ChatGPT Provides Misinformed Responses to Medical Questions.

Surgeons have dealt with the negative effects of misinformation from "Dr. Google" since patients starting using search engines to seek out medical information. With the advent of natural language processing software such as ChatGPT, patients may have a seemingly real conversation with AI software. However, ChatGPT provides misinformation in response to medical questions, and responds at the reading level of a college freshman, whereas US National Institute of Health recommends medical information be written at a 6th grade level. The flaw of ChatGPT is that it recycles information from the internet. It is "artificially intelligent" because of its ability to mimic natural language - not because of its ability to understand and synthesize content. It fails to understand nuance or critically analyze new inputs. Ultimately, these skills require human intelligence, while ChatGPT provides responses that are exactly what you might expect - artificial.

ChatGPT Responses to Common Questions About Anterior Cruciate Ligament Reconstruction Are Frequently Satisfactory.

PURPOSE: To evaluate ChatGPT responses to common questions patients have regarding anterior cruciate ligament (ACL) reconstruction. METHODS: Ten frequently asked questions regarding ACL tears and ACL reconstruction were chosen from the frequently asked questions found on the websites of major institutions. These were presented to ChatGPT and responses were rated as "excellent response not requiring clarification," "satisfactory requiring minimal clarification," "satisfactory requiring moderate clarification," or "unsatisfactory requiring substantial clarification." RESULTS: Four responses were satisfactory, requiring minimal clarification, 3 were satisfactory, requiring moderate clarification, 2 were unsatisfactory, and 1 was excellent, requiring no clarification. CONCLUSIONS: As hypothesized, ChatGPT provided generally accurate information to common questions around ACL reconstruction. Although clarification often was needed, responses were satisfactory for providing generalized information about ACL tears and ACL reconstruction. CLINICAL RELEVANCE: ChatGPT is a promising avenue for patients to learn about general background information regarding ACL reconstruction, although questions specific to any planned operation need to be addressed directly with an orthopaedic provider.

ChatGPT Responses to Common Questions About Slipped Capital Femoral Epiphysis: A Reliable Resource for Parents?

BACKGROUND: We sought to evaluate the ability of ChatGPT, an AI-powered online chatbot, to answer frequently asked questions (FAQs) regarding slipped capital femoral epiphysis (SCFE). METHODS: Seven FAQs regarding SCFE were presented to ChatGPT. Initial responses were recorded and compared with evidence-based literature and reputable online resources. Responses were subjectively rated as "excellent response requiring no further clarification," "satisfactory response requiring minimal clarification," "satisfactory response requiring moderate clarification," or "unsatisfactory response requiring substantial clarification." RESULTS: ChatGPT was frequently able to provide satisfactory responses that required only minimal clarification. One response received an excellent rating and required no further clarification, while only 1 response from ChatGPT was rated unsatisfactory and required substantial clarification. CONCLUSIONS: ChatGPT is able to frequently provide satisfactory responses to FAQs regarding SCFE while appropriately reiterating the importance of always consulting a medical professional.

High Case Volume Predicts Greater Odds of Autograft Use and Meniscal Repair for Anterior Cruciate Ligament Reconstruction.

PURPOSE: To evaluate how both annual surgeon and facility volume affect the cost and outcomes of anterior cruciate ligament reconstruction surgery. We also aimed to identify trends in how surgeon caseload predicts graft selection. METHODS: The 2014 State Ambulatory and Surgical Database from Florida was used. Every case with Current Procedural Terminology code 29888 ("Arthroscopic anterior cruciate ligament reconstruction") was selected. Surgeon and facility identifiers were used to separate high- and low-volume groups, defined as >25 cases for surgeons and >125 cases for facilities. Univariate analysis was performed for patient demographics and surgical characteristics. Multivariate analysis was performed on significant factors to determine how these variables impact cost and odds of allograft usage, postoperative admission, and meniscal repair. RESULTS: There were 7905 cases performed between January 1, 2014, and December 31, 2014 after excluding same-year revisions. High-volume surgeons had $6155 lower total charges, were 1.949 times more likely to use an autograft, and had 54.5% lower odds of postoperative admission (all P < .001). They were also 1.196 times more likely to perform a meniscal repair (P = .017). In patients younger than 18, low-volume surgeons were 3.7 times more likely to use an allograft (P < .001). Concomitant multiligamentous procedures were also performed at greater rates in the high-volume group. Postoperative admission added $18,698, and allografts added $9174 (both P < .001). CONCLUSIONS: We found that high-volume surgeons were more likely to perform a meniscal repair and less likely to have their patients admitted postoperatively, which was the second largest cost driver of anterior cruciate ligament reconstruction. They were also significantly less likely to use an allograft, especially in patients younger than the age of 18 years. High-volume surgeons had lower costs despite greater rates of concomitant procedures. LEVEL OF EVIDENCE: III, retrospective cohort study.

Higher complication rates following primary total shoulder arthroplasty in patients presenting from areas of higher social deprivation.

Aims: The aim of this study was to characterize the influence of social deprivation on the rate of complications, readmissions, and revisions following primary total shoulder arthroplasty (TSA), using the Social Deprivation Index (SDI). The SDI is a composite measurement, in percentages, of seven demographic characteristics: living in poverty, with < 12 years of education, single-parent households, living in rented or overcrowded housing, households without a car, and unemployed adults aged < 65 years. Methods: Patients aged ≥ 40 years, who underwent primary TSA between 2011 and 2017, were identified using International Classification of Diseases (ICD)-9 Clinical Modification and ICD-10 procedure codes for TSA in the New York Statewide Planning and Research Cooperative System database. Readmission, reoperation, and other complications were analyzed using multivariable Cox proportional hazards regression controlling for SDI, age, ethnicity, insurance status, and Charlson Comorbidity Index. Results: A total of 17,698 patients with a mean age of 69 years (SD 9.6), of whom 57.7% were female, underwent TSA during this time and 4,020 (22.7%) had at least one complication. A total of 8,113 patients (45.8%) had at least one comorbidity, and the median SDI in those who developed complications 12 months postoperatively was significantly greater than in those without a complication (33 vs 38; p < 0.001). Patients from areas with higher deprivation had increased one-, three-, and 12-month rates of readmission, dislocation, humeral fracture, urinary tract infection, deep vein thrombosis, and wound complications, as well as a higher three-month rate of pulmonary embolism (all p < 0.05). Conclusion: Beyond medical complications, we found that patients with increased social deprivation had higher rates of humeral fracture and dislocation following primary TSA. The large sample size of this study, and the outcomes that were measured, add to the literature greatly in comparison with other large database studies involving TSA. These findings allow orthopaedic surgeons practising in under-served or low-volume areas to identify patients who may be at greater risk of developing complications.

The Primary Cost Drivers of Outpatient Distal Radius Fracture Fixation: A Cost-Minimalization Analysis of 15,379 Cases.

Background Distal radius fractures are the most common fracture of the upper extremity. While some distal radius fractures can be managed with closed reduction and immobilization, operative treatment is the standard of care, with open reduction internal fixation (ORIF) as a predominant operative method. Questions/Purpose To investigate how patient and surgical characteristics affect the overall costs of internal fixation of distal radius fractures in adults. Patients and Methods The 2014 State Ambulatory Surgery and Services Databases for six states were used to identify cases and surgical characteristics of distal radius fracture ORIF in adult patients. Results Surgical variables that significantly increased cost were postoperative admission within 30 days, regional anesthesia, simultaneous endoscopic carpal tunnel release, and increasing operating room time. Conclusion Substantial contributors to total cost are postoperative hospital admission within 30 days of surgery, use of regional anesthesia, simultaneous endoscopic carpal tunnel release, and longer operative time. Level of Evidence Level III, retrospective cohort study.

Trends in operative duration of total shoulder arthroplasty from 2008 to 2018: a national database study.

Background: As total shoulder arthroplasty has emerged as the fastest growing joint replacement performed, optimizing surgical efficiency and patient outcomes is essential. The goals of the current study were to identify trends and factors affecting the operative time of total shoulder arthroplasty over a 10-year period. Methods: The National Surgical Quality Improvement Program database was analyzed to determine the operative time and 30-day complications of total shoulder arthroplasty from 2008 to 2018. Factors affecting total shoulder arthroplasty operative time were also assessed. Multivariable linear regression was used to analyze operative time over years studied while controlling for patient demographics and comorbidities. Results: A total of 20,587 total shoulder arthroplasty cases from 2008 to 2018 were included. Mean operative time in 2008 was 139.0 min, while in 2018, mean operative time decreased to 105.6 min (P < .001). Male sex, outpatient surgery, increased body mass index, and low preoperative hematocrit were associated with longer operative times, while elevated international normalized ratio, resident involvement, and elective surgeries were associated with decreased operative duration. Discussion: Operative time for total shoulder arthroplasty has decreased from 2008 to 2018. Patient factors and comorbidities are associated with operative time, and such factors are important to consider in operative planning to ensure appropriate patient and surgeon expectations.

A novel comorbidity risk score for predicting postoperative 30-day complications in total shoulder arthroplasty and elucidation of potential racial disparities.

Background: Efficient and effective preoperative identification of those patients with elevated risk may allow for more cost-effective interventions, accurate bundled payment adjustments, and overall improved patient care. Few comorbidity indices have provided clinical utility and adequate discriminative ability in the setting of complications after shoulder arthroplasty (SA). Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for anatomic and/or reverse SA procedures between 2010 and 2019. A subset of comorbidities were utilized including end-stage renal disease, history of hypertension, chronic obstructive pulmonary disease, functional status, history of bleeding disorder, and disseminated cancer. Results: A total of 25,927 patients with an average age of 69.2 (standard deviation ±9.5) years were included in the study. Patients with a comorbidity risk score (CRS) at or above 2 were indicated to have at least a 29.6% 30-day postoperative complication rate after undergoing total shoulder arthroplasty, significantly higher than the described average of approximately 15%. The area under receiver operator curve for the novel CRS scoring system was 0.595, indicating fair discriminative ability to predict 30-day postoperative complications after SA. This illustrates a discriminative ability similar to that of the American Society of Anesthesiologists classification (0.584, confidence interval [CI] 0.578-0.589), modified Charlson Comorbidity Index (0.567, CI 0.561-0.573), and modified Frailty Index (0.534, CI 0.529-0.539), each of which are common comorbidity indices used for the National Surgical Quality Improvement Program database. The average CRS for the population was 0.8537 (CI 0.8011-0.8150; P < .05) while that for the Black demographic was 1.08 (CI 1.03-1.13; P < .001). Our results suggest that if the disparity in CRS among races was corrected, the average complication rate would be decreased by 2.0%. Discussion and Conclusion: A higher CRS score resulted in higher rates of 30-day postoperative complications following SA. Black patients had a higher average CRS than all other races illustrating a racial disparity in comorbidity risk. Although the average complication rate of each race would still be unequal, this could mitigate some of the racial disparities observed and decrease the overall 30-day complication rate in SA. With the rise of bundled payments further increasing the need to preoperatively identify patients at high risk for costly complications, the CRS is based on easily identified, relevant comorbidities that may be an advantageous tool to identify patients at increased risk of complications following SA.

Epidemiology of rugby-related fractures in high school- and college-aged players in the United States: an analysis of the 1999-2018 NEISS database.

OBJECTIVES: Rugby is a high-impact collision sport with identical competition rules by sex. The aim of this study was to analyze the trend of rugby-related fractures by body site, sex, and age in amateur athletes from 1999 to 2018. METHODS: The National Electronic Injury Surveillance System (NEISS) database was queried to characterize rugby-related injuries from 1999 to 2018 in patients aged 14-23 years old. National injury estimates were calculated using sample weights. Chi-square analysis and one-way ANOVA were performed to compare categorical variables. RESULTS: Out of a total of 43,722 weighted cases of rugby-related fractures over the 19-year period, 70.9% were among high school- and college-aged males and females between the ages of 14-23 years (N = 30,996). Males constituted 79.3% of cases whereas females composed 20.7% of the cases. The proportion of upper extremity fractures was similar in both males and females, yet facial fractures were significantly more common among males than females (27.9% vs. 14.6%, P < 0.001). Among facial fractures, nasal fractures represented 74.4% of the sample, yet facial fractures only resulted in hospital admittance in 1.3% of cases. Lower extremity fractures were more likely to be severe, with 11.3% of LE cases being admitted to the hospital. CONCLUSION: Rugby players in the US diagnosed in the ED with fractures consisted largely of male, high school- and college-aged athletes. Males and females experienced upper and lower-extremity fractures at comparable rates, yet lower extremity injuries were more likely to be admitted to a hospital. Men were significantly more likely to experience a facial fracture in which a majority were nasal fractures.

Prevalence and Clinical Impact of Incidental Findings on Preoperative 3D Planning Computed Tomography for Total Shoulder Arthroplasty.

INTRODUCTION: 3D planning software for shoulder arthroplasty recently emerged for aiding in intraoperative determination of native glenoid. These protocols often require increased scan resolution, however, raising the question of an increased prevalence and clinical impact of incidental findings (IFs) from preoperative imaging. METHODS: A retrospective review of preoperative shoulder CT reports was conducted for 333 consecutive patients planning anatomic or reverse total shoulder arthroplasties. Patients with thin-sliced CT scans (1.25 mm) were compared with those with standard CT scans (2.5 mm). Poisson regression was performed with baseline characteristics and potentially pathologic IFs (PPIFs). RESULTS: IFs were present in 131 of the 333 scans (39.3%), and 38 of the 333 scans (11.4%) included PPIFs. Only 8 of the 333 scans (2.4%) required workup, with 2 of the 333 (0.6%) leading to new cancer diagnoses. Thin-sliced CT scans detected a higher mean number of IFs (1.12 versus 0.22, P < 0.001) while the mean number of PPIFs remained similar (0.13 versus 0.10, P = 0.43). CONCLUSION: IFs are frequent; however, only 0.6% scans led to new cancer diagnoses. Comparison of thin-sliced with standard CT scans revealed a higher frequency of IFs but similar PPIFs, indicating increased burden of IFs without the benefit of identifying additional malignancies. As demand rises for shoulder arthroplasties, surgeons should consider the potential hidden costs of IFs when using 3D planning programs.

Social and Demographic Factors Impact Shoulder Stabilization Surgery in Anterior Glenohumeral Instability.

Purpose: To assess independent predictors of surgery after an emergency department visit for shoulder instability, including patient-related and socioeconomic factors. Methods: Patients presenting to the emergency department were identified in the New York Statewide Planning and Research Cooperative System database from 2015 to 2018 by International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes for anterior shoulder dislocation or subluxation. All shoulder stabilization procedures in the outpatient setting were identified using Current Procedural Terminology codes (23455, 23460, 23462, 23466, and 29806). A multivariable logistic regression was performed to assess the impact of patient factors on the likelihood of receiving surgery. The variables included in the analysis were age, sex, race, social deprivation, Charlson Comorbidity Index, recurrent dislocation, and primary insurance type. Results: In total, 16,721 patients with a shoulder instability diagnosis were included in the analysis and 1,028 (6.1%) went on to have surgery. Patients <18 years old (odds ratio [OR] 8.607, P < .0001), those with recurrent dislocations (OR 2.606, P < .0001), or worker's compensation relative to private insurance (OR 1.318, P = .0492) had increased odds of receiving surgery. Hispanic (OR 0.711, P = .003) and African American (OR 0.63, P < .0001) patients had decreased odds of surgery compared with White patients. Patients with Medicaid (OR 0.582, P < .0001) or self-pay (OR 0.352, P < .0001) insurance had decreased odds of undergoing surgery relative to privately insured patients. Patients with greater levels of social deprivation (OR 0.993, P < .0001) also were associated with decreased odds of surgery. Conclusions: Anterior glenohumeral instability and subsequent stabilization surgery is associated with disparities among patient race, primary insurance, and social deprivation. Clinical Relevance: Considering the relationship between differential care and health disparities, it is critical to define and increase physician awareness of these disparities to help ensure equitable care.

Increased Total Cost and Lack of Diagnostic Utility for Emergency Department Visits After ACL Injury.

BACKGROUND: Patients are commonly evaluated at the emergency department (ED) with acute anterior cruciate ligament (ACL) tears, but providers without orthopaedics training may struggle to correctly diagnose these injuries. HYPOTHESIS: It was hypothesized that few patients would be diagnosed with an ACL tear while in the ED and that these patients would be of lower socioeconomic status and more likely to have public insurance. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The 2017 State Ambulatory Surgery and Services Database (SASD) and State Emergency Department Database (SEDD) from the state of Florida were utilized in this study. Cases with Current Procedural Terminology code 29888 (arthroscopically aided ACL reconstruction [ACLR]) were selected from the SASD, and data from the SEDD were matched to patients who had an ED visit for a knee injury within 120 days before ACLR. Chi-square analysis was used to test for differences in patient and surgical variables between the ED visit and nonvisit patient groups. A generalized linear model was created to model the effect of ED visit on total cost for an ACL injury. RESULTS: While controlling for differences in patient characteristics and concomitant procedure usage, a visit to the ED added $4587 in total cost (P < .001). The ED visit cohort contained a greater proportion of patients with Medicaid (20.2% vs 9.1%), patients who were Black (18.4% vs 10.3%), and patients in the lowest income quartile (34.4% vs 25.0%) (P < .001 for all). In the ED visit cohort, 14.4% of patients received an allograft versus 10.1% in the non-ED visit cohort (P = .001) despite having a similar mean age. An ACL sprain was diagnosed in only 29 of the 645 (4.5%) patients who visited the ED. CONCLUSION: Utilizing the ED for care after an ACL injury was expensive, averaging a $4587 increase in total cost associated with ACLR. However, patients rarely left with a definitive diagnosis, with only 4.5% of patients who underwent ACLR being correctly diagnosed with an ACL tear in the ED. This additional cost was levied disproportionately on patients of low socioeconomic status and patients with Medicaid.

Preoperative malnutrition increases odds of hospital admission and extended length of stay following arthroscopic rotator cuff repair.

BACKGROUND: Rotator cuff repair (RCR) is a common orthopedic procedure frequently performed in the outpatient setting. Malnutrition, as assessed by preoperative serum albumin <3.5 g/dL, has been independently associated with significantly higher risks of multiple adverse outcomes in several orthopedic procedures. The effect of preoperative hypoalbuminemia on short-term outcomes of RCR was previously unknown. HYPOTHESIS: we hypothesized that preoperative serum albumin <3.5 g/dL would be associated with higher odds of post-operative admission and prolonged length of stay. METHODS: This study represents a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database (NSQIP) for patients undergoing RCR between 2011 and 2015. RESULTS: Multivariate regression analysis adjusted for sex, ASA classification, age, BMI, and diabetes status (Table 3) showed preoperative hypoalbuminemia conferred a significantly increased adjusted odds ratio of postoperative admission (adjusted odds ratio 1.711, CI 1.134-2.583, p = 0.011) and extended length of stay (adjusted odds ratio 2.073, CI 1.073-4.003, p = 0.030). CONCLUSION: Malnutrition as assessed by preoperative serum albumin <3.5 g/dL is significantly associated with increased odds of hospital admission and extended length of stay following arthroscopic RCR. This has clinical implications in surgical patient selection and risk stratification. LEVEL OF EVIDENCE: III, Retrospective cohort study.

Cost Comparison of Open and Arthroscopic Treatment Options for SLAP Tears.

PURPOSE: To identify cost drivers of open biceps tenodesis, arthroscopic biceps tenodesis, and arthroscopic SLAP repair in the setting of isolated SLAP tears and to perform a direct cost comparison between the procedures. METHODS: The 2014 State Ambulatory Surgery and Services Databases from 6 US states were used. Cases with Current Procedural Terminology codes 23430 (tenodesis of long tendon of biceps), 29807 (shoulder arthroscopy, repair of SLAP lesion), and 29828 (shoulder arthroscopy, biceps tenodesis) were selected, excluding patients who were >50 years old or had a concomitant rotator cuff repair. Generalized linear models were used to model costs based on surgical and patient variables. RESULTS: The mean patient age was 41.8 years for open biceps tenodesis, 31.6 for arthroscopic SLAP repair, and 41.3 for arthroscopic biceps tenodesis (P < .001). Open biceps tenodesis had cost reductions of $5,664 over arthroscopic biceps tenodesis (P = .001) and $2,320 over arthroscopic SLAP repair (P = .043). Male sex was associated with $3,798 more in costs (P < .001), presence of ≥1 comorbidities added $1,829 (P = .002), and each minute in the operating room added $37 (P < .001). Operative time for open biceps tenodesis averaged 114 minutes, and both arthroscopic procedures averaged 94 minutes (P < .001). Low-volume facilities were associated with $5,536 higher costs for arthroscopic biceps tenodesis (P = .001). CONCLUSION: In patients aged ≤50 years with isolated SLAP tears, open biceps tenodesis provides cost savings over arthroscopic methods of treatment. There was no significant cost difference between arthroscopic SLAP repairs and arthroscopic biceps tenodesis. Given the increased emphasis on cost containment, surgeons should be aware of the procedural costs associated with the treatment of SLAP tears. LEVEL OF EVIDENCE: III, retrospective cohort study.

Socioeconomic and Demographic Disparities in Early Surgical Stabilization Following Emergency Department Presentation for Shoulder Instability.

PURPOSE: To describe which patients are the most likely to undergo surgical management within the same calendar year as their emergency department visit for anterior shoulder instability. METHODS: The State Emergency Department Databases and State Ambulatory Surgery and Services Databases from Florida were used. All patients presenting to the emergency department for anterior shoulder subluxation or dislocation between January 1 and September 30, 2017, were selected. Bivariate analysis was performed for associations with demographic variables. A binary logistic regression was performed with all significant factors to assess which were predictors of undergoing surgery the same calendar year. RESULTS: While controlling for all significant factors, we found that patients with recurrent dislocations were 3.14 times more likely to have surgery within the same year (P = .037). Patients younger than 40 years were also 2.04 times more likely to have surgery than those aged 40 years or older (P < .001). White patients were 2.47 times more likely to have surgery than black patients (P < .001). On bivariate analysis, there was an association between greater income quartile and higher odds of undergoing surgery within 30 days. CONCLUSIONS: Following an emergency department visit for acute shoulder instability, the following variables were associated with undergoing surgical stabilization within the same calendar year: previous dislocation, age younger than 40, and white race. Patients living in the greatest income quartile of patients had a significantly greater percentage of patients having surgery within 30 days. This demonstrates that disparities and barriers to care may exist for patients with shoulder instability. LEVEL OF EVIDENCE: Level III, Retrospective Comparative Study.

Predictors of Surgery and Cost of Care Associated with Patellar Instability in the Pediatric and Young Adult Population.

PURPOSE: To determine how patient demographics, socioeconomic status, history of recurrence, and initial point of presentation for health care influenced the decision for surgical treatment following a patellar instability episode. METHODS: The New York SPARCS database from 2016 to 2018 was queried for patients aged 21 and younger who were diagnosed with a patellar instability episode. These were linked to later surgeries with Current Procedural Terminology (CPT) codes 27405 (MPFL repair), 27418 (tibial tubercle osteotomy), 27420 (dislocating patella reconstruction), 27422 (Campbell/Roux-Goldthwait procedure), and 27427 (extra-articular knee ligamentous reconstruction). χ2-analysis and binary logistic regression were used to assess demographic and injury-specific variables for association with operative management. A generalized linear model was used to estimate charges associated with patellar instability. RESULTS: There were 2,557 patients with patellar instability, 134 (5.2%) of whom underwent surgery. Patients with recurrent instability had 1.875 times higher odds of undergoing surgery (P = .017). Compared to white patients, black patients had 0.428 times the odds of surgery (P = .004). None of the patients without insurance had surgery. In the cost model, an initial visit to an outpatient office was associated with $1,994 lower charges compared to an emergency department (ED) visit (P < .001). Black patients had $566 more in charges than White patients (P = .009). Compared with nonoperative treatment, surgeries with CPT 27405 added $13,124, CPT 27418 added $10,749, CPT 27422 added $18,981, CPT 27420 added $23,700, and CPT 27427 added $25,032 (all P < .001). CONCLUSIONS: Patients with recurrent instability had higher odds of surgery, while Black and uninsured patients had lower odds of surgery. ED visits were associated with significantly higher charges compared to office visits, and Black patients had higher charges than white patients. Minority and uninsured patients may face barriers in access to orthopedic care. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Incidence of Posterior Shoulder Instability in the United States Military: Demographic Considerations From a High-Risk Population.

BACKGROUND: Relatively little is known about the true incidence of posterior shoulder instability in the United States. PURPOSE/HYPOTHESIS: The purpose of this study was to characterize the incidence of posterior shoulder instability in the US military population and to examine which characteristics place these patients at highest risk. We hypothesized that the rate of posterior instability in this cohort of patients would be higher than previously reported. STUDY DESIGN: Descriptive epidemiology study. METHODS: All initial cases of posterior shoulder dislocation and subluxation in the Defense Medical Epidemiology Database were screened between 2016 and 2018 using the relevant International Classification of Diseases-Tenth Revision-Clinical Modification codes. Incidences were calculated, and multivariate Poisson regression was used to calculate adjusted rate ratios for the effects of sex, race, age, military service branch, rank, and year. RESULTS: The overall unadjusted incidence was 0.032 per 1000 person-years for posterior dislocations, 0.064 per 1000 person-years for posterior subluxations, and 0.096 per 1000 person-years for all cases of posterior shoulder instability. The total incidence of all shoulder instability was 1.84 per 1000 person-years, with posterior shoulder instability accounting for 5.2% of total cases. For posterior subluxation, significant differences between groups were found in the unadjusted and adjusted rate ratio (ARR) for sex (ARR, 3.31; 95% CI, 1.85-5.93 for men), race (ARR, 0.458; 95% CI, 0.294-0.714 for Black servicemembers and ARR, 0.632; 95% CI, 0.421-0.948 for servicemembers of other race), age (ARR, 3.69; 95% CI, 1.56-8.70 for patients aged 30-34 years), and military service branch (ARR, 0.663; 95% CI, 0.460-0.955 for Air Force servicemembers). For posterior shoulder dislocations, a significant difference was found only between men and women (ARR, 4.55; 95% CI, 1.85-11.2 for men). CONCLUSION: The incidence of posterior shoulder instability among US military personnel is higher than previously reported in the general US population, with a majority of cases due to subluxation. This increased incidence is likely reflective of a young and highly active population along with improvements in awareness and diagnosis of posterior instability in recent years.

Decline in Racial Disparities for United States Hospital Admissions After Anterior Cruciate Ligament Reconstruction From 2007 to 2015.

BACKGROUND: Racial disparities in perioperative complications have been shown to exist for many procedures in orthopaedic surgery. Although anterior cruciate ligament reconstruction (ACLR) is commonly performed as an outpatient procedure, the rate of admission to the hospital postoperatively is not insignificant. Hispanic patients have been shown to have higher odds of admission compared with non-Hispanic patients. HYPOTHESIS: We hypothesized that racial disparities would decrease from 2007 to 2015, resulting in lower rates of hospital admission for Black and Hispanic patients. STUDY DESIGN: Descriptive epidemiology study. METHODS: This study represents a retrospective analysis of the National Surgical Quality Improvement Program (NSQIP) database for patients undergoing ACLR between 2007 and 2015. We performed bivariate analysis as well as binary logistic regression, with postoperative admission as the primary outcome. Previously identified risk factors for admission were used as predictors in addition to a term for the statistical interaction between year of surgery and ethnicity. RESULTS: A total of 7542 patients undergoing ACLR were assessed. The logistic regression model showed that Hispanic patients had higher overall odds of admission (odds ratio [OR], 3.320; P < .001) than White patients; Black patients also had higher odds compared with White patients (OR, 1.929; P = .009). However, there was a significant interaction between year of surgery and both Black ethnicity (OR, 0.907; P = .026) and Hispanic ethnicity (OR, 0.835; P = .002), indicating a significant decrease in the admission rates for these minority patients compared with White patients over time. Other risk factors for admission were the use of regional anesthesia (OR, 3.482; P < .001), bleeding disorders (OR, 5.064; P = .002), a higher body mass index (OR, 1.029; P < .001), and longer operative times (OR, 1.012; P < .001). More recent surgery was associated with lower odds of admission (OR, 0.826; P < .001). CONCLUSION: Admission rates after ACLR declined from 2007 to 2015. Black and Hispanic patients were more likely to be admitted overall, but they also saw a greater decrease in the odds of admission than White patients. This represents a reduction in disparity between the 2 groups and is a reassuring improvement in racial disparity trends after a common sports procedure.

Cost Drivers Associated With Anterior Shoulder Stabilization Surgery.

BACKGROUND: Arthroscopic Bankart repair, open Bankart repair, and the Latarjet procedure are common treatments for anterior shoulder instability; however, little is known of costs by patient- and surgeon-specific factors. This study aimed to identify areas where cost reduction may be achieved. HYPOTHESIS: Increased total charges will be associated with low-volume surgeons and surgical facilities, hospital-owned facilities, open surgical techniques, and patients with at least 1 comorbidity. STUDY DESIGN: Economic and decision analysis; Level of evidence, 3. METHODS: The 2014 State Ambulatory Surgery and Services Databases from 6 states were utilized. There were 3 Current Procedural Terminology codes (23455, 23462, 29806) used to identify open Bankart repair, the Latarjet procedure, and arthroscopic Bankart repair, respectively. Patient demographic and surgical variables were evaluated on a univariate basis, and all significant factors were then included in the multiple linear regression to determine which factors had the largest effect on cost. Total charges billed for the encounter were used as a proxy for cost of surgery. RESULTS: For open Bankart repair, arthroscopic Bankart repair, and the Latarjet procedure, longer operative times increased costs, and high-volume surgical facilities had decreased charges. For the arthroscopic Bankart group, additional factors that increased charges included postoperative hospital admission (US$11,516; P < .001), patient residence in a ZIP code with a below-median income (US$2909; P < .001), presence of a comorbidity (US$1982; P < .001), male sex (US$1545; P = .003), Hispanic race (US$2493; P = .005), and use of regional anesthesia (US$1898; P = .025). Additional cost drivers for the Latarjet procedure included postoperative hospital admission (US$7028; P = .022) and older age (US$187/y; P = .039). CONCLUSION: Postoperative admission to the hospital was the largest cost driver for arthroscopic Bankart repair and the Latarjet procedure. Low-volume facilities were the largest cost driver for open Bankart repair. High-volume surgery centers had lower costs when compared with low-volume surgery centers. Regional anesthesia increased costs in the arthroscopic Bankart group. These findings may help to show where cost savings can be achieved, particularly considering increasing trends toward bundled health care payments.

High-Volume and Privately Owned Ambulatory Surgical Centers Reduce Costs in Achilles Tendon Repair.

BACKGROUND: While Achilles tendon repairs are common, little data exist characterizing the cost drivers of this surgery. PURPOSE: To examine cases of primary Achilles tendon repair, primary repair with graft, and secondary repair to find patient characteristics and surgical variables that significantly drive costs. STUDY DESIGN: Economic and decision analysis; Level of evidence, 3. METHODS: A total of 5955 repairs from 6 states were pulled from the 2014 State Ambulatory Surgery and Services Database under the Current Procedural Terminology codes 27650, 27652, and 27654. Cases were analyzed under univariate analysis to select the key variables driving cost. Variables deemed close to significance (P < .10) were then examined under generalized linear models (GLMs) and evaluated for statistical significance (P < .05). RESULTS: The average cost was $14,951 for primary repair, $23,861 for primary repair with graft, and $20,115 for secondary repair (P < .001). In the GLMs, high-volume ambulatory surgical centers (ASCs) showed a cost savings of $16,987 and $2854 in both the primary with graft and secondary repair groups, respectively (both P < .001). However, for primary repairs, high-volume ASCs had $2264 more in costs than low-volume ASCs (P < .001). In addition, privately owned ASCs showed cost savings compared with hospital-owned ASCs for both primary Achilles repair ($2450; P < .001) and primary repair with graft ($11,072; P = .019). Time in the operating room was also a significant cost, with each minute adding $36 of cost in primary repair and $31 in secondary repair (both P < .001). CONCLUSION: Private ASCs are associated with lower costs for patients undergoing primary Achilles repair, both with and without a graft. Patients undergoing the more complex secondary and primary with graft Achilles repairs had lower costs in facilities with greater caseload.