BackgroundAlthough venous thromboembolism (VTE) has been studied in lower-extremity arthroplasty, there are few guidelines regarding established risk factors for VTE in total shoulder arthroplasty (TSA). With literature suggesting the VTE rate may be as high as 13%, VTE prevention and risk factors should be considered in preoperative planning.MethodsAll TSAs from 2011 through 2016 were queried from the National Surgical Quality Improvement Program database. Age, sex, body mass index, American Society of Anesthesiologists class, ethnicity, functional status, comorbidities, discharge destination, surgical indication, length of stay, and operative time were compared between patients with and without 30-day postoperative VTE. Pearson χ2 and t tests were used to assess baseline categorical and continuous variables, respectively. Multivariate logistic regression analysis was conducted to determine associated independent risk factors for VTE.ResultsThe analysis included 13,299 patients; VTE developed in 83 patients (0.62%). Patients with VTE were older (72 years vs. 69 years) and had a longer hospital stay (3.5 days vs. 1.9 days). Compared with patients with no VTE, patients with VTE were more likely to undergo TSA for proximal humeral fractures, to be discharged to a rehabilitative center, to have a preoperative albumin level lower than 3.5 g/dL, to undergo non-elective surgery, to have an American Society of Anesthesiologists class of 3 or greater, to have a surgical-site infection develop, and ultimately to need a shoulder reoperation (all P < .05). Multivariate logistic regression analysis revealed that hypoalbuminemia (albumin level < 3.5 g/dL), an increased length of stay, and African American ethnicity were independent risk factors for VTE development.ConclusionPatients with hypoalbuminemia, an increased length of stay, and African American ethnicity are at an increased risk of VTE after shoulder arthroplasty. A high index of suspicion is warranted for elderly patients with fractures who may need preoperative medical optimization.

Background Although studies have shown improved pain, function, and patient satisfaction after total shoulder arthroplasty (TSA), preoperative factors predicting poor outcomes are unexplored. Comparison of postoperative complications between osteoarthritis (OA), cuff arthropathy (CA), and fracture patients is important for identifying at-risk patients. Methods Primary TSAs from 2014 to 2016 with preoperative OA, CA, and proximal humerus fractures as indications were queried from the National Surgical Quality Improvement Program database. Short-interval postoperative complications were compared using multivariate binary logistic regression, and postoperative time to discharge between groups was analyzed using univariate analysis of variance with Tukey comparison. Statistical significance was defined as P < .05 using SPSS software version 23.0 (IBM Corp., Armonk, NY, USA). Results Of 9684 TSA cases, the primary indication was OA in 6571 patients, CA in 725 patients, and fractures in 646 patients. Compared with fractures, OA patients had statistically significant lower risk of dislocation, readmission, return to operating room, nonhome discharge, surgical site infection, perioperative bleeding requiring transfusion, and pulmonary embolism (all P < .05). Statistically significant lower risk of dislocation, nonhome discharge, and transfusion was also found between CA and fracture patients (all P < .03). However, in comparing CA vs. OA as preoperative indications, only postoperative venous thromboembolism (odds ratio, 4.5; P = .01) and surgical site infection (odds ratio, 3.7; P = .007) were significant. Mean differences in discharge time were significant between both OA and CA groups compared with fractures ( P < .001), but there was no significance between OA and CA ( P = .116). Conclusion Proximal humerus fracture is a risk factor for increased postoperative complications compared with OA and CA. With new outcomes-based reimbursement models, nonroutine discharge and increased discharge time should be considered in arthroplasty planning.

PurposeWith the increasing elderly population and obesity epidemic, diabetes is an important factor in arthroplasty planning. Although research suggests diabetes is associated with increased postoperative morbidity after hip and knee replacement, the effect of diabetes and varying management with insulin versus non-insulin agents on total shoulder arthroplasty (TSA) is not established.MethodsAll TSAs from 2015 to 2016 were queried from the American College of Surgeons National Surgical Quality Improvement Program database. Age, gender, BMI, steroid, ASA, operative time, and smoking status were compared between all diabetics, diabetics on insulin, diabetics on non-insulin agents, and non-diabetics to account for confounding variables. Thirty-day postoperative complications, readmission rate, surgical site infection (SSI), and non-routine discharge to rehabilitation were compared using bivariate and multivariate binary logistic regression. Postoperative time to discharge between diabetic groups was analyzed using univariate ANOVA with Tukey’s test.ResultsThe analysis included 7246 patients (insulin in 5% (n = 380), non-insulin in 13% (n = 922), and non-diabetics in 82% (n = 5944)). Diabetics were more likely to have an ASA ≥ 3 compared to non-diabetics (89.5% vs 50.1%; p < 0.001). Bivariate logistic regression showed statistical significance in readmission and non-routine discharge between all diabetics and non-diabetics (OR 1.7, 1.4; p = 0.001, 0.001), but there was no significance between SSI rate (0.3% vs 0.4%; p = 0.924). Multivariate logistic regression between groups showed significance in readmission between non-insulin diabetics vs non-diabetics (OR 1.5; p = 0.027), readmission and non-routine discharge in insulin vs non-diabetics (OR 2.1, 1.7; p = 0.003, < 0.001), and no significance between insulin and non-insulin diabetics. Postoperative days to discharge were 2.4, 2.0, and 1.8 days in insulin, non-insulin, and non-diabetics respectively. Mean differences were significant between all groups.ConclusionsDiabetic patients are at a higher risk for readmission and non-routine discharge compared to non-diabetics. Despite no increased risk in SSI, longer postoperative discharge time in diabetics should be considered in TSA planning.Trial registrationNot applicableLevel of evidenceLevel III, case-control study

Background: The safety of hyaluronan intra-articular injections is mostly based on animal studies and clinical evidence rather than histologic studies from human administration. Objective: This study analyzed the histologic effects of viscosupplementation with sodium hyaluronate on the synovium and articular cartilage of human knee specimen status post total knee arthroplasty within 3 years of viscosupplementation. Methods: Twenty-four specimens from total knee arthroplasties from April 2012 to August 2016 at NYU Winthrop Hospital were selected for microscopic analysis. All cases had a diagnosis of end-stage osteoarthritis at the time of surgery. Thirteen of the cases had 3 viscosupplementation injections of the knee with Euflexxa, a hyaluronate-based viscosupplementation agent, within 3 years preceding a total knee replacement. The remaining 11 did not receive viscosupplementation and were incorporated as controls. Upon histologic review, synovium was categorized by degree of hyperplasia and inflammation and the presence or absence of foreign material and giant cell reactions. Residual articular cartilage was categorized by staining intensity, and the presence or absence of crystals, foreign material, and giant cell reactions. Results: No significant difference was found between these groups for degree of synovial hyperplasia ( P = .33) or for cartilage staining density ( P = .42). None of the samples displayed evidence of foreign material, crystals, or giant cell reactions. Conclusion: In this cohort of patients, we demonstrated that Euflexxa was administered without any discernible microscopic adverse tissue effects.