 2-surgeon shoulder arthroplasty registry, we identified 31 patients with glenohumeral OA and full-thickness RCTs confirmed by plain radiography and magnetic resonance imaging, respectively. Sixty-two age- and gender-matched controls (1:2 ratio) with glenohumeral OA and an intact rotator cuff were identified from the same registry. Two independent observers evaluated the radiographs for CSA and acromiohumeral index. RESULTS: The average CSA was 30° in the OA control group and 35° in the concurrent RCT and OA group (P \u3c .0001). Acromiohumeral index was comparable between the groups (P = .13). Interobserver reliability of the independent reviewers was excellent (κ = 0.89; Ρ = 0.95). The receiver operating characteristic curve for CSA demonstrated that a value \u3e35° was 90% specific and 52% sensitive for a full-thickness RCT in the setting of OA (area under curve = 0.84). CONCLUSION: Concurrent glenohumeral OA and full-thickness RCT are associated with greater CSA values compared with patients with glenohumeral OA alone. The CSA measurement may be useful in determining the need for magnetic resonance imaging to assess rotator cuff integrity in the arthritic population

Risk factors for fracture mobility six weeks after initiation of brace treatment of mid-diaphyseal humeral fractures

BACKGROUND: Recent studies have identified specific subsets of diaphyseal humeral fractures for which functional bracing is less effective. The present study tested the hypothesis that a gap between fracture fragments may be a risk factor (after accounting for other potential risk factors) for fracture instability six weeks after functional bracing of humeral shaft fractures. METHODS: We retrospectively identified seventy-nine adult patients (forty-six men, thirty-three women; forty-two fractures on the right side, thirty-seven fractures on the left), each with an acute, closed, AO type-A2 (oblique, ≥30°) or type-A3 (transverse, &lt;30°) mid-diaphyseal humeral shaft fracture treated nonoperatively at three different level-I trauma centers from June 2004 to August 2011. The gap between the fracture fragments was measured on the first radiographs made after the affected upper extremity was placed in a brace. RESULTS: Sixty-three patients (80%) had documented healing of the fracture. Sixteen patients (20%) had motion at the fracture site and a persistent fracture line shown on radiographs six weeks or more after injury. In multivariable analysis, each millimeter of gap between the main fragments with the patient wearing the brace (odds ratio [OR] = 1.4, 95% confidence interval [CI] = 1.1 to 1.7), smoking (OR = 5.8, 95% CI = 1.4 to 25), and female sex (OR = 5.3, 95% CI = 1.2 to 23) increased the risk of fracture instability six weeks after injury (R2 = 0.38, area under the receiver operating characteristic [ROC] curve = 0.81). CONCLUSIONS: The magnitude of the gap between the fracture fragments is an independent risk factor for fracture instability and the lack of a bridging callus six weeks after a diaphyseal humeral fracture. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence