RESUMEN
BACKGROUND: The management of Walch B2 glenoid deformities in primary glenohumeral osteoarthritis is frequently debated. Previous literature has shown that the treatment of B2 glenoids with high-side reaming and anatomic total shoulder arthroplasty (aTSA) perform well in the short-term but is associated with an increased glenoid component failure rate in severe deformities. Therefore, many have explored alternative options, including augmented anatomic glenoid components and reverse shoulder arthroplasty. Our goal in this study is to provide mid-term radiographic and clinical outcomes after high-side reaming and aTSA for B2 glenoids. METHODS: Patients were followed both clinically and radiographically. Preoperative computed tomography scans were used for retrospective analysis of deformity. Both preoperative and postoperative visual analog scale pain, American Shoulder and Elbow Surgeons score, and Simple Shoulder Test scores were collected. Radiographs were analyzed preoperatively and postoperatively for humeral head decentering relative to the glenoid vault, immediate glenoid seating, and final glenoid peg radiolucency. RESULTS: Of the original cohort of 59 patients (6 now deceased) reported at a mean radiographic follow-up of 3.4 years, 34 shoulders in 33 patients with B2 glenoids (mean retroversion 18.9°, range 4°-32°) were available for follow-up at a mean of 8.6 years (range 5.5-11.2) after high-side glenoid reaming with aTSA. Three (5.1%) of the original 59 shoulder were revised. At final follow-up, 3 of 30 (10.0%) shoulders had radiographic glenoid component failure, but were unrevised. Glenoid component failure was associated with worse initial glenoid component seating (mean Lazarus score 1.2 vs. 2.0, P = .002). Glenoid failure was also associated with increased posterior humeral head subluxation at 2-4 year follow-up (mean 5.6% vs. 12.6%, P = .045) and at final follow-up (mean 7.0% vs. 21%, P = .002). There was no association between glenoid component failure and preoperative retroversion, inclination, or humeral head subluxation (all P > .05). Glenoid component failure was associated with worse American Shoulder and Elbow Surgeons (88 vs. 73) and visual analog scale pain (0.8 vs. 2.1) scores (both P = .03). CONCLUSIONS: At a mean of 8.6 years, 88% of shoulders available for follow-up had well-fixed glenoid components. Glenoid component failure was associated with poor initial glenoid component seating, with failed components having an average of 25% of the glenoid component not seated. Preoperative deformity such as glenoid retroversion, inclination, or humeral head subluxation did not predict glenoid component failure. This study supports that initial glenoid component seating and recurrence of posterior humeral head subluxation may be the most important factors for mid-term glenoid component survival in aTSA in patients with B2 glenoids.
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Artroplastía de Reemplazo de Hombro , Cavidad Glenoidea , Luxaciones Articulares , Osteoartritis , Articulación del Hombro , Humanos , Artroplastía de Reemplazo de Hombro/métodos , Articulación del Hombro/diagnóstico por imagen , Articulación del Hombro/cirugía , Estudios Retrospectivos , Estudios de Seguimiento , Osteoartritis/diagnóstico por imagen , Osteoartritis/cirugía , Luxaciones Articulares/cirugía , Cabeza Humeral/cirugía , Cavidad Glenoidea/diagnóstico por imagen , Cavidad Glenoidea/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND: The purpose of this prospective study is to describe the mid- to long-term natural history of untreated asymptomatic degenerative rotator cuff tears in patients 65 years and younger. METHODS: Subjects with an asymptomatic rotator cuff tear in one shoulder and a contralateral painful cuff tear aged 65 years or younger were enrolled in a previously described prospective longitudinal study. Annual physical and ultrasonographic evaluations and surveillance for pain development were performed using independent examiners for the asymptomatic shoulder. RESULTS: Two hundred twenty-nine participants (mean age 57.1 years) were followed for a median of 7.1 (range 0.3-13.1) years. Tear enlargement occurred in 138 (60%) shoulders. Full-thickness tears were at greater risk for enlargement compared with partial-thickness (hazard ratio [HR] 2.93, 95% confidence interval [CI] 1.71-5.03, P < .0001) and control shoulders (HR 18.8, 95% CI 4.63-76.1, P < .0001). Mean survival rates from Kaplan-Meier analyses indicate that full-thickness tears enlarged earlier (mean 4.7, 95% CI 4.1-5.2 years) than partial-thickness (mean 7.4, 95% CI 6.2-8.5 years) and control shoulders (mean 9.7, 95% CI 9.0-10.4 years). Tear presence in the dominant shoulder was associated with a greater enlargement risk (HR 1.70, 95% CI 1.21-1.39, P = .002). Patient age (P = .37) and gender (P = .74) were not associated with tear enlargement. The 2-, 5-, and 8-year survivorship free of tear enlargement for full-thickness tears was 74%, 42%, and 20%, respectively. Shoulder pain developed in 131 (57%) shoulders. Pain development was associated with tear enlargement (HR 1.79, 95% CI 1.24-2.58, P = .002) and was more common in full-thickness tears compared with controls (P = .0003) and partial tears (P = .01). An analysis of progression of muscle degeneration was performed in 138 shoulders with full-thickness tears. Tear enlargement was seen in 104 of 138 (75%) of these shoulders during follow-up (median 7.7 [interquartile range 6.0] years). Progression of muscle fatty degeneration was seen in the supraspinatus in 46 (33%) and the infraspinatus in 40 (29%) shoulders. Adjusting for age, both the presence of fatty muscle degeneration and the progression of muscle changes for both the supraspinatus (P < .0001) and infraspinatus (P < .0001) muscles were associated with tear size. For both the supraspinatus (P = .03) and infraspinatus (P = .03) muscles, tear enlargement was significantly associated with progression of muscle fatty degeneration. Anterior cable integrity was significantly associated with the risk of muscle degeneration progression for both the supraspinatus (P < .0001) and the infraspinatus (P = .005) muscles. CONCLUSIONS: Asymptomatic degenerative rotator cuff tears progress in patient 65 years and younger. Full-thickness rotator cuff tears have a higher risk of continued tear enlargement, progression of fatty muscle degeneration, and pain development than partial-thickness tears.
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Laceraciones , Lesiones del Manguito de los Rotadores , Humanos , Lactante , Preescolar , Niño , Adolescente , Lesiones del Manguito de los Rotadores/complicaciones , Lesiones del Manguito de los Rotadores/diagnóstico por imagen , Estudios de Seguimiento , Estudios Longitudinales , Estudios Prospectivos , Rotura , Atrofia Muscular , Dolor de Hombro/etiologíaRESUMEN
BACKGROUND: Patients undergoing total knee arthroplasty (TKA) who have malnutrition possess an increased risk of periprosthetic joint infection (PJI). Although malnutrition screening and intervention may decrease the risk of PJI, it utilizes healthcare resources. To date, no cost-effectiveness analyses have been performed on the screening and treatment of malnutrition prior to TKA. METHODS: A Markov model projecting lifetime costs and quality-adjusted life years (QALYs) was built to determine the cost-effectiveness of malnutrition screening and intervention for TKA patients from a societal perspective. Costs, health state utilities, and state transition probabilities were obtained from previously published literature, hospital costs at our institution, and expert opinions. Two important assumptions included that 30% of patients would be malnourished and that a malnutrition intervention would be 50% effective. The primary outcome of this study was the incremental cost-effectiveness ratio, with a willingness-to-pay threshold of $100,000 per QALY. One-way and two-way sensitivity analyses were performed to evaluate model parameter assumptions. RESULTS: When using the base case values, universal malnutrition screening and intervention was cost-effective compared to no malnutrition screening or intervention, with an incremental cost-effectiveness ratio of $6,454 per QALY. Universal screening and intervention remained cost-effective, provided the cost of screening remained less than $3,373, the cost of nutritional intervention remained less than $12,042, the prevalence of malnutrition among surgical candidates was higher than 2%, and the risk of PJI among patients with malnutrition was greater than 1%. CONCLUSION: Universal preoperative malnutrition screening and intervention among TKA candidates is cost-effective at parameters encountered in clinical practice. Nutritional optimization programs should be considered to facilitate malnutrition screening and intervention and future studies should evaluate their efficacy at lowering PJI risk.
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Artroplastia de Reemplazo de Rodilla , Humanos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Análisis Costo-Beneficio , Probabilidad , Análisis de Costo-Efectividad , Años de Vida Ajustados por Calidad de Vida , Cadenas de MarkovRESUMEN
PURPOSE: There is currently no consensus regarding the optimal treatment for stiffness following total knee arthroplasty (TKA). With the increased utilization of value-based models, it is important to determine the most effective treatments that will reduce the need for further intervention and additional expenditure. A systematic review was performed to compare the outcomes of manipulation under anaesthesia (MUA), arthroscopic lysis of adhesions (aLOA), and revision TKA (rTKA) for arthrofibrosis and stiffness following TKA. METHODS: PubMed and MEDLINE databases were reviewed for articles published through October 2020. Studies were included if they reported patient-reported outcome measures (PROMs) following MUA, aLOA, or rTKA. The primary endpoint was PROMs, while secondary outcomes included range of motion and the percentage of patients who pursued further treatment for stiffness. RESULTS: A total of 40 studies were included: 21 on rTKA, 7 on aLOA, and 14 on MUA. The mean or median post-operative arc ROM was > 90° in 6/20 (30%) rTKA, 5/7 (71%) aLOA, and 7/10 (70%) MUA studies. Post-operative Knee Society (KSS) clinical and functional scores were the greatest in patients who underwent MUA and aLOA. As many as 43% of rTKA patients required further care compared to 25% of aLOA and 17% of MUA patients. CONCLUSION: Stiffness following TKA remains a challenging condition to treat. Nonetheless, current evidence suggests that patients who undergo rTKA have poorer clinical outcomes and a greater need for further treatment compared to patients who undergo MUA or aLOA.
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Artroplastia de Reemplazo de Rodilla , Artropatías , Artroplastia de Reemplazo de Rodilla/efectos adversos , Humanos , Artropatías/cirugía , Articulación de la Rodilla/cirugía , Rango del Movimiento Articular , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: This prospective cohort study evaluates the impact of total hip arthroplasty and total knee arthroplasty on patient's spouses/significant others (SSOs). METHODS: Patients and SSOs were provided similar outcome metrics (Global Health Patient-Reported Outcomes Measurement Information System, Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement) at preoperative and postoperative visits. Pearson correlation was used to evaluate scores. RESULTS: Our sample included 99 patients (58 total hip arthroplasties and 41 total knee arthroplasties). We found strong correlation between patient and SSO mental status scores. We found moderate correlation for some physical function domains. CONCLUSION: SSOs closely share total joint arthroplasty patient's mental and even some of the physical burden of disease and recovery.
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Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Traumatismos de la Rodilla , Osteoartritis de la Rodilla , Osteoartritis , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Humanos , Osteoartritis de la Rodilla/cirugía , Estudios Prospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Several patient-reported outcome measures (PROMs) exist to measure outcomes after total hip arthroplasty (THA) but can be limited by patient-perceived burden and completion rates. We analyzed whether the modified single assessment numerical evaluation (M-SANE), a one-question PROM, would perform similarly to multiple-question PROMs among patients undergoing primary THA. METHODS: Patients undergoing THA completed the Patient-Reported Outcomes Measurement Information System-10 (PROMIS-10), the Hip Disability and Osteoarthritis Outcomes Score Junior (HOOS-Jr), and M-SANE questionnaires both preoperatively and postoperatively. The M-SANE assessment asked patients to assess their hip on a scale from 0 to 10, with 10 being the best possible score. Validity of M-SANE compared with other PROMs was determined by Spearman's correlation and floor and ceiling effects. Responsiveness was analyzed using standardized response mean (SRM). RESULTS: One hundred and thirty six patients with at least 1-year follow-up were reviewed. The average M-SANE score improved from 3.3 preoperatively to 7.1 at one year postoperatively. There was moderate to strong correlation at one-year follow-up between the M-SANE and HOOS-Jr (ρ = 0.75, P < .001) and PROMIS-10 physical component summary (ρ = 0.63, P < .001). Floor and ceiling effects of the M-SANE (floor 2.0%, ceiling 21.3%) were comparable to the HOOS-Jr (floor 0.0%, ceiling 20.8%). The responsiveness of the M-SANE after THA (SRM = 1.06, 95% CI: 0.79-1.33) was comparable to HOOS-Jr (SRM = 1.33, 95% CI: 1.08-1.59) and superior to PROMIS-10 physical component summary (SRM = 0.65, 95% CI: 0.55-0.74). CONCLUSION: The M-SANE has performed similarly across multiple psychometric properties compared with more burdensome PROMs in assessing longitudinal patient-reported outcomes after THA.
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Artroplastia de Reemplazo de Cadera , Humanos , Medición de Resultados Informados por el Paciente , Psicometría , Encuestas y CuestionariosRESUMEN
Current shoulder clinical range of motion (ROM) assessments (e.g., goniometric ROM) may not adequately represent shoulder function beyond controlled clinical settings. Relative inertial measurement unit (IMU) motion quantifies ROM precisely and can be used outside of clinic settings capturing "real-world" shoulder function. A novel IMU-based shoulder elevation quantification method was developed via IMUs affixed to the sternum/humerus, respectively. This system was then compared to in-laboratory motion capture (MOCAP) during prescribed motions (flexion, abduction, scaption, and internal/external rotation). MOCAP/IMU elevation were equivalent during flexion (R2 = 0.96, µError = 1.7 deg), abduction (R2 = 0.96, µError = 2.9 deg), scaption (R2 = 0.98, µError = -0.3 deg), and internal/external rotation (R2 = 0.90, µError = 0.4 deg). When combined across movements, MOCAP/IMU elevation were equal (R2 = 0.98, µError = 1.4 deg). Following validation, the IMU-based system was deployed prospectively capturing continuous shoulder elevation in 10 healthy individuals (4 M, 69 ± 20 years) without shoulder pathology for seven consecutive days (13.5 ± 2.9 h/day). Elevation was calculated continuously daily and outcome metrics included percent spent in discrete ROM (e.g., 0-5 deg and 5-10 deg), repeated maximum elevation (i.e., >10 occurrences), and maximum/average elevation. Average elevation was 40 ± 6 deg. Maximum with >10 occurrences and maximum were on average 145-150 deg and 169 ± 8 deg, respectively. Subjects spent the vast majority of the day (97%) below 90 deg of elevation, with the most time spent in the 25-30 deg range (9.7%). This study demonstrates that individuals have the ability to achieve large ROMs but do not frequently do so. These results are consistent with the previously established lab-based measures. Moreover, they further inform how healthy individuals utilize their shoulders and may provide clinicians a reference for postsurgical ROM.
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Actividades Cotidianas , Fenómenos Mecánicos , Hombro/fisiología , Anciano , Fenómenos Biomecánicos , Femenino , Voluntarios Sanos , Humanos , Masculino , Rango del Movimiento ArticularRESUMEN
BACKGROUND: The mechanism by which surgical innovation is spread in orthopaedic surgery is not well studied. The recent widespread transition from open to arthroscopic rotator cuff repair techniques provides us with the opportunity to study the spread of new technology; doing so would be important because it is unclear how novel orthopaedic techniques disseminate across time and geography, and previous studies of innovation in healthcare may not apply to the orthopaedic community. QUESTIONS/PURPOSES: (1) How much regional variation was associated with the adoption of arthroscopic rotator cuff repair in the United States Medicare population between 2006 and 2014 and how did this change over time? (2) In which regions of the United States was arthroscopic rotator cuff repair first adopted and how did it spread geographically? (3) Which regional factors were associated with the adoption of this new technology? METHODS: We divided the United States into 306 hospital referral regions based upon referral patterns observed in the Centers for Medicare & Medicaid Services MedPAR database, which records all Medicare hospital admissions; this has been done in numerous previous studies using methodology introduced by the Dartmouth Atlas. The proportion of arthroscopic rotator cuff repairs versus open rotator cuff repairs in each hospital referral region was calculated using adjusted procedural rates from the Medicare Part B Carrier File from 2006 to 2014, as it provided a nationwide sample of patients, and was used as a measure of adoption. A population-weighted, multivariable linear regression analysis was used to identify regional characteristics independently associated with adoption. RESULTS: There was substantial regional variation associated with the adoption of arthroscopy for rotator cuff repair as the percentage of rotator cuff repair completed arthroscopically in 2006 ranged widely among hospital referral regions with a high of 85.3% in Provo, UT, USA, and a low of 16.7% in Seattle, WA, USA (OR 30, 95% CI 17.6 to 52.2; p < 0.001). In 2006, regions in the top quartiles for Medicare spending (+9.1%; p = 0.008) independently had higher adoption rates than those in the bottom quartile, as did regions with a greater proportion of college-educated residents (+12.0%; p = 0.009). The Northwest region (-14.4%; p = 0.009) and the presence of an academic medical center (-5.8%; p = 0.026) independently had lower adoption than other regions and those without academic medical centers. In 2014, regions in the top quartiles for Medicare spending (+5.7%; p = 0.033) and regions with a greater proportion of college-educated residents (+9.4%; p = 0.005) independently had higher adoption rates than those in the bottom quartiles, while the Northwest (-9.6%; p = 0.009) and Midwest regions (-5.1%; p = 0.017) independently had lower adoption than other regions. CONCLUSION: The heterogeneous diffusion of arthroscopic rotator cuff repair across the United States highlights that Medicare beneficiaries across regions did not have equal access to these procedures and that these discrepancies continued to persist over time. A higher level of education and increased healthcare spending were both associated with greater adoption in a region and conversely suggest that regions with lower education and healthcare spending may pursue innovation more slowly. There was evidence that regions with academic medical centers adopted this technology more slowly and may highlight the role that private industry and physicians in nonacademic organizations play in surgical innovation. Future studies are needed to understand if this later adoption leads to inequalities in the quality and value of surgical care delivered to patients in these regions. LEVEL OF EVIDENCE: Level III, therapeutic study.
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Artroscopía/estadística & datos numéricos , Difusión de Innovaciones , Lesiones del Manguito de los Rotadores/cirugía , Anciano , Femenino , Humanos , Masculino , Medicare/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Utilización de Procedimientos y Técnicas , Derivación y Consulta/estadística & datos numéricos , Factores Socioeconómicos , Estados UnidosRESUMEN
Payors, purchasers, health care providers, and patients are increasingly focused on improving the value-defined as health outcomes that matter to patients per dollar expended-of health care delivered to patients. Orthopaedic providers are in a unique position to pioneer this transition given the introduction of alternative payment models as well as the longitudinal, multidisciplinary, and relatively homogenous nature of high-cost, high-burden orthopaedic conditions (eg, osteoarthritis). First, doing so requires identifying and objectively measuring outcomes that are important to patients (eg, quality of life, pain, functional status) over time. Second, it requires applying value-based principles by reorganizing delivery systems into integrated practice units-a team-based, multidisciplinary model-focused on delivering longitudinal care in a method that is tailored to each patient's values, goals, and disease state. Third, providers must understand the true cost of delivering such care through time-driven activity-based costing approaches. With this knowledge of outcomes and cost, providers and payors/purchasers will be adequately equipped to develop contracts that reward providers for delivering better value (across an orthopaedic patient population) while minimizing risk. The transition to value-based health care is feasible regardless of practice setting.
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Atención a la Salud , Calidad de Vida , Humanos , Evaluación de Resultado en la Atención de SaludRESUMEN
BACKGROUND: Traditional clinical shoulder range-of-motion (ROM) measurement methods (ie, goniometry) have limitations assessing ROM in total shoulder arthroplasty (TSA) patients. Inertial measurement units (IMUs) are superior; however, further work is needed using IMUs to longitudinally assess shoulder ROM before TSA and throughout post-TSA rehabilitation. Accordingly, the study aims were to prospectively capture shoulder elevation in TSA patients and to compare the results with healthy controls. We hypothesized that patients would have reduced maximum elevation before TSA compared with controls but would have improved ROM after TSA. METHODS: A validated IMU-based shoulder elevation quantification method was used to continuously monitor 10 healthy individuals (4 men and 6 women; mean age, 69 ± 20 years) without shoulder pathology and 10 TSA patients (6 men and 4 women; mean age, 70 ± 8 years). Controls wore IMUs for 1 week. Patients wore IMUs for 1 week before TSA, for 6 weeks at 3 months after TSA, and for 1 week at 1 year after TSA. Shoulder elevation was calculated continuously, broken into 5° angle "bins" (0°-5°, 5°-10°, and so on), and converted to percentages. The main outcome measures were binned movement percentage, maximum elevation, and average elevation. Patient-reported outcome measures and goniometric ROM were also captured. RESULTS: No demographic differences were noted between the cohorts. Average elevation was not different between the cohorts at any time. Control maximum elevation was greater than pre-TSA and post-TSA week 1 and week 2 values. Time under 30° and time above 90° were equal between the cohorts before TSA. After TSA, patients showed decreased time under 30° and increased time above 90°. DISCUSSION: This study demonstrates that acute and chronic recovery after TSA can be assessed via maximum elevation and time above 90°, respectively. These results inform how healthy individuals and patients use their shoulders before and after TSA.
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Artrometría Articular/métodos , Artroplastía de Reemplazo de Hombro/métodos , Monitoreo Fisiológico/métodos , Osteoartritis/cirugía , Rango del Movimiento Articular/fisiología , Recuperación de la Función , Articulación del Hombro/cirugía , Anciano , Femenino , Humanos , Masculino , Movimiento (Física) , Osteoartritis/fisiopatología , Periodo Posoperatorio , Estudios Prospectivos , Articulación del Hombro/fisiopatologíaRESUMEN
BACKGROUND: There is a lack of consensus regarding indications for surgical management of rotator cuff disease, which can lead to increased regional variation. The objectives of this study were to describe the geographic variation in rates of rotator cuff repair (RCR) in the United States over time and to identify regional characteristics associated with utilization. METHODS: The United States was divided into 306 hospital referral regions. The adjusted per capita RCR rate was calculated using procedural counts derived from the Medicare Part B Carrier File from 2004-2014. Population-weighted multivariable regression was used to identify regional characteristics independently associated with utilization in 2014. RESULTS: In 2014, an 8-fold difference in rates of RCR was found between regions. Between 2010 and 2014, the overall rate of RCR grew only 3.6% and regional variation decreased. Higher regional utilization of several other orthopedic procedures (P < .02), as well as the regional supply of orthopedic surgeons (P = .002), was independently associated with significantly increased utilization. The South, Southeast, and Southwest were independently associated with significantly higher utilization (P < .001) compared with the Northeast. A higher prevalence of resident physicians, a marker of the academic presence within a region, was independently associated with decreased utilization (P < .001). CONCLUSION: Utilization of RCR has increased substantially over the past decade, but the rate of growth appears to be slowing. RCR remains a procedure with significant regional variation, and increased utilization across regions is associated with higher orthopedic surgeon supply and increased rates of other orthopedic procedures.
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Procedimientos Ortopédicos/estadística & datos numéricos , Aceptación de la Atención de Salud/estadística & datos numéricos , Lesiones del Manguito de los Rotadores/cirugía , Manguito de los Rotadores/cirugía , Anciano , Femenino , Humanos , Incidencia , Masculino , Lesiones del Manguito de los Rotadores/epidemiología , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Recent literature has shown that acute reverse total shoulder arthroplasty (RTSA) yields good outcomes in the treatment of displaced proximal humeral fractures, and there have also been recent studies showing that delayed RTSA can be successfully used for sequelae of proximal humeral fractures such as nonunion and malunion. The use of meta-analysis affords the opportunity to formally compare the outcomes of acute RTSA for fracture and delayed RTSA for fracture sequelae. METHODS: We searched the MEDLINE, Embase, and Cochrane Library databases. We included all studies reporting on RTSA for the treatment of proximal humeral fracture sequelae with a comparison group of acute RTSA or with no comparison group in adults with a mean age older than 65 years and at least 2 years of follow-up. We calculated weighted mean differences for range of motion, standardized mean differences for clinical outcome scores, and relative risks for dichotomous outcomes. RESULTS: Sixteen studies met the inclusion criteria, which comprised 322 patients undergoing RTSA for fracture sequelae. Of these studies, 4 were comparative (46 patients) whereas 12 were case series (276 patients). Among studies directly comparing acute versus delayed RTSA, no differences in forward flexion (P = .72), clinical outcome scores (P = .78), or all-cause reoperation (P = .92) were found between the 2 groups. Patients undergoing delayed RTSA achieved 6° more external rotation than those undergoing acute RTSA; this difference was significant (P = .01). CONCLUSIONS: Given the risks associated with surgery in the elderly population, consideration may be given to an initial trial of nonoperative treatment in these patients, saving RTSA for those in whom nonoperative treatment fails without compromising the ultimate outcome.
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Artroplastía de Reemplazo de Hombro , Fracturas del Hombro/cirugía , Articulación del Hombro/fisiopatología , Tiempo de Tratamiento , Anciano , Humanos , Rango del Movimiento Articular , Reoperación , Rotación , Resultado del TratamientoRESUMEN
BACKGROUND: Periprosthetic joint infection (PJI) after total knee arthroplasty is challenging to diagnose. Compared with culture-based techniques, next-generation sequencing (NGS) is more sensitive for identifying organisms but is also less specific and more expensive. To date, there has been no study comparing the cost-effectiveness of these two methods to diagnose PJI after total knee arthroplasty. METHODS: A Markov, state-transition model projecting lifetime costs and quality-adjusted life years (QALYs) was constructed to determine the cost-effectiveness from a societal perspective. The primary outcome was incremental cost-effectiveness ratio, with a willingness-to-pay threshold of $100,000/QALY. Sensitivity analyses were performed to evaluate parameter assumptions. RESULTS: At our base case values, culture was not determined to be cost-effective compared to NGS, with an incremental cost-effectiveness ratio of $422,784 per QALY. One-way sensitivity analyses found NGS to be the cost-effective choice above a pretest probability of 45.5% for PJI. In addition, NGS was cost-effective if its sensitivity was greater than 70.0% and its specificity greater than 94.1%. Two-way sensitivity analyses revealed that the pretest probability and test performance parameters (sensitivity and specificity) were the largest factors for identifying whether a particular strategy was cost-effective. CONCLUSION: The results of our model suggest that the cost-effectiveness of NGS to diagnose PJI depends primarily on the pretest probability of PJI and the performance characteristics of the NGS technology. Our results are consistent with the idea that NGS should be reserved for clinical contexts with a high pretest probability of PJI. Further study is required to determine the indications and subgroups for which NGS offers clinical benefit.
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Artritis Infecciosa/diagnóstico , Artroplastia de Reemplazo de Rodilla/efectos adversos , Secuenciación de Nucleótidos de Alto Rendimiento/economía , Infecciones Relacionadas con Prótesis/diagnóstico , Anciano , Artritis Infecciosa/economía , Artritis Infecciosa/etiología , Artroplastia de Reemplazo de Rodilla/economía , Análisis Costo-Beneficio , Técnicas de Cultivo/economía , Humanos , Probabilidad , Infecciones Relacionadas con Prótesis/economía , Infecciones Relacionadas con Prótesis/etiología , Años de Vida Ajustados por Calidad de VidaRESUMEN
BACKGROUND: Patient-reported outcome measures (PROMs) are important for tracking outcomes following total knee arthroplasty (TKA) but can be limited by time constraints and patient compliance. We sought to evaluate the utility of the one-question, modified single assessment numerical evaluation (M-SANE) score in TKA patients compared to legacy PROMs. METHODS: Patients undergoing TKA completed the Patient-Reported Outcomes Measurement Information System-10 (PROMIS-10), the Knee Disability and Osteoarthritis Outcomes Score Junior (KOOS Jr), and M-SANE (modified-SANE) assessments both preoperatively and postoperatively. The M-SANE score asked patients to rate their native or prosthetic knee on a scale from 0 to 10, with 10 being the best function. M-SANE validity was determined by the Spearman's correlation between the collected PROMs and the Bland-Altman plots. PROM responsiveness was assessed using the standardized response mean. RESULTS: In total, 217 patients completed PROMs preoperatively and at 1 year postoperatively. Floor and ceiling effects of the M-SANE were higher than other PROMs but still relatively low (4%-11%). There was a moderate to strong correlation at nearly all time points between the M-SANE and KOOS Jr (ρ = 0.44-0.78, P < .001). There was a weak correlation between the M-SANE and PROMIS physical component summary at the preoperative evaluation (ρ = 0.28) but a strong correlation at 1-year follow up (0.65, P < .001). The long-term responsiveness of the M-SANE to TKA (standardized response mean [SRM] = 0.98, 95% confidence interval [CI] 0.80-1.17) was comparable to both the KOOS Jr (SRM = 1.19, 95% CI 1.00-1.38) and PROMIS physical component summary (SRM = 0.82, 95% CI 0.74-0.91). Bland-Altman plots demonstrated that the M-SANE and KOOS Jr capture combined knee pain and functionality differently. CONCLUSION: The M-SANE score was comparable to validated multiple-question PROMs in TKA patients. The demonstrated validity of the M-SANE, as well as its comparable responsiveness to more lengthy PROMs, highlights its use as a one-question PROM for assessment of patient undergoing TKA.
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Artroplastia de Reemplazo de Rodilla , Osteoartritis de la Rodilla , Humanos , Articulación de la Rodilla/cirugía , Osteoartritis de la Rodilla/cirugía , Medición de Resultados Informados por el Paciente , Sistema de Registros , Resultado del TratamientoRESUMEN
BACKGROUND: Patients aged 80 and above who suffer from end-stage osteoarthritis may benefit from total knee arthroplasty (TKA), but at high potential risk. Additionally, there is controversy about whether functional improvement in patients above age 80 is similar to younger patients. We compared functional improvement, length of stay (LOS), and facility discharge rates after TKA between this cohort and patients less than 80 years of age. METHODS: We completed a retrospective cohort study comparing TKA patients aged 80 and above with all patients younger than 80. We utilized data from a prospectively collected institutional repository of 2308 TKAs performed from April 2011 through July 2016 at an academic medical center in the United States. We performed multivariable logistic regression to determine the association between age group and clinically significant improvement in the Patient-Reported Outcome Measurement Information System (PROMIS)-10 physical component summary (PCS) score. Secondary outcomes included the magnitude of PCS change, LOS, and facility discharge. RESULTS: There were 175 (7.6%) TKAs in patients older than 80 years compared with 2133 TKAs in patients younger than 80. Patients over 80 had similar adjusted odds of achieving clinically significant PCS improvement following TKA (P = .366), and there was no statistical difference in adjusted postoperative PCS improvement between the 2 age groups. Age 80 and above was associated with a longer adjusted LOS and demonstrated increased odds of facility discharge (odds ratio 4.11, P < .001) after TKA. CONCLUSION: Following TKA, patients older than 80 years demonstrate similar adjusted functional improvement in comparison to younger patients. However, older patients did require substantially more resources as they remained in the hospital longer and were discharged to rehabilitation more often.
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Artroplastia de Reemplazo de Rodilla/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , Medición de Resultados Informados por el Paciente , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Humanos , Modelos Logísticos , Masculino , Oportunidad Relativa , Osteoartritis/cirugía , Periodo Posoperatorio , Estudios Retrospectivos , Resultado del Tratamiento , Estados UnidosAsunto(s)
Conservadores de la Densidad Ósea/efectos adversos , Neoplasias Óseas/diagnóstico , Denosumab/efectos adversos , Fracturas del Fémur/diagnóstico , Anciano , Anciano de 80 o más Años , Neoplasias Óseas/secundario , Neoplasias de la Mama/patología , Carcinoma de Pulmón de Células no Pequeñas/patología , Diagnóstico Diferencial , Femenino , Fracturas del Fémur/inducido químicamente , Fracturas del Fémur/diagnóstico por imagen , Humanos , Neoplasias Pulmonares/patología , Masculino , Neoplasias de la Próstata/patología , RadiografíaRESUMEN
INTRODUCTION: Applying to orthopaedic surgery residency is competitive. Online information and mentorship are important tools applicants use to learn about programs and navigate the process. We aimed to identify which resources applicants use and their perspectives on those resources. METHODS: We surveyed all applicants at a single residency program for the 2018 to 2019 application cycle (n = 610) regarding the importance of online resources and mentors during the application process. We defined mentorship as advice from faculty advisors or counselors, orthopaedic residents, medical school alumni, or other medical students. We also assessed their attitudes about the quality and availability of these resources. Applicants were asked to rank resources and complete Likert scales (1 to 5) to indicate the relative utility and quality of options. Descriptive statistics were used to summarize data for comparisons. RESULTS: The response rate was 42% (259 of 610 applicants). Almost 50% of applicants reported that they would have likely applied to fewer programs if they had better information. Applicants used program websites with the highest cumulative frequency (96%), followed by advice from medical school faculty/counselors and advice from orthopaedic residents at home institution (both 82%). The next two most popular online resources were a circulating Google Document (78%) and the Doximity Residency Navigator (73%). On average, the quality of online resources was felt to be poorer than mentorship with advice from orthopaedic residents receiving the highest quality rating (4.16) and being ranked most frequently as a top three resource (122 votes). Mentorship comprised three of the top five highest mean quality ratings and three of the top five cumulative rankings by usefulness. CONCLUSION: Applicants reference online resources frequently, despite valuing mentorship more. If the orthopaedic community fostered better mentorship for applicants, they may not feel compelled to rely on subpar online information. Both online information and mentorship can be improved to create a more effective application experience.
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Internado y Residencia , Procedimientos Ortopédicos , Ortopedia , Docentes Médicos , Humanos , Mentores , Ortopedia/educaciónRESUMEN
BACKGROUND: Next-generation sequencing (NGS) offers improved sensitivity compared to culture-based methods for identifying organisms from synovial joints. It remains unclear whether native microorganisms exist in a joint, and positive NGS results may be interpreted as pathologic when in fact they may represent this native microbiome. The purpose of this study was to characterize the native knee microorganism profile in patients undergoing primary total knee arthroplasty (TKA). METHODS: Forty consecutive patients with osteoarthritis undergoing primary total knee arthroplasty were enrolled prospectively. During TKA surgery but prior to arthrotomy, the native knee was aspirated and the fluid was sent for NGS analysis. Immediately after arthrotomy, four separate tissue samples were also sent for NGS analysis. All microbes identified by NGS were recorded. RESULTS: Twelve out of forty patients (30%) had at least one positive organism identified by NGS from their native knee. Of those with positive NGS results, 9/12 (75%) had more than one organism identified (range two to 11). There were no significant differences in demographics, comorbidities, or incidence of prior knee injections between the two groups. There were 48 unique organisms identified from all patients, and the average number of organisms identified by NGS was 4.6 per patient. Four sterile water controls were all negative for organisms. CONCLUSION: A proportion of patients with osteoarthritis undergoing primary total knee arthroplasty have organisms identified in their joint by NGS at the time of surgery. Organisms identified after TKA by NGS when concern for periprosthetic joint infection exists may represent the native microbiome rather than pathogenic microbes.
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Artroplastia de Reemplazo de Rodilla , Articulación de la Rodilla/microbiología , Osteoartritis de la Rodilla/microbiología , Osteoartritis de la Rodilla/cirugía , Anciano , Femenino , Secuenciación de Nucleótidos de Alto Rendimiento , Humanos , Masculino , Persona de Mediana EdadRESUMEN
Background: Open reduction and internal fixation (ORIF) of proximal humerus fractures in elderly individuals (age >70) carries a relatively high short-term complication and reoperation rate but is generally durable once healed. Reverse total shoulder arthroplasty (RTSA) for fractures may be associated with superior short-term quality of life but carries the lifelong liabilities of joint replacement. The tradeoff between short and long-term risks, coupled with disparities in quality of life and cost, makes this clinical decision amenable to cost-effectiveness analysis. Methods: A Markov state-transition model was constructed with a base case of a 75 year-old patient. Reoperation rates, quality of life values, mortality rates, and costs were based upon published literature. The model was run until all patients had died to simulate the accumulated costs and benefits. Results: RTSA was associated with greater quality of life (7.11 QALYs) than ORIF (6.22 QALYs). RTSA was cost-effective with an incremental cost-effectiveness ratio of $3,945/QALY and $27,299/ QALY from payor and hospital perspectives, respectively. RTSA was favored and cost-effective at any age above 65 and any Charlson Score. The model was sensitive to the utility of both procedures. Conclusion: RTSA resulted in a higher quality of life and was cost-effective in comparison to ORIF for elderly patients.Level of Evidence: III.
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Artroplastía de Reemplazo de Hombro/economía , Fijación Interna de Fracturas/economía , Fracturas del Húmero/cirugía , Reducción Abierta/economía , Anciano , Anciano de 80 o más Años , Artroplastía de Reemplazo de Hombro/mortalidad , Análisis Costo-Beneficio , Fijación Interna de Fracturas/mortalidad , Humanos , Fracturas del Húmero/mortalidad , Reducción Abierta/mortalidad , Complicaciones Posoperatorias , Calidad de VidaRESUMEN
BACKGROUND: While extreme elderly patients (age 80 and above) benefit from joint replacement, there is controversy about whether their physical function improves as much as younger individuals following total hip arthroplasty. METHODS: We completed a retrospective cohort study comparing extreme elderly total hip arthroplasty (THA) patients to younger patients. We obtained data from a large institutional repository of 2327 consecutive THAs performed from April 2011 through July 2016 at an American academic medical centre. We performed multivariate regression analyses to determine associations between age group and clinically significant improvement in the Patient-Reported Outcome Measurement Information System (PROMIS)-10 physical component summary (PCS) score. Secondary outcomes included the magnitude of PCS change, length of stay (LOS), and facility discharge. RESULTS: There were 187 THAs (8.0%) in patients age ⩾ 80 years compared to 2140 THA procedures in patients < age 80. Extreme elderly patients had similar adjusted odds of achieving clinically significant PCS improvement after THA (p = 0.528) and there were no statistical differences in adjusted postoperative PCS score improvements between the cohorts. Extreme elderly patients were associated with a 0.68 day longer adjusted LOS (p < 0.001) and demonstrated higher adjusted odds of facility discharge following THA (OR 8.96, p < 0.001). CONCLUSIONS: Compared to younger patients, extreme elderly individuals had similar adjusted postoperative functional outcomes following THA but utilised substantially more resources in the form of increased time in the hospital and higher rates of facility discharges.