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Sex differences in utilization and perioperative outcomes of arthroscopic rotator cuff repair

Open AccessPublished:August 08, 2022DOI:https://doi.org/10.1016/j.jseint.2022.07.003

      Background

      As the volume and proportion of patients treated arthroscopically for rotator cuff repair increases, it is important to recognize sex differences in utilization and outcomes.

      Methods

      Patients who underwent arthroscopic rotator cuff repair between 2010 and 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Baseline demographic and clinical characteristics were collected, and information concerning utilization, operative time, length of hospital stay, days from operation to discharge, readmission, and adverse events were analyzed by sex.

      Results

      Of 42,443 included patients, 57.7% were male and 42.3% were female. Comparably, females were generally older (P < .001) and less healthy as indicated by American Society of Anesthesiologists class (P < .001) and rates of obesity (52.0% vs. 47.8%, P < .001), chronic obstructive pulmonary disease (4.0% vs. 2.7%, P < .001), and steroid use (2.7% vs. 1.6%, P < .001). Females experienced shorter operative times (mean difference [MD] 11.5 minutes, P < .001), longer hospital stays (MD 0.03 days, P < .001), longer times from operation to discharge (MD 0.03 days, P < .001), and more minor adverse events (odds ratio [OR], 1.75; 95% confidence interval [CI], 1.24-2.47) after baseline adjustment. Conversely, rates of serious adverse events (OR, 0.69; 95% CI, 0.55-0.86) and readmissions (OR, 0.88; 95% CI, 0.66-0.97) were lower among females. Disparities in utilization increased over the study period (P = .008), whereas length of stay (P = .509) and adverse events (P = .967) remained stable.

      Conclusion

      Sex differences among patients undergoing arthroscopic rotator cuff repair are evident, indicating the need for further research to understand and address the root causes of inequality and optimize care for all.

      Level of evidence

      Keywords

      Although healthcare providers strive for equal treatment of all patients, research suggests that implicit bias may disproportionately affect patient care based on race, ethnicity, sex, and socioeconomic status.
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      Sex differences among those undergoing arthroscopic rotator cuff repair are particularly important to recognize due to the increasing popularity of the procedure. Advances in minimally invasive surgical techniques have allowed surgeons to repair an increasing proportion of rotator cuff tears arthroscopically, and a recent national database study revealed that the volume of total rotator cuff repairs increased by 188% between 2007 and 2015.
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      Trends associated with open versus arthroscopic rotator cuff repair.
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      • Ensor K.L.
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      Patient gender and rotator cuff surgery: are there differences in outcome?.
      studied patient-reported outcomes between men and women undergoing rotator cuff surgery and found no differences in functional outcomes or pain scores within 12 months postoperatively. While this study analyzed sex differences in a small subset of patients undergoing arthroscopic rotator cuff repair, there remains an absence of studies examining this topic utilizing a large, national cohort of patients.
      The purpose of this study was, therefore, to retrospectively analyze a national database to investigate sex-related differences in utilization and several perioperative outcomes among patients following arthroscopic rotator cuff repair. Additionally, sex differences in total operative time, length of total hospital stay, and time from surgery to discharge were examined.

      Materials and methods

      This retrospective cohort study was conducted using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for the years 2010-2019. The ACS-NSQIP is a nationally validated, outcomes-based registry containing voluntarily provided data concerning more than 300 perioperative variables from over 700 participating medical institutions, including academic and private, community and tertiary, and inpatient and outpatient centers.
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      The NSQIP: a new frontier in surgery.
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      Use of the national surgical quality improvement program in orthopaedic surgery.
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      • Schilling P.L.
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      Prioritizing perioperative quality improvement in orthopaedic surgery.
      No attention is paid to payer type to promote a reasonably representative sample of United States payer types, including private, public, and self-pay patients. Baseline characteristics and 30-day perioperative outcomes are recorded directly from the electronic medical record by a team of well-trained surgical clinical reviewers through a process consistently shown to demonstrate excellent inter-rater reliability.
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      • Long 3rd, W.D.
      • et al.
      Variations in data collection methods between national databases affect study results: a comparison of the nationwide inpatient sample and national surgical quality improvement program databases for lumbar spine fusion procedures.
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      • Bohl D.D.
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      Nationwide databases in orthopaedic surgery research.
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      • Shiloach M.
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      • et al.
      Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program.
      As data from the ACS-NQSIP is deidentified and relies on no direct patient contact, this study was granted institutional review board approval by Mass General Brigham IRB Protocol #2021P001230.
      Adult patients aged 18 years or older who underwent primary arthroscopic rotator cuff repair were identified using current procedural terminology code 29827. Baseline demographic (patient age, sex, body mass index (BMI), race, smoking status) and clinical (American Society of Anesthesiologists [ASA] class, diabetes mellitus, steroid use for chronic condition, severe chronic obstructive pulmonary disease [COPD], congestive heart failure [CHF], hypertension requiring medication) data were recorded. Collected data were subsequently analyzed to determine sex-related differences in (1) utilization rates, (2) total operative time, (3) length of total hospital stay, (4) days from operation to discharge, (5) rates of 30-day readmission, and (6) rates of 30-day adverse events. Adverse events were further classified as serious or minor in accordance with previous ACS-NSQIP analyses.
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      • Ondeck N.T.
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      Comparison of outpatient vs inpatient total knee arthroplasty: an ACS-NSQIP analysis.
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      • Lan R.H.
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      Contemporary outpatient arthroplasty is safe compared with inpatient surgery: a propensity score-matched analysis of 574,375 procedures.
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      Outpatient total shoulder arthroplasty: a population-based study comparing adverse event and readmission rates to inpatient total shoulder arthroplasty.
      Explicitly, serious adverse events included death, reoperation, pulmonary complications (unplanned intubation, mechanical ventilation >48 hours), pneumonia, cardiac complications (cardiac arrest, myocardial infarction), renal complications (progressive renal insufficiency, acute renal failure), thromboembolic complications (deep vein thrombosis /thrombophlebitis, pulmonary embolism), deep wound complications (deep incisional surgical site infection [SSI], joint space infection, wound dehiscence), and sepsis, while minor adverse events consisted of superficial SSI and urinary tract infection. Sex-specific trends in procedure utilization rates, length of stay, and serious adverse events over time were also assessed.

      Statistical analysis

      Statistical analyses were conducted using SAS software version 9.4 (SAS Institute, Cary, NC, USA). Continuous variables are reported as means and standard deviations, and categorical variables are reported as percentages. Baseline unadjusted analyses were performed using Student t-tests for continuous variables and Pearson chi-square or Fisher’s exact tests for categorical variables as appropriate to determine sex-related differences. To adjust for differences in baseline demographic and clinical characteristics other than sex, multivariate analyses were performed using binomial logistic regression, and results are reported as odds ratios (ORs), mean differences (MDs), and rate ratios with 95% confidence intervals (CIs). Additionally, sex-by-year interactions were added to the models via Cochran–Armitage Trend testing to assess trends in disparities over time.
      • Armitage P.
      Tests for linear trends in proportions and frequencies.
      ,
      • Cochran W.M.
      Some methods for strengthening the common χ2 tests.
      P values < .05 were considered significant.

      Results

      In total, 42,443 patients undergoing arthroscopic rotator cuff repair between 2010 and 2019 met the inclusion criteria, including 24,483 (57.7%) male and 17,960 (42.3%) female patients. Overall, female patients were older (P < .001) and less healthy than their male counterparts as indicated by higher ASA class (P < .001) and greater rates of obesity (52.0% vs. 47.8%, P < .001), history of COPD (4.0% vs. 2.7%, P < .001), and steroid use for chronic conditions (2.7% vs. 1.6%, P < .001). Rates of smoking within one year prior to surgery were lower among females, however (14.2% vs. 15.6%, P < .001). Notably, the female cohort also consisted of a greater proportion of Black or African American patients than the male cohort (12.7% vs. 8.5%, P < .001). No differences between groups were observed for rates of diabetes mellitus, history of CHF, or hypertension requiring medication. A complete summary of baseline demographic and clinical characteristics is provided in Table I.
      Table IDemographic and clinical characteristics of male and female patients undergoing arthroscopic rotator cuff repair.
      VariablesTotal N = 42,443(%)Female N = 17,960(%)Male N = 24,483(%)P value
      Age group (y)<.001
      Chi-square test.
       0-24203 (0.5)60 (0.3)143 (0.6)
       25-34719 (1.7)203 (1.1)516 (2.1)
       35-443223 (7.6)1112 (6.2)2111 (8.6)
       45+38,297 (90.2)16,584 (92.3)21,713 (88.7)
      Race<.001
      Chi-square test.
       Black or African American4353 (10.3)2280 (12.7)2073 (8.5)
       White38,090 (89.7)15,680 (87.3)22,410 (91.5)
      BMI category<.001
      Chi-square test.
       Normal (≤24.9 kg/m2)6559 (15.6)3554 (19.9)30,05 (12.4)
       Overweight (25.0-29.9 kg/m2)14,706 (34.9)5018 (28.1)9688 (39.8)
       Obese (≥30.0 kg/m2)20,910 (49.6)9273 (52.0)11,637 (47.8)
      Diabetes mellitus.884
      Chi-square test.
       No35,461 (83.5)15,000 (83.5)20,461 (83.6)
       Yes6982 (16.5)2960 (16.5)4022 (16.4)
      ASA class<.001
      Chi-square test.
       13269 (7.7)1049 (5.8)2220 (9.1)
       224,310 (57.3)10,271 (57.2)14,039 (57.4)
       314,844 (35.0)6632 (36.9)8212 (33.6)
      Smoker (within past 1 y)<.001
      Chi-square test.
       No36,082 (85.0)15,413 (85.8)20,669 (84.4)
       Yes6361 (15.0)2547 (14.2)3814 (15.6)
      History of severe COPD<.001
      Chi-square test.
       No41,059 (96.7)17,234 (96.0)23,825 (97.3)
       Yes1384 (3.3)726 (4.0)658 (2.7)
      History of CHF.758
      Chi-square test.
       No42,382 (99.9)17,933 (99.8)24,449 (99.9)
       Yes61 (0.1)27 (0.2)34 (0.1)
      Hypertension requiring medication.373
      Chi-square test.
       No22,392 (52.8)9430 (52.5)12,962 (52.9)
       Yes20,051 (47.2)8530 (47.5)11,521 (47.1)
      Steroid use for chronic condition<.001
      Chi-square test.
       No41,567 (97.9)17,470 (97.3)24,097 (98.4)
       Yes876 (2.1)490 (2.7)386 (1.6)
      ASA, American Society of Anesthesiologists; BMI, body mass index; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease.
      P-values < .05 were considered statistically significant.
      Chi-square test.

      Perioperative outcomes of arthroscopic rotator cuff repair

      Significant sex-related differences in total operative time, length of total hospital stay, and days from operation to discharge following arthroscopic rotator cuff repair were noted on unadjusted analyses (Table II). Despite achieving shorter operative times than male patients (83.1 ± 43.4 vs. 94.1 ± 47.1 minutes, P < .001), female patients demonstrated longer total hospital stays (0.20 ± 3.1 vs. 0.14 ± 1.7 days, P < .001) and greater time from operation to discharge (0.16 ± 1.3 vs. 0.12 ± 1.5 days, P < .001) compared to male patients. Female patients were less likely to experience serious adverse events (0.67% vs. 0.95%, P = .002), as rates of reoperation (0.21% vs. 0.33%, P = .016), myocardial infarction (0.03% vs. 0.09%, P = .017), deep incisional SSI (0.01 % vs. 0.05%, P = .034), and joint space infection (0.01% vs. 0.04%, P = .031) were higher among males. In contrast, overall rates of minor adverse events were higher among females (0.43% vs. 0.23%, P < .001), though this was apparently a reflection of an increased incidence of urinary tract infection (0.34% vs. 0.09%, P < .001) as there was no difference between males and females in incidence of superficial SSI (0.09% vs. 0.14%, P = .140).
      Table IIComparison of outcomes between male and female patients following arthroscopic rotator cuff repair.
      VariablesTotal N = 42,443(%)Female N = 17,960(%)Male N = 24,483(%)P value
      Total operation time<.001
      Negative binomial model.
       N42,40317,94424,459
       Mean ± SD (minutes)89.5 ± 45.983.1 ± 43.494.1 ± 47.1
      Length of total hospital stay<.001
      Negative binomial model.
       N42,43317,95724,476
       Mean ± SD (days)0.2 ± 2.40.20 ± 3.10.14 ± 1.7
      Days from operation to discharge<.001
      Negative binomial model.
       N42,44317,96024,483
       Mean ± SD0.13 ± 1.40.16 ± 1.30.12 ± 1.5
      Readmission.166
      Chi-square test.
       No40,503 (98.93)17,181 (99.01)23,322 (98.87)
       Yes437 (1.07)171 (0.99)266 (1.13)
      Serious adverse events.002
      Chi-square test.
       No42,090 (99.17)17,839 (99.33)24,251 (99.05)
       Yes353 (0.83)121 (0.67)232 (0.95)
      Death.340
      Fisher’s exact test.
      Exact test.
       No42,433 (99.98)17,954 (99.97)24,479 (99.98)
       Yes10 (0.02)6 (0.03)4 (0.02)
      Reoperation.016
      Chi-square test.
       No42,325 (99.72)17,923 (99.79)24,402 (99.67)
       Yes118 (0.28)37 (0.21)81 (0.33)
      Unplanned intubation.949
      Chi-square test.
       No42,419 (99.94)17,950 (99.94)24,469 (99.94)
       Yes24 (0.06)10 (0.06)14 (0.06)
      Ventilator >48 Hours.778
      Chi-square test.
       No42,430 (99.97)17,955 (99.97)24,475 (99.97)
       Yes13 (0.03)5 (0.03)8 (0.03)
      Pneumonia.974
      Chi-square test.
       No42,386 (99.87)17,936 (99.87)24,450 (99.87)
       Yes57 (0.13)24 (0.13)33 (0.13)
      Cardiac arrest.142
      Fisher’s exact test.
      Exact test.
       No42,436 (99.98)17,955 (99.97)24,481 (99.99)
       Yes7 (0.02)5 (0.03)2 (0.01)
      Myocardial infarction.017
      Chi-square test.
       No42,417 (99.94)17,955 (99.97)24,462 (99.91)
       Yes26 (0.06)5 (0.03)21 (0.09)
      Progressive renal insufficiency.656
      Fisher’s exact test.
      Exact test.
       No42,438 (99.99)17,957 (99.98)24,481 (99.99)
       Yes5 (0.01)3 (0.02)2 (0.01)
      Acute renal failure.268
      Fisher’s exact test.
      Exact test.
       No42,440 (99.99)17,960 (100.0)24,480 (99.99)
       Yes3 (0.01)0 (0.00)3 (0.01)
      DVT/Thrombophlebitis.167
      Chi-square test.
       No42,378 (99.85)17,938 (99.88)24,440 (99.82)
       Yes65 (0.15)22 (0.12)43 (0.18)
      Pulmonary embolism.056
      Chi-square test.
       No42,375 (99.84)17,939 (99.88)24,436 (99.81)
       Yes68 (0.16)21 (0.12)47 (0.19)
      Deep incisional SSI.034
      Chi-square test.
       No42,429 (99.97)17,958 (99.99)24,471 (99.95)
       Yes14 (0.03)2 (0.01)12 (0.05)
      Wound dehiscence.729
      Fisher’s exact test.
      Exact test.
       No42,435 (99.98)17,956 (99.98)24,479 (99.98)
       Yes8 (0.02)4 (0.02)4 (0.02)
      Joint space infection.031
      Fisher’s exact test.
      Exact test.
       No42,432 (99.97)17,959 (99.99)24,473 (99.96)
       Yes11 (0.03)1 (0.01)10 (0.04)
      Sepsis.856
      Chi-square test.
       No42,428 (99.96)17,954 (99.97)24,474 (99.96)
       Yes15 (0.04)6 (0.03)9 (0.04)
      Minor adverse events<.001
      Chi-square test.
       No42,309 (99.68)17,883 (99.57)24,426 (99.77)
       Yes134 (0.32)77 (0.43)57 (0.23)
      Superficial SSI.140
      Chi-square test.
       No42,393 (99.88)17,944 (99.91)24,449 (99.86)
       Yes50 (0.12)16 (0.09)34 (0.14)
      Urinary tract infection<.001
      Chi-square test.
       No42,359 (99.80)17,899 (99.66)24,460 (99.91)
       Yes84 (0.20)61 (0.34)23 (0.09)
      DVT, deep vein thrombosis; SD, standard deviation; SSI, surgical site infection.
      Exact test.
      Chi-square test.
      Fisher’s exact test.
      § Negative binomial model.
      After adjusting to control for age, race, BMI, ASA class, smoking status, history of COPD, and steroid use for chronic conditions, differences in perioperative outcomes between male and female patients remained significant. Compared to males, total operation time was 11.5 minutes shorter for females (P < .001), while length of total hospital stay (MD 0.03 days, P < .001) and days from operation to discharge (MD 0.03 days, P < .001) were also increased (Table III). Moreover, rates of readmission (OR, 0.80; 95% CI, 0.66-0.97; P = .025) and serious adverse events (OR, 0.69; 95% CI, 0.55-0.86; P = .001) were 20% and 31% lower among female than male patients, respectively, though rates of minor adverse events were 75% higher (OR, 1.75; 95% CI, 1.24-2.47; P = .001; Table IV).
      Table IIIAdjusted analyses comparing perioperative outcomes between male and female patients undergoing arthroscopic rotator cuff repair.
      OutcomesSexAdjusted rate ratio (95% CI)P ValueEstimated mean difference
      Total operation timeFemale vs Male0.88 (0.88-0.89)<.001−11.50 minutes
      Length of total hospital stayFemale vs Male1.24 (1.13-1.36)<.0010.03 days
      Days from operation to dischargeFemale vs Male1.26 (1.16-1.38)<.0010.03 days
      CI, confidence interval.
      Note: Adjusted for age, race, body mass index, American Society of Anesthesiologists class, smoking status, history of COPD, and steroid use for chronic condition.
      Table IVAdjusted analyses comparing postoperative outcomes between male and female patients following arthroscopic rotator cuff repair.
      OutcomesGenderAdjusted OR (95% CI)P Value
      ReadmissionFemale vs Male0.80 (0.66-0.97).025
      Serious adverse eventsFemale vs Male0.69 (0.55-0.86).001
      Minor adverse eventsFemale vs Male1.75 (1.24-2.47).001
      CI, confidence interval; OR, odds ratio.
      Note: Adjusted for age, race, body mass index, American Society of Anesthesiologists class, smoking status, history of severe COPD, and steroid use for chronic condition.

      Trends in arthroscopic rotator cuff repair

      The proportion of arthroscopic rotator cuff repair procedures performed for male and female patients varied from year to year; however, analysis of trends in relative utilization rates revealed the proportion of procedures performed for female patients slightly decreased between 2010 and 2019 at an average rate of 0.011% annually (P = .008; Table V, Fig. 1). Length of total hospital stay decreased over the study period for both male (coefficient −0.10, P < .001) and female (coefficient −0.08, P < .001) patients, though disparities between sexes persisted (ptrend = 0.509). Additionally, rates of serious adverse events for male (coefficient 0.005, P = .900) and female (coefficient 0.007, P = .807) patients, as well as disparities between the two sexes (ptrend = 0.967), remained largely unchanged.
      Table VRates of arthroscopic rotator cuff repair utilization.
      YearTotal NFemale N (%)Male N (%)
      Total (2010-2019)42,43317,960 (42.3)24,483 (57.7)
      20101128482 (41.7)646 (57.3)
      20111481608 (41.1)873 (58.9)
      20122193966 (44.0)1227 (56.0)
      201329841325 (44.4)1659 (55.6)
      201439381669 (42.4)2269 (57.6)
      201549732108 (42.4)2865 (57.6)
      201659822592 (43.3)3390 (56.7)
      201766622825 (42.4)3837 (57.6)
      201863552597 (40.9)3758 (59.1)
      201967472788 (41.3)3959 (58.7)
      Figure thumbnail gr1
      Figure 1Trends in relative utilization of arthroscopic rotator cuff repair among males and females between 2010 and 2019.

      Discussion

      The development of arthroscopic methods for rotator cuff repair has enabled surgeons to substantially increase procedural volume while maintaining excellent outcomes.
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      • Bedard N.A.
      • Glass N.A.
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      Trends associated with open versus arthroscopic rotator cuff repair.
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      • Ensor K.L.
      • Kwon Y.W.
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      • Zuckerman J.D.
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      The rising incidence of rotator cuff repairs.
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      • Khan M.
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      Arthroscopic repair of full-thickness tears of the rotator cuff.
      ,
      • Stollsteimer G.T.
      • Savoie 3rd, F.H.
      Arthroscopic rotator cuff repair: current indications, limitations, techniques, and results.
      ,
      • Tauro J.C.
      Arthroscopic rotator cuff repair: analysis of technique and results at 2- and 3-year follow-up.
      whether males and females equitably benefit from such methodological advances remains uncertain. The present study therefore compared rates of utilization, operative time, length of hospital stay, readmission, and adverse events between sexes using the ACS-NSQIP registry. Between 2010 and 2019, female patients comprised a smaller proportion of arthroscopic rotator cuff repair procedures relative to male patients. Total operative time was shorter among females, though measures of length of total hospital stay and time from operation to discharge were each longer than for males. Moreover, female patients exhibited higher rates of minor adverse events within 30 days of surgery, whereas male patients were more likely to experience serious adverse events and readmission. As a secondary analysis, trends in relative utilization, length of total hospital stay, and rates of serious adverse events were examined. Results indicate the proportion of procedures performed for female patients slightly decreased over the study period, whereas both sexes experienced similar reductions in the length of total hospital stay, and rates of adverse events remained stable. These findings warrant the consideration of clinicians and researchers alike as they show sex-related disparities in utilization and perioperative outcomes exist as more than merely a reflection of differences in baseline demographic or clinical characteristics, highlighting the need for further research to identify root causes and address inequality in arthroscopic rotator cuff repair.
      Numerous differences in baseline demographic and clinical characteristics were noted between male and female cohorts. Female patients were generally older and less healthy, exhibiting higher rates of obesity, COPD, and steroid use for chronic conditions than males. Racial differences were also noted, as the female cohort consisted of a relatively larger proportion of Black and African American patients. However, such inconsistencies did not explain disparities in perioperative outcomes. Instead, sex differences in total operative time, length of total hospital stay, time from operation to discharge, readmission, and incidence of serious and minor adverse events persisted even after adjusting for age, race, BMI, ASA class, smoking status, history of COPD, and steroid use for chronic conditions.
      To our knowledge, this study is the first to explore sex differences in arthroscopic rotator cuff repair utilization and outcomes in a large, nationwide cohort of patients. Disparities identified herein build upon previous research comparing patient-reported outcomes between male and female patients, which has produced mixed findings to date. In a study of 283 patients, Daniels et al
      • Daniels S.D.
      • Stewart C.M.
      • Garvey K.D.
      • Brook E.M.
      • Higgins L.D.
      • Matzkin E.G.
      Sex-based differences in patient-reported outcomes after arthroscopic rotator cuff repair.
      observed women to report higher pain and lower shoulder function scores than men both preoperatively and within 3 months following surgery, translating to increased need for narcotic pain medication. Nevertheless, women did achieve greater improvements than males in both scores following surgery, demonstrating the benefit of arthroscopic repair for female patients. In contrast, Sabo et al
      • Sabo M.T.
      • LeBlanc J.
      • Hildebrand K.A.
      Patient gender and rotator cuff surgery: are there differences in outcome?.
      more recently demonstrated no significant differences in patient-reported pain or function at any timepoint within one year of surgery, though results may have been limited by a smaller sample size. Interestingly, the authors noted women were more likely to undergo rotator cuff repair on the dominant arm, have smaller tear size, and have full rotator cuff repair than men. However, the extent to which these factors impact patient-reported outcomes is a topic of debate. Rather, Wylie et al
      • Wylie J.D.
      • Suter T.
      • Potter M.Q.
      • Granger E.K.
      • Tashjian R.Z.
      Mental health has a stronger association with patient-reported shoulder pain and function than tear size in patients with full-thickness rotator cuff tears.
      determined mental health to be more strongly associated with patient-reported outcomes than tear characteristics, and differences in gender-based societal norms concerning pain expression and activity demands have also been postulated as potential influences.
      • Daniels S.D.
      • Stewart C.M.
      • Garvey K.D.
      • Brook E.M.
      • Higgins L.D.
      • Matzkin E.G.
      Sex-based differences in patient-reported outcomes after arthroscopic rotator cuff repair.
      ,
      • Razmjou H.
      • Holtby R.
      • Myhr T.
      Gender differences in quality of life and extent of rotator cuff pathology.
      ,
      • Sabo M.T.
      • LeBlanc J.
      • Hildebrand K.A.
      Patient gender and rotator cuff surgery: are there differences in outcome?.
      Thus, though findings of the current study demonstrate significant sex differences in objective measures of total operative time, length of hospital stay, and rates of adverse events among a much larger patient cohort, the underlying factors responsible for such disparities remain to be fully understood.
      It is interesting that female patients constituted a smaller percentage of arthroscopic rotator cuff repair procedures with growing disparity over the study period, particularly as women have been shown to display higher rates of multidirectional shoulder instability and generalized joint laxity which may predispose to rotator cuff injury.
      • Beasley L.
      • Faryniarz D.A.
      • Hannafin J.A.
      Multidirectional instability of the shoulder in the female athlete.
      ,
      • Cody E.A.
      • Strickland S.M.
      Multidirectional instability in the female athlete.
      ,
      • Maier SPR S.S.
      • Wright C.L.
      • Daniell H.D.
      • Lydston M.
      • O’Donnell E.A.
      Sex differences in shoulder anatomy and biomechanics: a systematic review and meta-analysis.
      This supports the notion that shoulder pathology is not explained solely by sex-related anatomic differences but more likely stems from a complex interplay of multiple causes including the effects of sex hormones and inflammatory mediators.
      • Hart D.A.
      • Frank C.B.
      • Kydd A.
      • Ivie T.
      • Sciore P.
      • Reno C.
      Neurogenic, mast cell, and gender variables in tendon biology: potential role in chronic tendinopathy.
      Genetic factors have also been implicated, as Figueiredo et al
      • Figueiredo E.A.
      • Loyola L.C.
      • Belangero P.S.
      • Campos Ribeiro-Dos-Santos A.K.
      • Emanuel Batista Santos S.
      • Cohen C.
      • et al.
      Rotator cuff tear susceptibility is associated with variants in genes involved in tendon extracellular matrix homeostasis.
      reported variation in collagen haplotype and dysregulation of matric metalloproteinases to impact injury risk in males and females, respectively. Moreover, the prevalence of asymptomatic rotator cuff pathology may differ between males and females, further contributing to differential need for arthroscopic rotator cuff repair.
      • Moosmayer S.
      • Smith H.J.
      • Tariq R.
      • Larmo A.
      Prevalence and characteristics of asymptomatic tears of the rotator cuff: an ultrasonographic and clinical study.
      Another noteworthy finding of the present study was that although female patients experienced higher rates of minor adverse events within 30 days, women exhibited lower rates of serious adverse events and readmission compared to men even after adjusting for baseline characteristics. The greater rate of minor adverse effects among females is evidently driven by an increased incidence of urinary tract infection, and this difference is likely a consequence of anatomic and hormonal contributions that naturally place females at greater risk rather than secondary to surgical intervention. The finding that males experience a higher rate of severe adverse events is in accordance with previous literature demonstrating similarly increased risk of death, myocardial infarction, and sepsis following orthopedic procedures including total shoulder arthroplasty,
      • Knapp B.M.
      • Botros M.
      • Sing D.C.
      • Curry E.J.
      • Eichinger J.K.
      • Li X.
      Sex differences in complications and readmission rates following shoulder arthroplasty in the United States.
      ,
      • Saltzman B.M.
      • Basques B.
      • Leroux T.
      • Frank R.M.
      • Nicholson G.P.
      • Verma N.N.
      • et al.
      The influence of gender on early adverse events, hospital charges and length of stay after shoulder arthroplasty.
      lower extremity arthroplasty,
      • Mantilla C.B.
      • Horlocker T.T.
      • Schroeder D.R.
      • Berry D.J.
      • Brown D.L.
      Frequency of myocardial infarction, pulmonary embolism, deep venous thrombosis, and death following primary hip or knee arthroplasty.
      ,
      • Santaguida P.L.
      • Hawker G.A.
      • Hudak P.L.
      • Glazier R.
      • Mahomed N.N.
      • Kreder H.J.
      • et al.
      Patient characteristics affecting the prognosis of total hip and knee joint arthroplasty: a systematic review.
      and spine surgery.
      • Basques B.A.
      • Hijji F.Y.
      • Khechen B.
      • Haws B.E.
      • Mayo B.C.
      • Massel D.H.
      • et al.
      Sex differences for anterior cervical fusion: complications and length of stay.
      ,
      • Manoharan S.R.
      • Baker D.K.
      • Pasara S.M.
      • Ponce B.
      • Deinlein D.
      • Theiss S.M.
      Thirty-day readmissions following adult spinal deformity surgery: an analysis of the National Surgical Quality Improvement Program (NSQIP) database.
      There are a number of possible explanations for these results. For example, various risk factors have been shown to differentially affect risk for myocardial infarction among males and females.
      • Manfrini O.
      • Yoon J.
      • van der Schaar M.
      • Kedev S.
      • Vavlukis M.
      • Stankovic G.
      • et al.
      Sex differences in modifiable risk factors and severity of coronary artery disease.
      Thus although analyses were adjusted for patient demographics and comorbidities, baseline risk for myocardial infarction may still be greater among men than women prior to surgery. Differences in joint space infection rates may stem from an increased risk for Cutibacterium acnes infection among males, as male gender is a known risk factor for C acnes infection particularly following shoulder procedures, with up to 71% of cases occurring in men.
      • Berthelot P.
      • Carricajo A.
      • Aubert G.
      • Akhavan H.
      • Gazielly D.
      • Lucht F.
      Outbreak of postoperative shoulder arthritis due to Propionibacterium acnes infection in nondebilitated patients.
      While there was insufficient data to delineate the reasons for differences in serious adverse event rates between male and female patients in the present study, it is not surprising that increased risk for severe adverse events was paired with higher rates of readmission among men.
      There are several limitations to consider when interpreting the results of this study. Alhough the ACS-NSQIP registry is a high-quality source of nationwide data validated by clinically trained reviewers, patient outcomes are only followed for 30 days following surgery, limiting capture of complications beyond this period and potentially underestimating rates of postoperative adverse event. Moreover, rates of adverse events are only captured for patients who seek care at an institution participating in the ACS-NSQIP. Information concerning surgeon experience, preoperative assessment, hospital volume, and procedural details were not documented, nor were more detailed clinical characteristics such as size and chronicity of rotator cuff tear, number of tendons affected, and extent of arthritis. Thus, their potential impact on arthroscopic rotator cuff repair utilization and perioperative outcomes could not be assessed. Relatedly, variation in postoperative rehabilitation was not evaluated despite their potential to attenuate risk for certain complications (eg, deep vein thrombosis). As a consequence of the large number of patients included in this study, analyses may produce results that are statistically but not clinically significant. For example, the mean difference in time between operation and discharge between male and female patients was statistically significant but measured only 0.03 days. Nevertheless, the ACS-NSQIP database remains an excellent resource for analysis of surgical utilization and short-term outcomes.
      • Bohl D.D.
      • Basques B.A.
      • Golinvaux N.S.
      • Miller C.P.
      • Baumgaertner M.R.
      • Grauer J.N.
      Extramedullary compared with intramedullary implants for intertrochanteric hip fractures: thirty-day outcomes of 4432 procedures from the ACS NSQIP database.
      ,
      • Bohl D.D.
      • Singh K.
      • Grauer J.N.
      Nationwide databases in orthopaedic surgery research.
      ,
      • Eberlin C.T.
      • Varady N.H.
      • Kucharik M.P.
      • Naessig S.A.
      • Best M.J.
      • Martin S.D.
      Comparison of perioperative complications following surgical treatment of shoulder instability.
      ,
      • Fox H.M.
      • Best M.J.
      • Mikula J.D.
      • Aziz K.T.
      • Srikumaran U.
      Short-term complications and readmission following total shoulder arthroplasty: a National Database Study.
      ,
      • Harris A.B.
      • Best M.J.
      • Weiner S.
      • Gupta H.O.
      • Jenkins S.G.
      • Srikumaran U.
      Hospital readmission rates following outpatient versus inpatient shoulder arthroplasty.
      ,
      • Kucharik M.P.
      • Varady N.H.
      • Best M.J.
      • Rudisill S.S.
      • Naessig S.A.
      • Eberlin C.T.
      • et al.
      Comparison of outpatient vs. inpatient anatomic total shoulder arthroplasty: a propensity score-matched analysis of 20,035 procedures.

      Conclusion

      As the use of arthroscopic techniques for rotator cuff repair continues to rise, it is imperative to recognize and characterize differences in procedure utilization and perioperative outcomes across patient groups. The present study focuses specifically on sex differences and demonstrates women to constitute a relatively smaller proportion of arthroscopic rotator cuff repair procedures, experience shorter operative time and longer hospital stay, and face greater risk of early postoperative minor adverse events, whereas male patients are at greater risk for severe adverse events and readmission following surgery. By highlighting sex-related disparities in rotator cuff repair, this study indicates the need for further research to understand and address the root causes of inequality and optimize orthopedic care for all.

      Acknowledgments

      The authors would like to express their gratitude to Yanzhi Wang, PhD, from the University of Illinois College of Medicine Research Services for her assistance with statistical analyses.

      Disclaimers

      Funding: This study was supported by the Conine Family Fund for Joint Preservation.
      Conflicts of interest: The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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