Workman's compensation as exclusion criteria in rotator cuff repair literature - are we inadvertently excluding race?

OBJECTIVE: Despite an equal willingness to participate in clinical trials, there is evidence that several minority populations are systematically under-represented in studies. One potential cause and frequently used exclusionary criterion in orthopedic trials is patients with active workman's compensation (WC) insurance claims. The purpose of this study is to determine demographic differences in patients undergoing arthroscopic rotator cuff repair with commercial and government insurance vs workers compensation claims. METHODS: This was a retrospective review of patients who underwent primary arthroscopic rotator cuff repair at a single institution in the northeastern United States from 2018 to 2019. Patients undergoing revision cases were excluded. Chart review was used to extract demographic data such as age, gender, insurance, and reported race. RESULTS: A total of 4553 patient records were reviewed and included. There were 742 WC patients and 3811 non-WC patients. Two hundred and forty-four patients did not report their race. Overall, WC patients differed from non-WC with respect to race (P < 0.001). One hundred and eleven (15.0%) of WC and 293 (7.7%) non-WC patients reported being 'Black' or 'African American' (P = 0.002). This compares to 368 (49.6%) WC and 2788 (73.2%) non-WC patients who reported 'White' (P < 0.001). About 16.8% of WC patients were identified as 'Hispanic or Latino,' compared to 5.2% of non-WC (P < 0.001). CONCLUSION: African American and Hispanic/Latino patients are over-represented in workman's compensation patient populations relative to non-workman's compensation. Conversely, white patients are over-represented in non-WC patient populations, which serve as the basis for the majority of clinical study populations. Excluding workman's compensation patients from clinical trials may lead to an underrepresentation of African American and Hispanic/Latino patient populations in orthopedic clinical trials. In doing so, the generalizability of the results of rotator cuff repair clinical outcomes research to all races and ethnicities may be compromised.

Disruptions in Standard Care in Patients After Arthroscopic Rotator Cuff Repair During the COVID-19 Pandemic.

Background: The coronavirus disease-2019 (COVID-19) pandemic led to disruptions in care for orthopaedic patients who underwent surgery just before the outbreak, rendering some unable to participate in standard postoperative care. Many of these patients underwent clinical follow-up and physical therapy via telehealth. Purpose: To evaluate the methods of postoperative care in patients who underwent arthroscopic rotator cuff repair (RCR) and had follow-ups during the height of the pandemic versus those who received prior standard of care. We aimed to compare the 1-year outcomes between these cohorts. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective chart review was used to identify patients who underwent primary RCR in February and March 2020 (COVID cohort) and the same period in 2019 (control cohort) at a single institution. Excluded were patients who underwent revision RCR, used workers' compensation, or were incarcerated or deceased. The included patients reported the postoperative care received, their satisfaction with care, physical therapy appointment type (in person, home based, telehealth, or self-guided), satisfaction with physical therapy, and minimum 1-year postoperative American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Penn Shoulder Score (PSS) outcomes. Results: Overall, 428 patients were included for final analysis--199 in the COVID cohort and 229 controls. Follow-up data were collected for 160 patients in the COVID group (80.4%) and 169 control patients (73.8%). In the COVID group, 110 patients (68.8%) had ≥1 clinical visit conducted via telehealth, compared with zero in the control group. There were no differences between the COVID and control groups in the ASES (84.2 ± 16.5 vs 86.5 ± 17; P = .27 ), SANE (83.9 ± 15.4 vs 84.8 ± 17.5; P = .66), PSS (84.8 ± 15.3 vs 87.1 ± 15.1; P = .22), or patient satisfaction with the care received (81.7 ± 22.6 vs 86.3 ± 23.5; P = .09). Satisfaction with physical therapy was significantly higher in the control group (88.3 ± 18.9 vs 81.9 ± 22.5; P = .01). Conclusion: Despite disruptions in care, RCR patients had comparable 1-year outcomes during the pandemic versus before the pandemic. Telehealth clinical follow-up appointments did not adversely affect patient-reported outcome measures and may be appropriate for RCR patients beyond the pandemic.

Disruptions in standard care: anterior cruciate ligament reconstruction outcomes during the SARS-COV2 pandemic.

OBJECTIVE: The SARS-COV2 pandemic led to massive disruptions of care for orthopedic patients. Although many elective procedures were put on hold, a cohort of patients who underwent surgery prior to the outbreak of the pandemic were rendered unable to participate in standard post-operative care. The purpose of this study was to determine the methods of post-operative care in arthroscopic anterior cruciate ligament reconstruction patients who received care during an early height of the pandemic to those who received standard of care in the prior year. We aimed to correlate those results with 1-year clinical outcomes in the form of subjective surveys. METHODS: Retrospective chart review was used to identify patients who underwent primary anterior cruciate ligament reconstruction in February and March of 2020 (case) and 2019 (control) at a single institution. Workman's compensation patients were excluded. Identified patients were asked to report post-operative care received, satisfaction with care, and complete the IKDC and Lysholm outcome measures. Surveys were conducted minimum 1-year post-operative. RESULTS: 236 patients were identified, including 103 in 2020 and 133 in 2019. Follow-up data was collected for 73 patients (70.9%) in 2020 and 97 patients (72.9%) in 2019. Fifty-one COVID cohort patients (69.9%) had at least one clinical visit conducted via telehealth, compared to zero in the control. There were no differences in IKDC (82.8 ± 13.2 vs 85.0 ± 12.0, P = 0.29) and Lysholm (89.2 ± 11.3 vs 89.6 ± 10.8, P = 0.82) between groups. There were no differences in patient satisfaction with the care received (82.9 ± 22.4 vs 81.9 ± 21.8, P = 0.79). CONCLUSION: Despite disruptions in care, anterior cruciate ligament reconstruction patients have excellent 1-year outcomes during the pandemic. Telehealth follow-up appointments may be appropriate for anterior cruciate ligament reconstruction patients beyond the pandemic and do not seem to adversely affect short-term patient reported outcome measures.

Intraoperative CT Scan Verification of Pedicle Screw Placement in AIS to Prevent Malpositioned Screws: Safety Benefit and Cost.

STUDY DESIGN: Prospective database review. OBJECTIVES: Determine if use of intraoperative 3D imaging of pedicle screw position provides clinical and cost benefit. SUMMARY OF BACKGROUND: Injury or reoperation from malpositioned pedicle screws in adolescent idiopathic scoliosis (AIS) surgery occurs but is increasingly considered to be a never-event. To avoid complications, intraoperative 3D imaging of screw position may be obtained. METHODS: A prospective, consecutive AIS database at a high-volume pediatric spine center was examined three years before and after implementation of an intraoperative low-dose computed tomographic (CT) scan protocol. All screws were placed via freehand technique and corrected if found to be outside optimal trajectory on the postplacement CT scan. Demographic and outcome data were compared between cohorts, along with number, location, and reason for screw change. Cost analysis was based on the average cost of revision surgery for screw malposition versus intraoperative CT use. RESULTS: There were 153 patients in the pre-CT and 153 in the post-CT cohorts with a minimum 2-year follow-up. Two reoperations were needed for revision of improper screw placement in the pre-CT group and none in the post-CT group. Number of patients needed to harm was 76 (absolute risk increase = 1.31% [-0.49%, 3.11%]). Of those who had intraoperative CT scans, 80 (52.3%) needed on average 1.75 screw trajectories/lengths changed. Forty-three percent were medial breaches; of these, 39% were in the concavity. There were no differences between patients who did and did not need screw repositioning with regard to body mass index (BMI), age, curve size, surgeon/trainee side, screw density, or preoperative and one-year postoperative Scoliosis Research Society-22 patient questionnaire (SRS-22) scores. The average cost of reoperation for malposition was $4,900, whereas the cost of a single intraoperative CT was $232. CONCLUSION: Intraoperative CT is an effective tool to prevent reoperation in AIS surgery for incorrect screw placement. Despite high volume, experience, and specialty training, incorrect trajectories occur and systems should be in place for preventable error. LEVEL OF EVIDENCE: Level II.