Effect of Facility Ownership on Utilization of Arthroscopic Shoulder Surgery.

INTRODUCTION: We examined practice patterns and surgical indications in the management of common shoulder procedures by surgeons practicing at physician-owned facilities. METHODS: This study was a retrospective analysis of 501 patients who underwent arthroscopic shoulder procedures performed by five surgeons in our practice at one of five facilities during an 18-month period. Two of the facilities were physician-owned, and three of the five surgeons were shareholders. Demographics, insurance status, symptom duration, time from injury/symptom onset to the decision to perform surgery (at which time surgical consent is obtained), and time to schedule surgery were studied to determine the influence of facility type and physician shareholder status. RESULTS: Median duration of symptoms before surgery was significantly shorter in workers' compensation patients than in non-workers' compensation patients (47% less; P < 0.0001) and in men than in women (31% less; P < 0.001), but was not influenced by shareholder status or facility ownership (P > 0.05). Time between presentation and surgical consent was not influenced by facility ownership (P = 0.39) or shareholder status (P = 0.50). Time from consent to procedure was 13% faster in physician-owned facilities than in non-physician-owned facilities (P = 0.03) and 35% slower with shareholder physicians than with nonshareholder physicians (P < 0.0001). DISCUSSION: The role of physician investment in private healthcare facilities has caused considerable debate in the orthopaedic surgery field. To our knowledge, this study is the first to examine the effects of shareholder status and facility ownership on surgeons' practice patterns, surgical timing, and measures of nonsurgical treatment before shoulder surgery. CONCLUSIONS: Neither shareholder status nor facility ownership characteristics influenced the speed with which surgeons determined that shoulder surgery was indicated or surgeons' use of preoperative nonsurgical treatment. After the need for surgery was determined, patients underwent surgery sooner at physician-owned facilities than at non-physician-owned facilities and with nonshareholder physicians than with shareholder physicians. LEVEL OF EVIDENCE: Level III.

Outcomes Following Arthroscopic Repair of Posterior Labral Tears in Patients Older Than 35 Years.

Although the results of arthroscopic management of posterior labral pathology in young athletes have been reported extensively in the literature, the clinical outcomes in older patients are unknown. This retrospective review included patients older than 35 years who underwent arthroscopic posterior labral repair. Functional outcome scores were collected, and subgroup analyses were performed to evaluate the impact of patient-specific factors. Forty-three patients met the inclusion criteria; average follow-up was 36.9 months (range, 24-54 months). Mean patient age at the time of surgery was 40.9 years (range, 35-57 years). Average outcome scores at final follow-up were Quick Disabilities of the Arm, Shoulder and Hand Scale (QuickDASH), 19±22; Simple Shoulder Test (SST), 9.9±3; Western Ontario Shoulder Instability Index (WOSI), 601±546; and Single Assessment Numeric Evaluation (SANE), 79.6%±23.4%. No significant differences in outcomes were observed in patients with preoperative symptomatic instability, active workers' compensation claims, or traumatic injury (P>.05). The presence of intraoperatively definable chondral damage (Outerbridge grade III or higher) was associated with significantly worse final functional outcomes (QuickDASH: 29 vs 11.9, P=.03; SST: 8.5 vs 10.9, P=.02; WOSI: 875 vs 407, P=.01; and SANE: 70.6% vs 86%, P=.05). One patient (2%) experienced a minor postoperative complication, and 3 patients (7%) required subsequent procedures: 2 total shoulder arthroplasties and 1 revision labral repair. The results of arthroscopic posterior labral repair in patients older than 35 years were variable and worse than those previously reported in younger patients. The presence of chondral damage at the time of the index procedure was a negative predictive factor. [Orthopedics. 2017; 40(2):e305-e311.].

Arthroscopic Transosseous and Transosseous-Equivalent Rotator Cuff Repair: An Analysis of Cost, Operative Time, and Clinical Outcomes.

The incidence of arthroscopic rotator cuff repair (RCR) continues to rise. Given the changing healthcare climate, it is becoming increasingly important to critically evaluate current practice and attempt to make modifications that decrease costs without compromising patient outcomes. We conducted a study of the costs associated with arthroscopic anchorless (transosseous [TO]) RCR and those associated with the more commonly performed anchor-based TO-equivalent (TOE) method to determine whether there are any cost savings with the TO-RCR method. Twenty-one consecutive patients who underwent arthroscopic TO-RCR were prospectively enrolled in the study and matched on tear size and concomitant procedures with patients who underwent arthroscopic TOE-RCR. The groups' implant costs and operative times were obtained and compared. Outcome measures, including scores on the VAS (visual analog scale) for pain, the SANE (Single Assessment Numeric Evaluation), and the SST (Simple Shoulder Test), recorded at 3, 6, and >12 months after surgery, were compared between the TO and TOE groups. Mean implant cost was $946.91 less for the TO group than the TOE group-a significant difference. Mean operative time was not significantly different between the TO and TOE groups. There was significant improvement on all outcomes measures (VAS, SANE, SST) at >12 months, and this improvement was not significantly different between the groups. Arthroscopic TO-RCR provides significant cost savings over TOE-RCR with no significant difference in operative time or short-term outcomes.

Heterotopic ossification of the long head of the triceps after reverse total shoulder arthroplasty.

BACKGROUND: Heterotopic ossification (HO) around shoulder arthroplasty is a frequent finding with unclear clinical relevance. This study evaluated the incidence, relevance, and predisposing factors of HO in the long head of the triceps tendon after reverse shoulder arthroplasty. METHODS: Retrospective chart review was conducted to identify patients who had a reverse shoulder arthroplasty performed between 2008 and 2012. Patient demographics, implant types, and diagnoses were noted. Three fellowship-trained shoulder/elbow surgeons independently evaluated postoperative Grashey radiographs using a novel classification system. RESULTS: Within a 164-patient cohort, the overall HO rate in the long head of the triceps tendon was 61.6%; 23.2% of osteophytes were considered impinging, 14.6% had notching, 14.0% were free-floating, and 3.0% appeared ankylosed. Although not statistically significant, revision surgery had a higher rate of HO (68.3%) compared with primary surgery (59.4%). There was no difference in HO rates between diagnoses or implant types. Male and female HO rates were 74.0% and 56.1%, respectively (P = .0304). Between patients with and without HO, forward elevation was 121° compared with 133° (P = .0087) and external rotation was 19° compared with 25° (P = .0266); however, HO size did not significantly affect motion. CONCLUSIONS: Using our novel classification scheme, HO was a common finding in this series. Men had a higher rate of HO formation, and HO formation was associated with worse postoperative motion. Further study is needed to fully characterize the clinical implications of HO involving the long head of the triceps tendon and to explore potential preventive measures.

Comparison of implant cost and surgical time in arthroscopic transosseous and transosseous equivalent rotator cuff repair.

BACKGROUND: We investigated the cost savings associated with arthroscopic transosseous (anchorless) double-row rotator cuff repair compared with double-row anchored (transosseous-equivalent [TOE]) repair. METHODS: All patients undergoing double-row arthroscopic rotator cuff repair from 2009 to 2012 by a single surgeon were eligible for inclusion. The study included 2 consecutive series of patients undergoing anchorless or TOE repair. Excluded from the study were revision repairs, subscapularis repairs, patients with poor tendon quality or excursion requiring medialized repair, and partial repairs. Rotator cuff implant costs (paid by the institution) and surgical times were compared between the 2 groups, controlling for rotator cuff tear size and additional procedures performed. RESULTS: The study included 344 patients, 178 with TOE repairs and 166 with anchorless repairs. Average implant cost for TOE repairs was $1014.10 ($813.00 for small, $946.67 for medium, $1104.56 for large, and $1507.29 for massive tears). This was significantly more expensive compared with anchorless repairs, which averaged $678.05 ($659.75 for small, $671.39 for medium, $695.55 for large, and $716.00 for massive tears). Average total operative time in TOE and anchorless groups was not significantly different (99 vs. 98 minutes). There was larger (although not statistically significant) case time variation in the TOE group. CONCLUSIONS: Compared with TOE repair, anchorless rotator cuff repair provides substantial implant-related cost savings, with no significant differences in surgical time for medium and large rotator cuff tears. Case time for TOE repair varied more with extremes in tear size.

Failure after reverse total shoulder arthroplasty: what is the success of component revision?

BACKGROUND: Complication rates remain high after reverse total shoulder arthroplasty (RTSA). Salvage options after implant failure have not been well defined. This study examines the role of reimplantation and revision RTSA after failed RTSA, reporting outcomes and complications of this salvage technique. METHODS: Sixteen patients underwent component revision and reimplantation after a prior failed RTSA from 2004 to 2011. Indications included baseplate failure (7 patients, 43.8%), instability (6 patients, 37.5%), infection (2 patients, 12.5%), and humeral loosening (1 patient, 6.3%). The average age of the patient during revision surgery was 68.6 years. Outcomes information at follow-up was recorded, including visual analog scale score for pain, subjective shoulder value, American Shoulder and Elbow Surgeons score, and Simple Shoulder Test score, and these were compared with pre-revision values. Repeated surgeries and complications were noted. RESULTS: Average time to follow-up from revision was 58.9 months (minimum, 2 years; range, 24-103 months). The average postoperative visual analog scale score for pain was 1.7/10 (7.5/10 preoperatively; P < .0001), and the subjective shoulder value was 62% (17% preoperatively; P < .0001). The average postoperative American Shoulder and Elbow Surgeons score was 66.7, and the Simple Shoulder Test score was 52.6. Fourteen patients (88%) noted that they felt "better" postoperatively than before their original RTSA and would go through the procedure again if given the option. Nine patients suffered major complications (56%), and 6 of these ultimately underwent further procedures (38% of cohort). DISCUSSION: Salvage options after failure of RTSA remain limited. Component revision and reimplantation can effectively relieve pain and improve function compared with baseline values, and patient satisfaction levels are moderately high. However, complication rates and reoperation rates are significant.

Arthroscopic transosseous rotator cuff repair: technical note, outcomes, and complications.

The goal of this study was to review the authors' initial experience with arthroscopic transosseous rotator cuff repair. Thirty-one patients with full-thickness rotator cuff tears underwent arthroscopic transosseous rotator cuff repair over a 15-month period. Preoperatively, demographics and subjective scores were recorded. Postoperatively, pain levels, subjective shoulder values, satisfaction scores, American Shoulder and Elbow Surgeons (ASES) scores, complications, and reoperations were noted with a minimum 2-year follow-up. The relationships between pre- and intraoperative variables and outcome scores were determined with univariate analysis. Average patient age was 56 years, and 23 patients (74%) were men. Twenty patients (65%) underwent primary rotator cuff repair, and 11 patients (35%) underwent revision repair. Average time to follow-up was 26 months. Average preoperative pain level and subjective shoulder value were 5.1 of 10 and 35%, respectively. Average postoperative scores included pain level of 0.9 of 10, subjective shoulder value of 84%, satisfaction score of 90.6 of 100, and ASES score of 86.3 of 100. There were 3 (9.7%) major and 2 (6%) minor complications. Patients undergoing revision rotator cuff repair had significantly worse outcomes (pain level, subjective shoulder value, ASES score; P<.05) compared with those undergoing primary repair, and cortical augmentation did not significantly affect outcome. Overall, outcomes after arthroscopic transosseous rotator cuff repair are good, although patients undergoing revision repair do not have the same outcomes as those undergoing primary cuff repair. The procedure is not without complications (9.7% major, 6% minor complications). Cortical augmentation may be used to supplement fixation, although it does not necessarily affect outcomes. Patients without such augmentation may be at increased risk for suture cutout through the bone.

Reverse shoulder arthroplasty as salvage for failed prior arthroplasty in patients 65 years of age or younger.

BACKGROUND: This study examined outcomes and complications in young patients undergoing revision reverse total shoulder arthroplasty (RTSA) for failed prior total shoulder arthroplasty or hemiarthroplasty and compared them with those of an age-matched cohort undergoing primary RTSA. METHODS: RTSA as a revision for failed shoulder arthroplasty was performed on 36 patients younger than 65 years. Follow-up was available for 32 patients at an average of 55.3 months. Results were compared with those of an age-matched cohort of 37 patients (33 available for follow-up; average, 54.7 months) undergoing primary RTSA. Average age for both groups was 59.3 years. Outcomes were compared before and after revision surgery and between cohorts. RESULTS: Preoperative visual analog scale (VAS) for pain and subjective shoulder value (SSV) scores were similar in both groups, 7.3 of 10 and 24%, respectively, before revision, and 7.0 of 10 and 19% before primary RTSA (P = .3). Postrevision VAS and SSV scores improved to 1.4 of 10 and 60% (P < .0001). Average American Shoulder and Elbow Surgeons and Simple Shoulder Test scores after revision were 69.7 and 58.8, with 9 complications (28.1%; 6 major and 3 minor). VAS and SSV scores improved to 2.1 of 10 and 76% after primary RTSA (P < .0001). American Shoulder and Elbow Surgeons and Simple Shoulder Test scores after primary RTSA were 74 and 67.3, with 6 complications (18.2%; 5 major and 1 minor). Only the postoperative SSV score was statistically different in comparing primary and revision RTSA (P < .05). CONCLUSION: RTSA is effective in reducing pain and improving function after failed arthroplasty in young patients, but complication rates are high and expectations should be managed appropriately. Subjective outcome scores are worse than those for age-matched patients undergoing primary RTSA, but pain, functional scores, and complication rates are similar.

Posterior sternoclavicular joint injuries in skeletally immature patients.

BACKGROUND: Posterior injuries to the sternoclavicular (SC) joint are uncommon. In the skeletally immature (SI) population, these injuries have been described as either dislocations of the SC joint or fractures of the medial clavicular physis. The current literature and standardized test questions state that a posterior SC injury, in a SI patient, is more likely a physeal fracture than a SC joint dislocation. However, this injury characterization is based on case reports or small case series. The purpose of this study is to characterize posterior SC injuries in SI patients in terms of the prevalence of dislocation versus medial clavicle physeal fracture. METHODS: A retrospective review was performed of 48 SI patients treated for posterior SC joint injuries over a 20-year period with a mean age of 15.4 years (range, 13 to 18 y). Forty patients underwent open reduction and internal fixation as their definitive treatment and 8 patients were treated exclusively with closed reduction. Patients treated operatively were utilized in determining the prevalence of SC joint dislocation versus physeal fracture. RESULTS: All patients treated operatively underwent primary repair without reconstruction. Twenty (50%), of the 40 patients treated operatively had a true SC joint dislocation and 20 patients (50%) had a medial clavicle physeal fracture. Twenty-two (46%) of the 48 total patients had an attempted closed reduction of which only 8 (36%) were successful. Among the 14 unsuccessful closed reductions, 12 (86%) were true dislocations (P<0.001). All successful closed reductions occurred in patients within 24 hours from injury. Eleven of the 48 (23%) patients' injuries were missed on initial presentation. CONCLUSIONS: Posterior SC joint dislocation and medial clavicular physeal fracture both occur with roughly equivalent prevalence in patients with an open medial physis. An attempted closed reduction may be more successful if performed within 24 hours after injury. Patients who fail attempts at closed reduction are more likely to have a posterior SC joint dislocation than a physeal fracture. Posterior SC joint injury may be missed in nearly 25% of patients on initial presentation. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Outcomes of open carpal tunnel release at a minimum of ten years.

BACKGROUND: There is little research on the long-term outcomes of open carpal tunnel release. The purpose of this retrospective study was to determine the functional and symptomatic outcomes of patients at a minimum of ten years postoperatively. METHODS: Two hundred and eleven patients underwent open carpal tunnel release from 1996 to 2000 performed by the same hand fellowship-trained surgeon. Follow-up with validated self-administered questionnaire instruments was conducted an average of thirteen years after surgery. The principal outcomes included the Levine-Katz symptom and function scores, ranging from 1 point (best) to 5 points (worst), and satisfaction with the results of surgery. The patients self-reported current comorbidities. RESULTS: After a mean follow-up of thirteen years (range, eleven to seventeen years), 92% (194) of 211 patients were located. They included 140 who were still living and fifty-four who had died. Seventy-two percent (113) of the 157 located, surviving patients responded to the questionnaire. The mean Levine-Katz symptom score (and standard deviation) was 1.3 ± 0.5 points, and 13% of patients had a poor symptom score (≥2 points). The mean Levine-Katz function score was 1.6 ± 0.8 points, and 26% had a poor function score (≥2 points). The most common symptom-related complaint was weakness in the hand, followed by diurnal pain, numbness, and tingling. The least common symptoms were nocturnal pain and tenderness at the incision. Eighty-eight percent of the patients were either completely satisfied or very satisfied with the surgery. Seventy-four percent reported their symptoms to be completely resolved. Thirty-three percent of men were classified as having poor function compared with 23% of women. Two (1.8%) of 113 patients underwent repeat surgery. CONCLUSIONS: At an average of thirteen years after open carpal tunnel release, the majority of patients are satisfied and free of symptoms of carpal tunnel syndrome.

Role of preoperative computed tomography scans in operative planning for malleolar ankle fractures.

BACKGROUND: There remains no consensus regarding the role of computed tomography (CT) scans in preoperative planning for malleolar ankle fractures. The aim of this study was to determine the role of preoperative CT scans on operative planning in these fractures. METHODS: A retrospective analysis was performed on 100 consecutive patients treated at our institution for malleolar ankle fractures (AO type 44) with both preoperative radiographs and CT scans. Six study participants reviewed available radiographs and formulated an operative (or nonoperative) plan including positioning, operative approach, and fixation. Participants then analyzed CT scans of the same fractures, deciding whether (and how) they would alter operative strategy. Characteristics of fractures and radiographs were correlated with changes in operative strategy. RESULTS: Operative strategy was notably changed in 24% of cases after CT review, with strong intraclass correlation (0.733). Common changes included alterations in medial malleolar (21%) or posterior malleolar (15%) fixation and fixation of an occult anterolateral plafond fracture (9%). Notable predictors of changes in operative strategy included trimalleolar over unimalleolar fractures (29% vs 10% rate of change), preoperative dislocation over no dislocation (31% vs 20%), the presence of only radiographs with overlying plaster versus fractures with at least 1 set of radiographs without plaster (25% vs 14%), and suprasyndesmotic versus trans- and infra-syndesmotic fractures (40% vs 20% and 4%, respectively). CONCLUSIONS: CT scans may be useful adjuncts in preoperative planning for malleolar ankle fractures, most notably in fracture dislocations, cases in which all available radiographs are obscured by plaster, trimalleolar fractures, and suprasyndesmotic fractures. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Value-based shoulder surgery: practicing outcomes-driven, cost-conscious care.

BACKGROUND: Pathology of the shoulder contributes significantly to the increasing burden of musculoskeletal disease. Currently, there exists high variability in the nature and quality of shoulder care, and outcomes and cost reporting are not uniform. Value-based practice aims to simultaneously maximize outcomes and minimize costs for given disease processes. METHODS: The current state of the shoulder care literature was examined with regards to cost and outcomes data, initiatives in streamlining care delivery, and evidence-based practice improvements. This was synthesized with value-based care theory to propose new avenues to improve shoulder care in the future. CONCLUSION: The treatment of shoulder disorders is ideal for the value-based model but has been slow to adopt its principles thus far. We can begin to advance value-based practices through (1) the universal reporting of outcomes and costs, (2) integrating shoulder care across provider specialties, and (3) critically analyzing data to formulate best practices.

Dupuytren disease: an evolving understanding of an age-old disease.

Dupuytren disease, a clinical entity originally described more than 400 years ago, is a progressive disease of genetic origin. Excessive myofibroblast proliferation and altered collagen matrix composition lead to thickened and contracted palmar fascia; the resultant digital flexion contractures may severely limit function. The pathophysiology is multifactorial and remains a topic of research and debate. Genetic predisposition, trauma, inflammatory response, ischemia, and environment, as well as variable expression of proteins and growth factors within the local tissue, all play a role in the disease process. Common treatments of severe disease include open fasciectomy or fasciotomy. These procedures may be complicated by the complex anatomic relationships between cords (pathologic contracted fascia) and adjacent neurovascular structures. Recent advances in the management of Dupuytren disease involve less invasive treatments, such as percutaneous needle fasciotomy and injectable collagenase Clostridium histolyticum. Postoperative management focuses on minimizing the cellular response of cord disruption and maximizing range of motion through static or dynamic extension splinting.

Endothelial nitric oxide synthase gene single-nucleotide polymorphism predicts cerebral vasospasm after aneurysmal subarachnoid hemorrhage.

Vasospasm is a major cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). Studies have shown a link between single-nucleotide polymorphisms (SNPs) in the endothelial nitric oxide synthase (eNOS) gene and the incidence of coronary spasm and aneurysms. Alterations in the eNOS T-786 SNP may lead to an increased risk of post-aSAH cerebral vasospasm. In this prospective clinical study, 77 aSAH patients provided genetic material and were followed for the occurrence of vasospasm. In multivariate logistic regression analysis, genotype was the only factor predictive of vasospasm. The odds ratio (OR) for symptomatic vasospasm in patients with one T allele was 3.3 (95% confidence interval (CI): 1.1 to 10.0, P=0.034) and 10.9 for TT. Patients with angiographic spasm were 3.6 times more likely to have a T allele (95% CI: 1.3 to 9.6, P=0.013; for TT: OR 12.6). Patients with severe vasospasm requiring endovascular therapy were more likely to have a T allele (OR 3.5, 95% CI: 1.3 to 9.5, P=0.016; for TT: OR 12.0). Patients with the T allele of the eNOS gene are more likely to have severe vasospasm. Presence of this genotype may allow the identification of individuals at high risk for post-aSAH vasospasm and lead to early treatment and improved outcome.