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Although obesity has been shown to increase the risk of short-term medical complications following total shoulder arthroplasty (TSA), evidence is lacking on the influence of obesity on longer-term surgical complications such as revision. The purpose of this study was to assess the association of increasing obesity with 2-year and 5-year all-cause revision, periprosthetic joint infection (PJI), aseptic loosening, and manipulation under anesthesia (MUA) among patients undergoing reverse total shoulder arthroplasty (RTSA) or TSA.Patients who underwent RTSA or TSA with a minimum five-year follow-up were identified in a national claims database (PearlDiver Technologies). Patients with obesity (body mass index [BMI] ≥ 30) were compared to patients who are normal or overweight (18.5 ≤ BMI30). Those with obesity were further stratified to those with type I or II obesity (30≤ BMI40) and those with type III obesity (BMI ≥ 40). Outcomes for comparison included all-cause revision, PJI, aseptic loosening, and MUA within 2 or 5 years. These cohorts were compared using univariate and multivariable analysis.Patients with obesity had no significant difference in any surgical complication within 2 or 5 years for both those who underwent TSA or RTSA. After stratifying by class I or II obesity and class III obesity, there was still no significant difference in surgical complications with 2 or 5 years for both TSA patients and RTSA patients.Obesity, when other major comorbidities are controlled for, was not associated with increased risk of long-term surgical complications after shoulder replacement surgery.

Introduction The COVID-19 pandemic resulted in a transition to a virtual format for all medical residency and fellowship application processes. Previous studies have discussed the successful implementation of virtual interviews, but a deep analysis of how the application process has changed for orthopedic surgery fellowship programs during the pandemic is lacking. The purpose of this study was to assess how COVID-19 impacted the orthopedic spine fellowship application and selection process. Methods A web-based survey was administered to the program directors of all 75 U.S. orthopedic surgery spine fellowship programs, which often can accept both orthopedic surgery and neurosurgery trained graduates. Questions focused on the changes from the 2019-2020 application cycle to the 2020-2021 cycle. We collected data on connecting with potential applicants, the general application process, and interviews offered by programs. Univariate analyses were used to compare data from the 2020-2021 cycle with the prior 2019-2020 cycle. Results Twenty-five of the 75 contacted program directors responded to our survey (33% response rate). The percentage of programs that offered virtual open houses/meet-and-greets increased from 20% in 2019-2020 to 52% in 2020-2021 (p=0.018). Social media use was unchanged (0.0% vs. 4.0%, p0.05). Compared to the prior year, the number of interviews offered by programs increased by 1.5 (32.7 vs. 21.9 interviews, p=0.024). There were no significant differences in the numbers of applications received by programs, interview dates available, or separate interviews each candidate completed during an interview day (p0.05 for all). The in-person interview was the most important factor in 2019-2020 for selecting applicants, whereas the virtual interview, letters of recommendation (LOR), and research were equally ranked as the most important factors in 2020-2021. Regarding interviews, 50% of respondents would "likely" consider virtual interviews as an option in addition to in-person interviews in the future, but most (55%) answered that it was "unlikely" that virtual interviews would entirely replace in-person interviews. Conclusion Spine fellowship programs were more likely to use virtual social events to recruit potential applicants, send out more interview invitations, and equally consider LOR and research with interview performance during an entirely virtual application cycle. Half of the program directors would consider offering virtual interviews as an option for future application cycles, which may help reduce costs associated with the process.

Periprosthetic infections after total shoulder arthroplasty (TSA) are associated with devastating complications and prolonged treatment. Patients with identified antibiotic allergy (ABX) may be at increased risk for complications because of suboptimal preincisional prophylaxis. This study aims to quantify the risk of postoperative outcomes and complications for patients undergoing TSA with a history of ABX.Retrospective cohort analysis of patient data was conducted using the PearlDiver Patient Records Database. Patients who underwent TSA for osteoarthritis were identified using Current Procedural Terminology and International Classification of Diseases codes and were stratified based on self-reported (1) penicillin, (2) sulfonamide, or (3) other antibiotic allergies. We analyzed patient demographics, comorbidities, 90-day medical complications, and rate of revision at 30 days, 90 days, 1 year, and 2 years.In total, 85,606 patients who underwent TSA for osteoarthritis from 2010 to 2018 were identified, of whom 7,836 (9.15%) had a reported ABX. Univariate analysis found the ABX cohort was younger (67.5 versus 67.7 year; P = 0.042), more often female (67.57% versus 54.79%; P0.001), and more likely to have Elixhauser comorbidities than nonallergic control subjects. Multivariate analysis found patients who reported ABX had increased likelihood of periprosthetic joint infection (PJI) within 30 days (odds ratio [OR]: 3.129), 1 year (OR: 2.016), and 2 years of surgery (OR: 2.221). Patients with reported ABX had increased likelihood of postoperative anemia (OR: 1.126), blood transfusion (OR: 1.238), and readmission (OR: 1.585) within 90 days of surgery. Patients with penicillin allergy had a greater incidence of revision due to PJI at 30 days (OR: 4.811), 90 days (OR: 2.91), 1 year (OR: 2.105), and 2 years (OR: 2.72). Rates of reported ABX increased from 2010 to 2018 (8.60% to 10.91%; P = 0.001) in patients undergoing TSA.Patients undergoing TSA with a history of ABX had a higher risk of readmission, postoperative anemia, blood transfusions, and PJI. These findings support critical assessment and clarification of reported allergies before TSA and possibly the use of preoperative allergy testing.Level 3 therapeutic study.

Background Patients with Coronavirus disease 2019 (COVID-19)-related acute respiratory disease (ARDS) increasingly receive extracorporeal membrane oxygenation (ECMO) support. While ECMO has been shown to increase risk of stroke, few studies have examined this association in COVID-19 patients. Objective We conducted a systematic review to characterise neurological events during ECMO support in COVID-19 patients. Design Systematic review of cohort and large case series of COVID-19 patients who received ECMO support. Data Sources Studies retrieved from PubMed, EMBASE, Cochrane, Cochrane COVID-19 Study Register, Web of Science, Scopus, Clinicaltrials.gov, and mdRxiv from inception to November 11, 2020. Eligibility Criteria Inclusion criteria were a) Adult population (>18 year old); b) Positive PCR test for SARS-CoV-2 with active COVID-19 disease; c) ECMO therapy due to COVID-19 ARDS; and d) Neurological events and outcome described while on ECMO support. We excluded articles when no details of neurologic events were available. Results 1,322 patients from 12 case series and retrospective cohort studies were included in our study. The median age was 49.2, and 75% (n=985) of the patients were male. Diabetes mellitus and dyslipidaemia were the most common comorbidities (24% and 20%, respectively). Most (95%, n=1,241) patients were on venovenous ECMO with a median P:F ratio at the time of ECMO cannulation of 69.1. The prevalence of intracranial haemorrhage (ICH), ischaemic stroke, and hypoxic ischaemic brain injury (HIBI) was 5.9% (n=78), 1.1% (n=15), and 0.3% (n=4), respectively. The overall mortality of the 1,296 ECMO patients in the 10 studies that reported death was 36% (n=477), and the mortality of the subset of patients who had a neurological event was 92%. Conclusions Neurological injury is a concern for COVID-19 patients who receive ECMO. Further research is required to explore how neuromonitoring protocols can inform tailored anticoagulation management and improve survival in COVID-19 patients with ECMO support.

Introduction: The goal of this study was to assess the influence of the coronavirus disease 2019 pandemic on the orthopaedic surgery residency application process in the 2020 to 2021 application cycle. Methods: A survey was administered to the program directors of 152 Accreditation Council for Graduate Medical Education–accredited orthopaedic surgery residency programs. The following questions were assessed: virtual rotations, open houses/meet and greet events, social media, the selection criteria of applicants, the number of applications received by programs, and the number of interviews offered by programs. Results: Seventy-eight (51%) orthopaedic residency programs responded to the survey. Of those, 25 (32%) offered a virtual away rotation, and 57 (75%) held virtual open houses or meet and greet events. Thirteen of these programs (52%) reported virtual rotations as either “extremely important” or “very important.” A 355% increase was observed in social media utilization by residency programs between the 2019 to 2020 and 2020 to 2021 application cycles, with more programs finding social media to be “extremely helpful” or “very helpful” for recruiting applicants in 2020 to 2021 compared with the previous year (39% versus 10%, P < 0.001). Conclusion: Although many of the changes seen in the 2020 to 2021 application cycle were implemented by necessity, some of these changes were beneficial and may continue to be used in future application cycles.

Although prescribing opioid medication on a limited basis for postoperative pain control is common practice, few studies have focused on chronic opioid use following anterior cervical discectomy and fusion (ACDF).To determine the prevalence of and risk factors for chronic opioid use following one and two-level ACDF for degenerative cervical pathology.Retrospective cohort.Using an insurance claims database, we identified patients aged 18-64 who underwent one or two-level primary ACDF from 2010 to 2015 for degenerative cervical pathology.Opioid prescription strength at various timepoints pre- and postoperatively and development of chronic postoperative opioid use.Prescription opioid use was examined during the following periods: 90 days before 7 days preceding surgery (preoperative), 6 days preceding surgery to 90 days following surgery (perioperative) and from 91 to 365 days following surgery (postoperative). The primary outcome was chronic postoperative opioid use, defined as ≥120 days' supply of opioid prescriptions filled or ≥10 opioid prescriptions between 3 and 12 months postoperatively. Secondary outcomes were high-dose (90 morphine milligram equivalents [MME]/day) and very high-dose (200 MME/day) opioid prescriptions. A multivariate logistic model (area under the ROC curve 0.75, p.001) was built to predict long-term opioid use.Among 28,813 patients who underwent ACDF, most were female (55%) and underwent single-level ACDF (68%), with mean age of 50±8.0 years. Fifty-two percent of patients filled an opioid prescription in the preoperative period, 95% of patients filled a prescription in the perioperative period, and 39% of patients filled a prescription in the postoperative period. High-dose and very high-dose opioid prescriptions in the perioperative period were identified in 45% and 24% of patients, respectively, whereas 17% met criteria for chronic postoperative opioid use. The odds of chronic opioid use were highest in the Western US (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.3, 1.6). Duration of opioids prescribed was also highest in the Western US (median 111 days, interquartile range 11-336), p.001. Factors associated with the highest risk for chronic opioid use were preoperative opioid use (OR 5.7, 95% CI 5.3, 56.2), drug abuse (OR 3.5, 95% CI 2.6, 4.5), depression (OR 1.7, 95% CI 1.6, 1.9), anxiety (OR 1.5, 95% CI 1.4, 1.6), and surgery in the western region of the United States (OR 1.5, 95% CI 1.3, 1.6).Patients undergoing ACDF commonly receive high-dose opioid prescriptions after surgery, and certain patient factors increase risk for chronic opioid use following ACDF. Intervention focusing on patients with these factors is essential to reduce long-term use of prescription opioids and postoperative care.

To compare 90-day postoperative complications, health care use, 2-year and 5-year rates of reoperation and manipulation under anesthesia, and costs at the 30-day, 90-day, and 1-year postoperative intervals following open and arthroscopic rotator cuff repair (RCR).Patients who underwent an open or arthroscopic RCR with minimum 5-year follow-up were identified in a national database (PearlDiver Technologies) using Common Procedural Terminology andIn total, 3,266 patients who underwent open RCR were matched with 3,266 patients who underwent arthroscopic RCR. Compared with patients who underwent arthroscopic RCR, patients who underwent open RCR were at significantly increased risk of 90-day surgical-site infection (0.89% vs 0.34%,Patients undergoing open RCR were at increased risk of 90-day surgical-site infection and MUA both within 2 years and within 5 years of surgery in this study cohort.Level III, retrospective cohort study.

Objective Neck pain is a leading cause of years lived with disability and is often managed with opioid medications in primary care settings, though this is contraindicated by national guidelines. The aim of this study was to determine the prevalence of opioid prescription for neck pain at a primary care visit and to analyze the geographic variation and trends in opioid prescriptions between 2011 and 2017. Methods Using a prescription drug claims database, we identified 591,961 adult patients who presented for neck pain in primary care settings between 2011 and 2017. Patients who had outpatient specialty visits within 1 year before presentation, a concomitant diagnosis of a non-musculoskeletal cause of neck pain, or preexisting chronic opioid use were excluded. Results The mean age of the patients was 45 ± 12 years, and 64% were female. Fifteen percent of patients were prescribed opioids within 30 days of their encounter. Eleven percent of patients were prescribed moderate- to high-dose opioids (>20 morphine milligram equivalents). From 2011–2017, the proportion of both overall opioid prescriptions and moderate- to high-dose prescriptions given to first time presenters to an outpatient clinic for neck pain was highest in Mississippi (20%) and lowest in New Mexico (6%) (P Conclusions Opioid medication use for neck pain in the primary care setting is significant. Although opioid prescriptions are declining, there remains a need for further standardization in prescription practices.