Background: Low albumin levels have previously been shown to be a risk factor for increased complications in the 30-day postoperative period after total hip or knee arthroplasty. In this study, we examined the effect that albumin levels have on complications in all total joint primary arthroplasties or revisions (shoulder, elbow, wrist, hip, knee, ankle, and fingers). Methods: Patients who underwent a primary total joint arthroplasty or revision from 2005 to 2015 and who had preoperative serum albumin concentration levels recorded were identified from the U.S. National Surgical Quality Improvement Program (NSQIP) database. Patients were grouped into those with normal serum albumin concentrations (≥3.5 g/dL) and those who were hypoalbuminemic (<3.5 g/dL); hypoalbuminemia was subdivided into quartiles for statistical analysis. Univariate analyses were conducted with use of the Student t test for categorical outcomes and the chi-square test for continuous variables. Following univariate analysis, all significant comorbidity variables for both the primary and revision arthroplasty groups were used in a multivariate regression analysis to determine independent association of hypoalbuminemia and postoperative outcomes. Results: Using available data from 2005 to 2015, 135,008 patients fit the eligibility criteria, including those who had undergone primary arthroplasty (n = 125,162) and those who had undergone revision arthroplasty (n = 9,846). The revision arthroplasties included the shoulder (2%), hip (46%), and knee (52%), and the primary arthroplasties included the shoulder (3%), hip (39%), knee (57%), and other (1%). We found that patients who had lower albumin levels had a greater rate of postoperative complications including cardiac arrest, myocardial infarction, cerebrovascular accident, organ or space surgical site infection, sepsis, septic shock, pneumonia, renal insufficiency in general, unplanned intubation, return to the operating room within 30 days, urinary tract infection, and wound infection (all p < 0.005). Conclusions: There was a significant difference in 30-day postoperative complications between patients with normal preoperative albumin levels and those with low albumin levels after all primary total joint arthroplasties or revisions. Patients with low albumin levels were at significantly increased risk for infection, pneumonia, sepsis, myocardial infarction, and other adverse outcomes. Further research is needed to develop interventions to improve serum albumin concentrations preoperatively to mitigate adverse outcomes. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Over the past decade, understanding of disorders compromising greater trochanteric pain syndrome (GTPS) has increased dramatically. Nonsurgical treatment options include physical rehabilitation and activity modification, antiinflammatory as well as biologic injections into the peritrochanteric compartment, and administration of oral analgesics. Multiple open and endoscopic treatment options exist when nonsurgical management is unsuccessful in patients with refractory lateral-sided hip pain, with or without weakness. No true consensus exists within the literature regarding operative techniques of GTPS or postoperative rehabilitation protocols. We present an endoscopic classification system of GTPS with 5 distinct types, which seems to correlate well with preoperative diagnoses and postoperative rehabilitation protocols. The classification system is intuitive, and the corresponding surgical techniques are reproducible for surgeons treating peritrochanteric pathology. Level of Evidence: I (hip); II (extra-articular, impingement).
Background: Ulnar collateral ligament (UCL) reconstruction is a common surgery among Major League Baseball (MLB) pitchers that results in a significant number of missed games. Little has been reported regarding game-by-game trends that can identify those on the verge of becoming injured. Purpose: To determine if there is a patterned change in MLB pitchers’ pitch selection, velocity, or spin rate in games leading up to Tommy John surgery that may predict subsequent UCL surgery. Study Design: Case series; Level of evidence, 4. Methods: A retrospective review of MLB pitchers who underwent primary UCL reconstruction between 2009 and 2019 was performed. Pitch characteristics were evaluated on a game-by-game basis for the 15 games leading up to surgery. A Mann-Kendall trend test was used to identify trends in pitch selection, velocity, and spin rate for multiple pitch types. A Kendall τb correlation coefficient was identified, with values closer to 1 or –1 signifying a stronger monotonic trend. Results: A total of 223 MLB pitchers underwent UCL reconstruction in the time period. In the 15 games leading up to surgery, decreases in pitch velocity for 4-seam fastballs (τb = –0.657; P < .001), 2-seam fastballs (τb = –0.429; P = .029), and sliders (τb = –0.524; P = .008) were significantly associated with game number closer to injury. There was a significant positive association in the spin rate for cutters (τb = 0.410; P = .038) and a significant negative association in spin rate for 4-seam fastballs over the course of these 15 games (τb = –0.581; P = .003). In addition, there was a significant positive association in the percentage of curveballs thrown (τb = 0.486; P = .013). Conclusion: The study results suggest that there is a patterned change in certain pitch statistics in MLB pitchers in the games leading up to Tommy John surgery. Although the absolute change from game to game may be small, it may be possible for these trends to be monitored before a player becomes injured, thus reducing the significant burden Tommy John surgery places on these athletes.
Arthrofibrosis following total knee arthroplasty (TKA) is a debilitating complication. Treatment options include physical therapy, manipulation under anesthesia (MUA), and arthroscopic lysis of adhesions (ALOA) with or without MUA. The authors studied 70 patients with arthrofibrosis after TKA treated with MUA or ALOA plus MUA. In this matched cohort study, 35 patients were treated with MUA and 35 patients were treated with ALOA plus MUA. Total knee arthroplasty followed by MUA was performed by 2 surgeons and TKA followed by MUA plus ALOA was performed by 1 surgeon at 1 institution. Electronic records were used to collect information and match cohorts based on age, sex, body mass index, diabetes mellitus, perioperative range of motion (ROM), and timing of the procedure for arthrofibrosis. The combination of MUA and ALOA yielded changes in ROM: a 72.7% increase 4 to 12 weeks after index TKA ( P =.032), a 50.0% increase 12+ weeks after TKA ( P =.032), and a 99.8% increase in patients with a pre-manipulation ROM of 0° to 60° ( P =.001). Manipulation under anesthesia yielded a 49.2% increase 4 to 12 weeks after TKA ( P =.161), a 27.0% increase 12+ weeks after TKA ( P =.161), and a 68.8% increase in patients with pre-manipulation ROM of 0° to 60° ( P =.084). Patients treated with ALOA plus MUA had greater increases in ROM ( P =.026) and final knee flexion ( P =.028) compared with those treated with MUA alone. Arthrofibrosis following TKA is a complication that often requires additional procedures. Traditionally, ALOA is added 3+ months from index TKA, when abundant scar formation has occurred. This study found a benefit to ALOA plus MUA compared with MUA alone, with the largest benefit in patients whose pre-manipulation ROM was 0° to 60°. [ Orthopedics . 2019; 42(3):163–167.]
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