Are patients without insurance coverage less likely to undergo surgery for humeral shaft fractures? A national database analysis.

BACKGROUND: Historically, humeral shaft fractures have been managed nonoperatively in a functional brace. However, recent studies suggest an increase in rates of operative fixation. Disparities in surgical management based on insurance status have been demonstrated across many orthopedic conditions. This study aimed to identify if a correlation exists between insurance coverage and the probability of undergoing operative fixation for a humeral shaft fracture. METHODS: A retrospective examination of the National Readmissions Database from 2016 to 2021 was conducted. Patients diagnosed with isolated closed humeral shaft fractures were identified via International Classification of Disease, 10th Revision codes, and surgical interventions were identified using International Classification of Disease, 10th Revision procedural codes. Utilizing weighted data, a total of 56,468 patients with isolated closed humeral shaft fractures were identified, 25,075 (44.4%) of whom underwent operative fixation. A univariate analysis was conducted using Pearson's chi-square test to isolate variables for inclusion in a multivariable analysis. A binary logistic regression analysis was then employed to explore demographic and other pertinent factors. Findings were reported as odds ratios. RESULTS: After controlling for social and demographic variables, patients with Medicaid (OR, 0.54; 95% CI, 0.50-0.58; P < .001), Medicare (OR, 0.64; 95% CI, 0.60-0.68; P < .001), and self-pay patients (OR, 0.75; 95% CI, 0.67-0.84; P < .001) were less likely to undergo operative fixation of humeral shaft fracture than those with private insurance. CONCLUSIONS: Patients without private insurance or those with no insurance coverage are less likely to undergo operative fixation for humeral shaft fractures compared to those with private insurance, even after adjusting for social and demographic variables. The observed variability underscores the necessity for more refined treatment guidelines for humeral shaft fractures. Surgeons should be aware of these potential biases affecting management decisions.

No difference in abstract publication rates between the open and closed American Shoulder and Elbow Surgeons meetings from 2013 to 2019.

BACKGROUND: The American Shoulder and Elbow Surgeons (ASES) society has advanced the practice of shoulder and elbow care through the exhibition of research at academic meetings. The ASES annual meeting is a closed (member-only) conference annually held in October, while the specialty day is an open (non-members included) event that takes place during the American Academy of Orthopaedic Surgeons (AAOS) meeting week in March. This study aims to compare the rate of publication for abstracts presented at the open and closed ASES meetings from 2013 to 2019. METHODS: The ASES website was searched to obtain the annual meeting and specialty day program agendas from 2013 to 2019. A standardized search protocol was employed to identify conference abstracts that went on to be published. Publications associated with an ASES abstract were analyzed through several variables including the time to publication, journal impact factor (JIF), and level of evidence. RESULTS: There was no difference between the rates of publication of the open (76.5%, 121/158) and closed (75.3%, 223/296) meetings (P = .904). The median time to publication significantly differed between the open (7 months, 95% confidence interval [CI]: 5.0-10.0) and closed (11 months, 95% CI: 9.0-13.0) meetings (P = .02). There was no difference between the median JIF between the open (2.69, 95% CI: 2.41-2.81) and closed (2.73, 95% CI: 2.41-2.81) meetings. The distribution of the level of evidence in published articles comparing the open and closed meetings did not differ significantly (P = .446). DISCUSSION: The overall quality of academic research presented at orthopedic subspecialty conferences can be objectively evaluated through abstract publication rates. Our analysis demonstrates that there is not a single significant difference among the publication rates, median JIF, and level of evidence distribution between the ASES open and closed meetings from 2013 to 2019. Impactful research is showcased at both the open and closed meetings. Societies that limit submissions from members only at annual meetings can consider soliciting research from non-members. While the quality of research would not decline if non-ASES members were invited to participate, the presence of a closed annual meeting may be a valuable tool for societies to expand their reach through member-exclusive benefits.

Medical malpractice litigation after total shoulder arthroplasty: a comprehensive analysis based on the Westlaw legal database.

INTRODUCTION: Orthopedic surgery is one of the most common subspecialties subject to medical malpractice claims. Although total shoulder arthroplasty (TSA) is associated with favorable patient outcomes and relatively low complication rates, surgeons performing this procedure may be subject to malpractice litigation leading to significant economic and psychological burden on the provider. The purpose of this study is to characterize and describe malpractice claims against orthopedic surgeons performing TSA using the Westlaw legal database. METHODS: The Westlaw legal database was queried for all cases related to TSA using the terms "malpractice" AND "shoulder replacement" OR "shoulder arthroplasty." Cases were excluded if the defendant was not an orthopedic surgeon, the procedure involved was not a TSA, or if the patient was a minor. Patient demographics, causes cited for litigation, case outcomes, and indemnity payments were analyzed to determine common factors that lead plaintiffs to pursue legal action. RESULTS: Thirty-five TSA cases were identified that met inclusion criteria. The mean plaintiff age was 55 years with 63.6% female. The most common category of negligence alleged was intraoperative error, which occurred in 25 claims (71%). The most common types of damages incurred were nerve injury (23%), functional limitation (20%), and infection (17%). Overall, 27 cases (77%) resulted in a defense verdict. Four cases (11%) resulted in settlements and 4 cases (11%) resulted in plaintiff verdicts. The average inflation-adjusted monetary award in these cases was $1,619,919 (standard deviation, $1,689,452). DISCUSSION: This study provides a comprehensive summary of malpractice claims and associated outcomes in TSA. Given the rapidly increasing rate of TSA in the United States and the burden of associated malpractice claims, understanding potential legal implications of TSA is of great value to orthopedic surgeons. Intraoperative error was the category of negligence cited most commonly in TSA malpractice claims. Nerve injury, functional limitation, and infection were the most commonly cited specific damages. These findings highlight the need for orthopedic surgeons to educate patients regarding potential postoperative complications while continuing to focus on minimizing their occurrence.

Factors associated with functional improvement after posteriorly augmented total shoulder arthroplasty.

BACKGROUND: Posteriorly augmented glenoid components in anatomic total shoulder arthroplasty (TSA) address posterior glenoid bone loss with inconsistent results. The purpose of this study was to identify preoperative and postoperative factors that impact range of motion (ROM) and function after augmented TSA in patients with type B2 or B3 glenoid morphology. METHODS: This was a retrospective review of all patients who underwent TSA with a step-type augmentation performed by a single surgeon between 2009 and 2018. Patients with Walch type B2 or B3 glenoids were included. Outcomes included forward elevation (FE), external rotation (ER), internal rotation (IR), Single Assessment Numeric Evaluation (SANE) score, and visual analog scale pain score. Preoperative imaging was reviewed to assess glenoid retroversion and posterior humeral head subluxation relative to the scapular body and midglenoid face. Postoperative measurements included glenoid retroversion, subluxation relative to the scapular body, subluxation relative to the central glenoid peg, and center-peg osteolysis. Measurements were performed by investigators blinded to ROM and functional outcome scores. RESULTS: Fifty patients (mean age, 68.1 ± 8.0 years) with a mean follow-up period of 42.0 months (range, 24-106 months) were included. Glenoid morphology included type B2 glenoids in 41 patients and type B3 glenoids in 9. One patient had center-peg osteolysis, and 1 patient had glenoid component loosening. Average preoperative FE, ER, and IR were 110°, 21°, and S1, respectively. Average postoperative FE, ER, and IR were 155°, 42°, and L1, respectively. The mean postoperative visual analog scale score was 0.5 ± 0.8, and the mean SANE score was 94.5 ± 5.6. Type B3 glenoids were associated with better postoperative IR compared with type B2 glenoids (T10 vs. L1, P = .024), with no other differences in ROM between the glenoid types. Preoperative glenoid retroversion did not significantly impact postoperative ROM. Postoperative glenoid component retroversion and residual posterior subluxation relative to the scapular body or glenoid face did not correlate with ROM in any plane. However, posterior subluxation relative to the glenoid face was moderately associated with lower SANE scores (r = -0.448, P = .006). CONCLUSION: Patients achieved excellent functional outcomes and pain improvement after TSA with an augmented glenoid component. Postoperative ROM and function showed no clinically important associations with preoperative or postoperative glenoid retroversion or humeral head subluxation in our cohort of posteriorly augmented TSAs, except for worse functional scores with increased humeral head subluxation in relation to the glenoid surface.

Anatomic shoulder arthroplasty in Walch type C glenoid deformity: mid- to long-term outcomes.

BACKGROUND: Hypoplastic glenoid morphology in the setting of glenohumeral osteoarthritis is a rare yet complex surgical problem. Treatment of this patient population with anatomic total shoulder arthroplasty (aTSA) remains controversial. Furthermore, there is no gold-standard approach, with limited guidance for surgeons on the need for glenoid version correction in the setting of a dysplastic glenoid. The purpose of this study was to evaluate mid- to long-term outcomes and reoperation rates of aTSA for the treatment of primary glenohumeral osteoarthritis with Walch type C glenoid deformity. METHODS: This observational, retrospective cohort study identified patients with a Walch type C glenoid who underwent aTSA at 2 institutions between 2007 and 2016. Patients were contacted to complete updated patient-reported outcome measures at a minimum of 5.5 years postoperatively. The outcome measures collected included the American Shoulder and Elbow Surgeons (ASES) score and Single Assessment Numeric Evaluation (SANE) score. Secondary outcomes included any additional surgical procedures on the operative shoulder, patient satisfaction, and willingness to undergo aTSA again. RESULTS: In total, 30 patients met the inclusion criteria, of whom 26 (86.7%) were able to be contacted to undergo final outcome evaluations. The mean age at the time of surgery was 61.3 years (range, 40.9-75.5 years), and 20 patients (76.9%) were men. The mean follow-up period was 8.5 years (range, 5.5-11.3 years) after surgery. Treatment was performed with an augmented component in 9 patients and with a standard component in 17. Of the 17 patients with non-augmented components, 9 underwent partial correction with asymmetrical reaming, 3 received a mini-inset glenoid component, and 2 had an anteriorly offset humeral component. At final follow-up, patients had a mean ASES score of 83.6 ± 16.7, ASES pain score of 24.7 ± 20.8, SANE score of 80.4 ± 20.9, and patient satisfaction rate of 84.1%. No statistically significant differences in any outcome measure were observed between patients with augmented glenoid components and those with non-augmented glenoid components. One revision to reverse shoulder arthroplasty was performed for instability at 7 years postoperatively after a traumatic dislocation. All patients reported that they would be willing to undergo the same surgical procedure again. DISCUSSION: Despite variance in glenoid reconstructive approach, aTSA provides satisfactory and sustained improvements in patient-reported outcomes in patients with glenoid dysplasia and primary glenohumeral osteoarthritis with a low revision rate at a mean of 8.5 years. Anatomic shoulder arthroplasty should remain a surgical option in patients with Walch type C glenoid deformity.

New Approaches to the Diagnosis and Management of Periprosthetic Joint Infection of the Shoulder.

Periprosthetic joint infection (PJI) of the shoulder is a potentially devastating complication following shoulder arthroplasty. It is important to review the workup of PJI in the shoulder, including recently developed diagnostic criteria for shoulder PJI, along with detailed examination of the most common causative organism, Cutibacterium acnes. Treatment strategies for PJI of the shoulder include antibiotic therapy, surgical options, and what to do with unexpected positive cultures in revision arthroplasty. Surgeons should be familiar with bony and soft-tissue reconstructive options following explantation of an infected shoulder prosthesis.

Mid- to long-term outcomes of augmented and nonaugmented anatomic shoulder arthroplasty in Walch B3 glenoids.

BACKGROUND: In cases of severe osteoarthritis, posterior glenoid wear leads to acquired retroversion of the glenoid. Surgical treatment of glenoids with acquired retroversion and posterior humeral subluxation with anatomic total shoulder arthroplasty (aTSA) is controversial. The purpose of this study was to determine mid- to long-term outcomes and reoperation rates of augmented and nonaugmented aTSA for treatment of glenohumeral osteoarthritis with Walch B3 glenoid deformity. METHODS: This observational cohort study reviewed patients with a Walch B3 glenoid undergoing aTSA at a single institution between 2007 and 2014. Patients were contacted to complete updated patient-reported outcome measures at a minimum of 6 years postoperatively. Outcome measures collected included the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score and Single Alpha Numeric Evaluation (SANE) score. Secondary outcomes included any additional surgery on the operative shoulder, patient satisfaction, and willingness to undergo aTSA again. RESULTS: Thirty-nine patients met inclusion criteria, and thirty-five (89.7%) were able to be contacted for final outcomes evaluation. Mean follow-up was 8.7 years (range 6-13) after surgery. Sixteen patients were treated with an augmented glenoid component, and 19 patients were treated with a standard glenoid component. Of those with standard components, all were partially corrected with asymmetric reaming. At final follow-up, there were no statistically significant differences between those with augmented and standard glenoid components for mean ASES score (93.3 vs. 85.7, P = .217), ASES pain score (47.2 vs. 41.6, P = .161), SANE score (87.8 vs. 86.0, P = .692), and percentage patient satisfaction (95.6% vs. 96.8%, P = .735), forward elevation (148° vs. 149°, P = .852), or external rotation (36° vs. 39°, P = .202). No patient in either group had undergone revision surgery of the operative shoulder over the study period and all patients stated that they would undergo the same surgery again. DISCUSSION: Both augmented and standard aTSA can provide satisfactory and sustained improvements in patient-reported outcomes in patients with acquired glenoid retroversion due to glenohumeral osteoarthritis. Despite a trend toward alternative treatment options, anatomic shoulder arthroplasty should remain a surgical consideration even in the setting of a Walch B3 glenoid deformity.

The influence of mental health on Patient-Reported Outcomes Measurement Information System (PROMIS) and traditional outcome instruments in patients with symptomatic glenohumeral arthritis.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) assessment includes computerized adaptive tests (CATs) that assess function, pain, depression, and anxiety. The influence of mental health on patients' self-reported pain and function has not been explored using PROMIS in patients with symptomatic glenohumeral osteoarthritis. METHODS: This cross-sectional study included 284 shoulders in 276 patients presenting with isolated glenohumeral osteoarthritis. All patients completed the American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST), Visual Analog Pain Scale (VAS), and PROMIS CATs at the time of presentation. PROMIS anxiety and depression scores were converted into Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9 scores, respectively, using the PROsetta Stone "crosswalk" tool. Mean pain and functional scores were compared between patients with and without PROMIS-converted scores corresponding to a diagnosis of anxiety or depression, as well as between scores corresponding to varying degrees of anxiety or depression. RESULTS: Patients with scores corresponding to a diagnosis of anxiety or depression reported lower functional and higher pain scores compared to those with scores in the normal range (P < .001). Analysis of variance showed progressively lower functional and higher pain scores as anxiety severity increased (P < .001). Similar results were seen with ASES, upper extremity CAT, and pain scores as depression severity increased (P < .001). Functional ASES (P = .004), SST (P < .001), and physical function CAT (P = .002) scores were statistically significantly lower in patients with moderate to severe depression than those without depression or with mild depression. DISCUSSION: In patients with glenohumeral osteoarthritis, PROMIS-reported anxiety and depression scores, particularly in those with moderate-to-severe scores, correlate with lower functional and higher pain scores. Further investigation is necessary to examine the influence that mental health has on outcomes after operative intervention in this population.

Lumbar computed tomography scans are not appropriate surrogates for bone mineral density scans in primary adult spinal deformity.

OBJECTIVE The authors examined the correlation between lumbar spine CT Hounsfield unit (HU) measurements and bone mineral density measurements in an adult spinal deformity (ASD) population. METHODS Patients with ASD were identified in the records of a single institution. Lumbar CT scans were reviewed, and the mean HU measurements from L1-4 were recorded. Bone mineral density (BMD) was assessed using femoral neck and lumbar spine dual-energy x-ray absorptiometry (DEXA). The number of patients who met criteria for osteoporosis was determined for each imaging modality. RESULTS Forty-eight patients underwent both preoperative DEXA and CT scanning. Forty-three patients were female and 5 were male. Forty-seven patients were Caucasian and one was African American. The mean age of the patients was 62.1 years. Femoral neck DEXA was more likely to identify osteopenia (n = 26) than lumbar spine DEXA (n = 8) or lumbar CT HU measurements (n = 6) (p < 0.001). There was a low-moderate correlation between lumbar spine CT and lumbar spine DEXA (r = 0.463, p < 0.001), and there was poor correlation between lumbar spine CT and femoral neck DEXA (r = 0.303, p = 0.036). CONCLUSIONS Despite the opportunistic utility of lumbar spine CT HU measurements in identifying osteoporosis in patients undergoing single-level fusion, these measurements were not useful in this cohort of ASD patients. The correlation between femoral neck DEXA and HU measurements was poor. DEXA assessment of BMD in ASD patients is essential to optimize the care of these complicated cases.

Dislocation following reverse total shoulder arthroplasty.

BACKGROUND: The etiology of instability following reverse total shoulder arthroplasty (RTSA) remains incompletely understood. The purpose of this study was to describe the shared characteristics, etiologies, and outcomes of early and late dislocations requiring operative revision. METHODS: We identified all patients at our institution who underwent operative revision of an RTSA for instability. Baseline demographic, clinical, and radiographic data were collected. Standardized outcome scores were collected preoperatively and at final follow-up. Characteristics of dislocations that occurred less than 3 months postoperatively (early) were compared with those that occurred more than 3 months postoperatively (late). RESULTS: Twenty-two patients met the criteria, and follow-up was obtained on 19 patients at 4.9 ± 2.5 years, with 14 early and 5 late dislocations. Most patients in both groups were men, were aged over 70 years, and had a history of shoulder surgery. On analysis of instability etiology, 68% had inadequate soft-tissue tensioning (10% due to partial axillary nerve injuries). The remaining patients had asymmetric liner wear, mechanical liner failure, or impinging heterotopic ossification. Asymmetric liner wear accounted for 60% of late dislocations. Recurrent instability after revision was present in 29% of early and 40% of late dislocators. DISCUSSION: No significant differences in outcomes or recurrence rates were found for early and late dislocations. Of the late dislocations, 80% had evidence of adduction impingement, via either heterotopic ossification or asymmetric polyethylene wear. Post-RTSA instability had 2 distinct etiologies: (1) instability due to inadequate soft-tissue tensioning and/or axillary nerve palsy and (2) instability due to impingement or liner failure.

YouTube videos on ulnar collateral ligament reconstruction are highly variable in terms of reliability and quality: A quantitative analysis.

Background: Ulnar collateral ligament reconstruction (UCLR) is commonly performed on adolescent athletes, who often turn to online sources such as YouTube for health information. The purpose of this study was to retrospectively review the accuracy, reliability, and quality of UCLR videos using validated scoring instruments. Methods: YouTube was queried for "Tommy John surgery," "UCL reconstruction," and "ulnar collateral ligament reconstruction." After categorization by physician, nonphysician/trainer, patient or commercial source, videos were assessed for reliability and quality using the Journal of the American Medical Association (JAMA) benchmark criteria (0-4) and DISCERN tool (16-80). Results: 104 videos were included in the final analysis. 74% of videos (77/104) were made by physicians. The mean JAMA and DISCERN scores for all videos were 3.1 ± 0.8 and 46.1 ± 8.5, respectively. The majority of videos were rated as "fair" based on DISCERN score (56/104, 53.8%). JAMA scores were significantly higher for physician videos compared to nonphysician videos (3.3 ± 0.8 vs 2.6 ± 0.7, p < 0.0001), but no such difference was found for DISCERN scores (46.3 ± 7.7 vs 45.3 ± 10.57, p = 0.43). Conclusion: Physicians should be cognizant of the quality and reliability of YouTube videos when instructing patients on information sources related to UCLR.

Nearly All Peer-to-Peer Reviews for CT and MRI Prior Authorization Denials for Orthopedic Specialists Are Approved.

In the event of prior authorization denial, physicians may request peer-to-peer review, which may delay treatment and increase administrative burden. The purpose of this study was to quantify the approval rate of peer-to-peer review and evaluate its efficiency in the context of advanced imaging use in an orthopedic practice. Patients at a single outpatient orthopedic clinic initially receiving an insurance denial for computed tomography or magnetic resonance imaging requiring peer-to-peer review from March to December 2022 were prospectively enrolled. Characteristics of the request, peer-to-peer review, and the reviewer and dates in the process were collected. If the study was approved after peer-to-peer review, the date of the imaging study and brief results were recorded. A total of 62 denials were included. One denial was approved prior to peer-to-peer review. Fifty-eight (of 61, 95.1%) reviews were approved, of which 51 (of 58, 87.9%) studies were completed by patients. Reviewers were always physicians (61 of 61, 100%), but of those whose specialty was known, none were orthopedic surgeons. Forty-four of 61 (72.1%) reviewers reported reviewing clinical notes in advance. The median number of days from visit to peer-to-peer review was 9.0 (interquartile range, 7.0-13.25). The median number of days from visit to imaging center appointment was 13.5 (interquartile range, 9.0-20.75) for approved studies. Of the 51 approved studies completed by patients, the results of 38 (74.5%) confirmed the suspected diagnosis. In an orthopedic specialty practice, almost all peer-to-peer reviews were approved, with the majority of the completed studies confirming the suspected diagnosis. Thus, patient care was delayed. Reform is crucial to improve the efficiency of the review process, especially in light of additional administrative and financial burden. [Orthopedics. 202x;4x(x):xx-xx.].

Outcome of biceps suspensionplasty for recurrent multidirectional shoulder instability.

INTRODUCTION: Recurrent multidirectional shoulder instability after failed capsular repair/plication, is a challenging treatment problem. The long head of the biceps has been identified as a structure that may be utilized as a checkrein to stop abnormal anterior and inferior translation of the humeral head. The purpose of this study is to analyse the outcomes of biceps suspensionplasty (BS) in the treatment of recurrent shoulder instability. METHODS: A retrospective review identified patients with recurrent multidirectional instability that underwent BS as part of a revision shoulder stabilization procedure. Clinical records were reviewed for demographics, pain, complications, recurrent instability, reoperations, and range of motion. Patients were also administered ASES/SST/SANE/Rowe and Oxford instability questionnaire at minimum of 2-year clinical follow-up. RESULTS: Five patients (7 shoulders) were included with a mean follow-up of 3.2 years (2-7 years). Patients had an average of 1.6 prior procedures (1-3). Average patient age was 24.2 years (18.7-32.4 years) and all were female. Four shoulders were treated open while 3 were treated arthroscopically with a capsular shift and biceps suspension. Four shoulders also underwent capsular reconstruction with allograft. At final follow-up three shoulders had recurrent inferior subluxation, although all patients considered their shoulders to be much better (4) or somewhat better (3) and none have undergone repeat surgery. CONCLUSION: In our series of patients, we found BS may be useful as an adjunct to a revision capsular shift or reconstruction. While 42.8% of patients experienced recurrent subluxations, this high-risk population demonstrated encouraging subjective results and avoiding joint arthrodesis in the short-term.

Severity of Glenohumeral Osteoarthritis Does Not Correlate With Patient-Reported Outcomes.

BACKGROUND: Patient pain and clinical function are important factors in decision-making for patients with glenohumeral osteoarthritis (GHOA). The correlation between radiographic severity of arthritis and demographic factors with modern patient-reported outcome measures has not yet been well defined. METHODS: This cross-sectional study included 256 shoulders in 246 patients presenting with isolated GHOA. All patients obtained standard radiographs and completed the American Shoulder and Elbow Surgeons score, Simple Shoulder Test (SST), Shoulder Activity Scale, Visual Analog Scale, and Patient-Reported Outcome Measurement Information System (PROMIS) computer adaptive tests at the time of presentation. Radiographs were graded according to the Samilson-Prieto classification. Mean pain and functional scores were compared between the radiographic grades of osteoarthritis (OA) and demographic factors. RESULTS: There were 6 shoulders rated as grade 1 OA, 41 shoulders as grade 2, 149 shoulders as grade 3a, and 65 shoulders as grade 3b. There was excellent interobserver reliability in grade of OA (κ = 0.77). There were no significant differences in patient-reported pain or any validated measure of clinical function between radiographic grades of OA (P > .05). Males reported higher function and lower pain scores than females (P = .001-.066), although only the values for the SST and PROMIS physical function test were clinically relevant. DISCUSSION: While gender correlated with pain and function, the clinical relevance is limited. Radiographic severity of GHOA does not correlate with patient-reported pain and function, and symptoms should remain the primary determinants of surgical decision-making. Further investigation is necessary to examine whether radiographic severity of OA influences improvement following operative intervention in this population.