Gwyneth C. Maloy

Introduction: Patients undergoing total shoulder arthroplasty (TSA) may experience postoperative new-onset depression (NOD), which is gaining attention because of its detrimental effect on patient outcomes. Methods: The PearlDiver Mariner database from 2010 through October 2022 was queried for adult patients undergoing first-time TSA. Exclusion criteria included patients with diagnoses of tumors, trauma, and infections within 30 days before surgery and patients with previous depression or psychiatric risk factors for depression. The incidence of NOD diagnoses within 1 year after surgery was identified. Those with and without NOD were exact matched 1:4 based on age, sex, and Elixhauser Comorbidity Index and compared on multivariate logistic regression to determine whether various 90-day postoperative complications were associated with the development of NOD. After Bonferroni correction, significance was established at P < 0.003. Five-year revision rates were also compared with the log-rank test. Results: Overall, 144,773 TSA patients meeting inclusion criteria were identified. NOD diagnoses in the year after surgery were identified for 4,321 (3.0%). Those with NOD were more likely to be female and have greater comorbidity burden ( P < 0.003 for both). Among matched comparisons, those with NOD had higher odds of experiencing various 90-day complications, visits to the emergency department, hospital readmission, and were more likely to undergo revision TSA within 5 years ( P < 0.003). Conclusions: Postoperative NOD was diagnosed in 3% of patients after TSA. Having NOD was associated with various postoperative complications and higher revision rates. Recognizing predisposing factors for NOD may help target risk mitigation strategies.

Background: Vitamin D deficiency has been linked to poor outcomes after spinal deformity correction, but it is unclear whether osteoporosis is the underlying factor. This study analyzed a national administrative database to clarify this association. Methods: The 2010 to Q1 2022 PearlDiver M161 database was queried for adult spinal deformity surgeries. Patients were stratified by not having versus having vitamin D deficiency diagnosis and matched 4:1 based on age, sex, and Charlson Comorbidity Index (CCI), and multivariate analysis (controlling for age, sex, and CCI) for 90-day postoperative adverse events was used to calculate odds ratios (ORs, Bonferroni correction, α < 0.00417). These methods were then repeated adding osteoporosis to the matching and multivariate controlling variables. Kaplan-Meier analysis comparing 5-year cumulative revision surgery rates was also performed for both sets of comparisons. Results: In the primary analyses matching for age, sex, and CCI, the vitamin D deficiency cohort showed a higher likelihood of osteoporosis. Multivariate analysis demonstrated that vitamin D deficiency was associated with increased odds of aggregated any (OR 1.34) and minor adverse events (1.39), as well as wound dehiscence (OR 1.91). The vitamin D deficiency group had a higher 5-year revision surgery rate (39.3% vs. 31.7%, P = 0.006). When osteoporosis was included as a matched/controlled variable, vitamin D deficiency was only associated with higher odds of aggregate any (OR 1.35) adverse events and urinary tract infection (OR 1.56). No difference in 5-year revision surgery rates was observed. Conclusion: Following adult deformity surgery, many of the perioperative adverse outcomes were similar regardless of controlling for osteoporosis, but 5-year revisions seemed to be driven by the osteoporosis rather than vitamin D deficiency.

Background Context: Endoscopic lumbar decompression is growing in popularity as an alternative to an open approach for management of lumbar radiculopathy. Although endoscopic procedures are inherently less invasive, emergency department (ED) visits may occur postoperatively. Although many quality improvement initiatives target readmissions, ED visits may be more common, be a marker of quality of care, affect patient satisfaction, and contribute to healthcare resource utilization and costs. Purpose: To characterize the timing and risk factors of ED utilization following single-level endoscopic lumbar decompression. Study Design/Setting: Retrospective database review. Patient Sample: PearlDiver M165Ortho data set. Outcome Measures: Timing of ED utilization following endoscopic lumbar decompression, independent risk factors of ED utilization following endoscopic lumbar decompression, and revision surgery rate among patients who use the ED. Methods: Single-level endoscopic lumbar decompression patients were identified from the PearlDiver M165Ortho data set. Patients were excluded if additional procedures were performed, if they were younger than 18 years, if they had a concomitant diagnosis of trauma, neoplasm, or infection on the day of surgery, or if there was not 90-day follow-up in the data set. Patient factors were extracted, including age, sex, Elixhauser Comorbidity Index, region of the country in which their procedure was performed (Midwest, Northeast, South, West), and patient insurance plan (Commercial, Medicaid, Medicare). The incidence, timing, and frequency of ED utilization within 90 days of endoscopic lumbar decompression was then determined. A baseline rate of weekly ED utilization for the study cohort was calculated based on average weekly ED utilization at 52 to 56 weeks postoperatively. Patient factors predictive of postoperative ED utilization were then determined by univariate and multivariate analyses. Results: Of 1397 endoscopic lumbar decompression patients identified, 151 (10.8%) visited the ED within 90 days of surgery. Of note, approximately 29% of these ED visits occurred in the first 2 postoperative weeks. Multivariate analysis revealed several independent predictors of ED utilization following endoscopic lumbar decompression, including female sex (odds ratio [OR] 1.57 relative to male), higher Elixhauser Comorbidity Index (OR 1.15 per two-point increase), and Medicaid coverage (OR 2.49 relative to Medicare). Of patients who visited the ED, 97 (64.2%) were readmitted. Less than 11 patients who used the ED underwent revision surgery in the subsequent 2 weeks. Conclusions: Following endoscopic lumbar decompression, close to 11% of patients were found to visit the ED in the 90 days following their surgery, most commonly in the first two postoperative weeks. Several factors were independently associated with ED utilization, including female sex, greater comorbidity burden, and having Medicaid insurance. Notably, ED utilization rates following endoscopic lumbar decompression are similar to those following open lumbar decompression previously published in the literature. Thus, patients undergoing endoscopic decompression are at similar risk of postoperative ED utilization—surgeons should be aware of this risk and care pathways should be modified to reduce the occurrence of postoperative ED visits in this population.