Venous thromboembolism prophylaxis in shoulder surgery: a break-even cost-effectiveness study.

BACKGROUND: Venous thromboembolism (VTE) is a serious complication following orthopedic shoulder surgery; however, research is limited involving the break-even cost-effectiveness of VTE prophylaxis. The purpose of this study was to determine whether the cost of aspirin and enoxaparin would break even for VTE prevention in patients following shoulder surgery. METHODS: A drug retail database was used to obtain the lowest price for a course of aspirin (81 mg) and enoxaparin (40 mg) to perform a break-even cost analysis. Our institutional purchasing records were then searched to estimate the cost of treating a symptomatic VTE. The TriNetX national database was queried to establish a rate of VTE after shoulder surgery. A break-even cost analysis was performed by determining the absolute risk reduction (ARR). This value was used to calculate the number of patients who are treated to prevent a single VTE while breaking even on cost. Sensitivity analyses were performed for drugs that did not break even at the database-derived VTE rates. RESULTS: Full medication courses of aspirin and enoxaparin were found to cost $1.18 and $125.37, respectively. The cost of treating a symptomatic VTE was determined to be $9407.00. Data from the TriNetX database showed rates of symptomatic VTE following shoulder arthroplasty, hemiarthroplasty, and arthroscopic rotator cuff repair of 1.60%, 1.50%, and 0.68%, respectively. Aspirin broke even on cost for all procedures if the initial rate decreased by an ARR of 0.01% (number needed to treat, 7972). Similarly, enoxaparin broke even for shoulder arthroplasty and hemiarthroplasty if the initial rate of VTE decreased by an ARR of 1.33% (number needed to treat, 75). Enoxaparin did not break even at the initial VTE rate for arthroscopic rotator cuff repair; however, sensitivity analysis found enoxaparin would break even if the drug could be obtained at a cost of ≤$60.00. Enoxaparin broke even if the cost of treating a symptomatic VTE was ≥$20,000.00. CONCLUSIONS: The cost of a 3-week course of twice-daily aspirin or once-daily enoxaparin breaks even for VTE prophylaxis following shoulder arthroplasty and hemiarthroplasty if these drugs reduce the VTE rate by a calculated ARR. Given the lower rate of VTE observed for patients undergoing arthroscopic rotator cuff repair, only the 3-week course of aspirin broke even under these conditions. Once-daily enoxaparin did not break even at current market rate. Further research is needed to help determine optimal VTE prophylaxis after shoulder surgery.

Animal model detects early pathologic changes of Charcot neuropathic arthropathy.

Charcot neuropathic arthropathy is a degenerative, debilitating disease that affects the foot and ankle in patients with diabetes and peripheral neuropathy, often resulting in destruction, amputation. Proposed etiologies include neurotraumatic, inflammatory, and neurovascular. There has been no previous animal model for Charcot. This study proposes a novel rodent model of induced neuropathic arthropathy to understand the earliest progressive pathologic changes of human Charcot. High-fat-diet-induced obese (DIO) Wild-type C57BL/6J mice (n = 8, diabetic) and age-matched low-fat-diet controls (n = 6) were run on an inclined high-intensity treadmill protocol four times per week for 7 weeks to induce mechanical neurotrauma to the hind-paw, creating Charcot neuropathic arthropathy. Sensory function and radiologic correlation were assessed; animals were sacrificed to evaluate hindpaw soft tissue and joint pathology. With this model, Charcot-DIO mice reveals early pathologic features of Charcot neuropathic arthropathy, a distinctive subchondral microfracture callus, perichondral/subchondral osseous hypertrophy/osteosclerosis, that precedes fragmentation/destruction observed in human surgical pathology specimens. There is intraneural vacuolar-myxoid change and arteriolosclerosis. The DIO mice demonstrated significant hot plate sensory neuropathy compared (P < 0.01), radiographic collapse of the longitudinal arch in DIO mice (P < 0.001), and diminished bone density in DIO, compared with normal controls. Despite exercise, high-fat-DIO mice increased body weight and percentage of body fat (P < 0.001). This murine model of diet-induced obesity and peripheral neuropathy, combined with repetitive mechanical trauma, simulates the earliest changes observed in human Charcot neuropathic arthropathy, of vasculopathic-neuropathic etiology. An understanding of early pathophysiology may assist early diagnosis and intervention and reduce patient morbidity and mortality in Charcot neuropathic arthropathy.

Comparing the Efficacy of True-Volume Analysis Using Magnetic Resonance Imaging With Computerized Tomography and Conventional Methods of Evaluation in Cystic Osteochondral Lesions of the Talus: A Pilot Study.

Background: Osteochondral lesions of the talus (OLT) often require advanced imaging if they prove to be refractory to preliminary microfracture. Orthopedic surgeons may misinterpret the size and morphology of the OLT when evaluating through conventional methods. The purpose of this study was to evaluate MRI as a modality for calculating true-volumes and compare its utility to that of CT true-volume and conventional methods of measuring lesion size. METHODS: With IRB approval, an institutional radiology database was queried for patients with cystic OLT that had undergone and failed microfracture and had compatible CT and MR scans between 2011 and 2016. Five lesions, previously analyzed and described in the literature using CT true-volume, were selected. 10 orthopedic surgeons independently estimated the volume of these 5 OLT via standard MRI. Next, 3D reconstructions were created and morphometric true-volume (MTV) analysis measurements of each OLT were generated. The percent change in volumes from CT and MR was compared based upon MTVs determined from 3D reconstructive analysis. RESULTS: The volume calculated using conventional methods in CT and MR scans grossly overestimated the size by of the OLT by 285-864% and 56-374% respectively when compared to 3D true-volume analysis of those CT and MR scans. CONCLUSIONS: This study demonstrates that true-volume is more accurate for calculating lesion size than conventional methods. Additionally, when comparing MRI and CT, thin slice CT true-volume is superior to MRI true-volume. True-volume calculation improves accuracy with CT and MRI and should be recommended for use in revision OLT cases.Levels of Evidence: Level III: Case control study.

Outcomes of NCAA Defensive Football Players Following Achilles Tendon Repair.

BACKGROUND: The incidence of Achilles ruptures has been on the rise in National Collegiate Athletic Association (NCAA) football players, but the career impact of this injury is not fully understood. In this study, we analyzed a large series of Achilles tendon injuries in NCAA Football Bowl Subdivision (FBS) defensive football players who required repair in order to determine their return to play, performance, and career outcomes afterward. METHODS: FBS defensive football players who required Achilles repair from 2010 to 2016 were identified. The return to play of the eligible underclassmen athletes was then determined and the preinjury and postoperative performances of players who met criteria were compared with matched controls. The number of underclassmen who went on to participate in the National Football League (NFL) Combine or play in at least 1 NFL game was also determined and compared with controls. RESULTS: Fifty-seven total Achilles ruptures were identified, 40 of which occurred in underclassmen, who returned at a rate of 92.5%. Of the players who met performance criteria, only defensive backs differed from matched controls in terms of solo tackling (P = .025) and total tackling (P = .038), while still increasing compared with preoperative performance. Only 5.0% of underclassmen performed at NFL Combine and only 7.5% competed in at least 1 NFL game (20.0% and 21.3%, respectively, for matched controls). CONCLUSION: Defensive FBS players returned at a high rate following Achilles rupture and did not seem to experience a significant drop-off in performance upon return. An Achilles rupture did appear to impact their chances of playing professionally in the future, however. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Cost Comparison of Synthetic Hydrogel Implant and First Metatarsophalangeal Joint Arthrodesis.

Background. First metatarsophalangeal (MTP) arthrodesis is the "gold standard" treatment for hallux rigidus. Recently, there has been increased interest in new synthetic cartilage implants to preserve joint motion while eradicating pain. With current health care economics, the cost of a treatment is gaining particular importance. This study set out to perform a cost comparison between MTP arthrodesis and synthetic hydrogel implant to determine which treatment modality is more cost-effective based on direct aggregate costs. Study design. Economic and decision analysis. Methods. Studies in the available literature were analyzed to estimate hardware removal rates for MTP fusion and failure rates for a synthetic hydrogel implant and MTP fusion. Costs were determined by examining direct costs at a single institution for implants and data reported in the literature for operating room time. Sensitivity analysis and Monte Carlo simulation were performed to examine cost and measurement uncertainty. Results. Assuming a 4.76% MTP arthrodesis revision rate and 7.06% hardware removal rate, the total direct cost of MTP joint arthrodesis was $3632. Using a 9.2% failure rate with subsequent conversion to MTP arthrodesis, the total cost of synthetic hydrogel implant was $4565. Sensitivity analysis revealed that MTP fusion was more cost-effective even if the failure rate increased to 15% and synthetic hydrogel implant failure rate was 0%. The synthetic cartilage implant cost would have to be reduced 28% or approximately 200% the cost of MTP fusion implants to be comparable to MTP arthrodesis. Conclusion. Hallux rigidus treatment with a synthetic hydrogel implant resulted in a higher direct aggregate cost than MTP arthrodesis.Level of Evidence: Level II: Cost analysis.

Three-Dimensional Morphometric Modeling Measurements of the Calcaneus in Adults with Stage IIB Posterior Tibial Tendon Dysfunction: A Pilot Study.

Background: The pathophysiology of adult-acquired flatfoot deformity (AAFD) is not fully explained by degeneration of the posterior tibial tendon alone. While a shortened or dysplastic lateral column has been implicated in flatfoot deformity in pediatrics, there is no study that has quantified the degree of dysplasia in adults with a stage IIb flatfoot deformity, or if any exists at all. Methods: An institutional radiology database was queried for patients with posterior tibial tendon dysfunction (PTTD) who had computed tomography (CT) performed. Controls were patients receiving CT scan for an intra-articular distal tibia fracture without preexisting foot or calcaneal pathology. Clinical notes, physical examination, and weightbearing radiographs were used to find patients that met clinical criteria for stage IIb PTTD. Morphometric measurements of the calcanei were performed involving the length of the calcaneal axis (LCA), height of the anterior process (HAP), and length of the anterior process (LAP). All measurements were performed independently by separate observers, with observers blinded to group assignment. We considered a difference of ±4 mm as our threshold. Results: 7 patients and 7 controls were available for reconstruction and analysis. On average, the LCA was 3.1 mm shorter in patients with stage IIb PTTD compared with controls (P < .05). The LAP was shorter in PTTD patients compared with controls 3.4 mm (P < .001). Conclusions: Our results support the hypothesis that the calcaneus of adult patients with stage IIb AAFD is dysplastic when compared with healthy controls, which further supports the utility of lateral column lengthening. Levels of Evidence: Level III: Case-control study.