Health Care Costs Following Anterior Cervical Discectomy and Fusion or Cervical Disc Arthroplasty.

STUDY DESIGN: Observational cohort study. OBJECTIVE: To describe the postoperative costs associated with both anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) in the two-year period following surgery. SUMMARY OF BACKGROUND DATA: CDA has become an increasingly common alternative to ACDF for the treatment of cervical disc disorders. Although a number of studies have compared clinical outcomes between both procedures, much less is known about the postoperative economic burden of each procedure. MATERIALS AND METHODS: By analyzing a commercial insurance claims database (Marketscan, Merative), patients who underwent one-level or two-level ACDF and CDA procedures between January 1, 2017 and December 31, 2017 were identified and included in the study. The primary outcome was the cost of payments for postoperative management in the two-year period following ACDF or CDA. Identified postoperative interventions included in the study were: (i) physical therapy, (ii) pain medication, (iii) injections, (iv) psychological treatment, and (iv) subsequent spine surgeries. RESULTS: Totally, 2304 patients (age: 49.0±9.4 yr; male, 50.1%) were included in the study. In all, 1723 (74.8%) patients underwent ACDF, while 581 (25.2%) underwent CDA. The cost of surgery was similar between both groups (ACDF: $26,819±23,449; CDA: $25,954±20,620; P =0.429). Thirty-day, 90-day, and two-year global costs were all lower for patients who underwent CDA compared with ACDF ($31,024 vs. $34,411, $33,064 vs. $37,517, and $55,723 vs. $68,113, respectively). CONCLUSION: Lower two-year health care costs were found for patients undergoing CDA compared with ACDF. Further work is necessary to determine the drivers of these findings and the associated longer-term outcomes.

Anterior Cervical Discectomy and Fusion With Structural Allograft is Associated With Lower Postoperative Health Care Utilization and Reoperations Compared With Cage Implants.

BACKGROUND AND OBJECTIVES: Implants represent a large component of surgical cost, with several available options for anterior cervical discectomy and fusion (ACDF). Rising ACDF volume highlights the need for accurate cost characterization among implant configurations to inform efficient utilization. METHODS: A cohort study of patients who underwent 1-level or 2-level ACDF in 2017 was conducted using the MarketScan national insurance databases, which contain deidentified clinical and financial data. Implant configurations included plate with cage, standalone cage, and plate with structural allograft. Patients who switched insurance providers within 2 years after surgery or underwent concurrent posterior cervical surgery, cervical disk arthroplasty, or cervical corpectomy were excluded. A combined plate/cage and standalone cage group was compared with the allograft group followed by the comparison of the plate/cage and standalone cage groups. In total, 30-day, 90-day, and 2-year aggregate costs; component costs of physical therapy, injections, medications, psychological treatment, and subsequent spine surgery; and reoperation rates were evaluated. RESULTS: Of 1723 patients identified, 360 (20.9%) underwent surgery with plate/cage, 184 (10.7%) with standalone cage, and 1179 (68.4%) with allograft. Aggregate costs were lower in the allograft group compared with the combined cage group at 90 days ($36 428 vs $39 875, P = .04) and 2 years ($64 951 vs $74 965, P = .005) postoperatively. There were no significant differences in aggregate costs between the plate/cage and standalone cage groups. The 2-year reoperation rate was higher in the combined cage compared with the allograft group (23.9% vs 10.9%, P < .001) and was also higher in the standalone cage compared with the plate/cage group (32.0% vs 19.7%, P = .002). CONCLUSION: Compared with alternative ACDF constructs, allograft is associated with lower postoperative costs and reoperation rates. Although costs are similar, reoperation rates are lower with plate/cage constructs compared with those of standalone cages. Surgeons should consider these financial and clinical differences when selecting implant configurations.

Arthroscopic Procedures Are Performed in 5% of Patients With Knee Osteoarthritis 1 Year Preceding Total Knee Arthroplasty and Are Associated With Increased Stiffness and Increased Costs.

Purpose: To describe the different types of arthroscopic procedures that patients undergo in the year prior to total knee arthroplasty (TKA), reveal the cost associated with these procedures, and understand the relationship between preoperative arthroscopy and clinical outcomes after TKA. Methods: An observational cohort study was conducted using the IBM Watson Health MarketScan databases. Patients with knee osteoarthritis who underwent unilateral isolated primary TKA between January 1, 2018, and September 30, 2019, were included. Knee arthroscopic procedures performed in the 1-year period before a primary TKA was identified. The primary outcomes of interest were cost of these procedures and the risk of 90-day postoperative complications. Results: In total, 2,904 patients, representing 5.2% of the analyzed cohort, underwent arthroscopic procedures in the year prior to TKA. The most common procedure and diagnosis were meniscectomy and meniscal tear, respectively, with procedures performed an average of 7.2 ± 3.0 months before TKA. Average per patient costs were $9,716 ± $5,500 in the highest payment quartile vs $1,789 ± 636 in the lowest payment quartile. Patients with a history of arthroscopy were more likely to develop postoperative stiffness (P = .001), while no difference was found in the risk of 90-day periprosthetic joint infection (PJI). Conclusions: Of the patients, 5.2% underwent knee arthroscopy in the year prior to TKA. While no association was seen with PJI risk, the costs associated with these procedures are high and may increase the overall cost of management of knee osteoarthritis. Level of Evidence: Level III, retrospective comparative study.

The Cost of Stiffness After Total Knee Arthroplasty.

BACKGROUND: Stiffness after primary total knee arthroplasty (TKA) is debilitating and poorly understood. A heterogenous approach to the treatment is often utilized, including both nonoperative and operative treatment modalities. The purpose of this study was to examine the prevalence of treatments used between stiff and non-stiff TKA groups and their financial impact. METHODS: An observational cohort study was conducted using a large database. A total of 12,942 patients who underwent unilateral primary TKA from January 1, 2017, to December 31, 2017, were included. Stiffness after TKA was defined as manipulation under anesthesia and a diagnosis code of stiffness or ankylosis, and subsequent diagnosis and procedure codes were used to identify the prevalence and financial impact of multiple common treatment options. RESULTS: The prevalence of stiffness after TKA was 6.1%. Stiff patients were more likely to undergo physical therapy, medication, bracing, alternative treatment, clinic visits, and reoperation. Revision surgery was the most common reoperation in the stiff TKA group (7.6%). The incidence of both arthroscopy and revision surgery were higher in the stiff TKA population. Dual component revisions were costlier for patients who had stiff TKAs ($65,771 versus $48,287; P < .05). On average, patients who had stiffness after TKA endured costs from 1.5 to 7.5 times higher than the cost of their non-stiff counterparts during the 2 years following index TKA. CONCLUSION: Patients who have stiffness after primary TKA face significantly higher treatment costs for both operative and nonoperative treatments than patients who do not have stiffness.

Costs of Nonoperative Procedures for Knee Osteoarthritis in the Year Prior to Primary Total Knee Arthroplasty.

BACKGROUND: The convergence of national priorities to reduce health-care costs and deliver high-value care warrants the need to examine health-care utilization. The objective of this study was to describe the costs associated with nonoperative procedures in the 1-year period leading up to primary total knee arthroplasty (TKA). METHODS: An observational cohort study was conducted using the IBM Watson Health MarketScan databases. Patients with late-stage knee osteoarthritis (OA) who underwent unilateral, isolated primary TKA from January 1, 2018, to December 31, 2019, were included. The main outcome was the cost of knee OA-related payments for identified nonoperative procedures in the 1-year period before surgery. Nonoperative procedures examined were (1) physical therapy (PT); (2) bracing; (3) intra-articular injections: professional fee, hyaluronic acid (IA-HA), and corticosteroids (IA-CS); (4) medication: nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and acetaminophen; and (5) knee-specific imaging. RESULTS: The study population included 24,492 TKA patients with a mean age of 60.4 ± 8.0 years. The average total cost of nonoperative procedures per patient was $1,355 ± $2,087. The most common nonoperative treatment prescribed was IA-CS (54.3%). The nonoperative procedure with the highest cost per patient was IA-HA ($1,019 ± $913 per patient). The total cost of nonoperative procedures was higher among female compared with male patients ($1,440 ± $2,159 versus $1,254 ± $1,992 per patient; p < 0.01). The highest costs were found for patients in the Northeast ($1,740 ± $2,437 per patient). A total of 14,346 (58.6%) and 7,831 (32.0%) of the patients had >1 and ≥3 nonoperative treatments, respectively. CONCLUSIONS: There is substantial variation in the type and the cost of nonoperative treatment for patients with late-stage OA. Future studies should investigate the effectiveness of nonoperative treatments at different stages of the disease. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Drivers of Unequal Healthcare Costs in the Nonoperative Treatment of Late-Stage Knee Osteoarthritis Prior to Primary Total Knee Arthroplasty.

BACKGROUND: In the United States, patients with late-stage knee osteoarthritis (OA) often undergo several nonoperative treatments and related procedures prior to total knee arthroplasty. The costs of these treatments and procedures are substantial, and the variation in healthcare costs among different groups of patients may exist. The purpose of this study is to examine these costs and determine the drivers of costs in patients with the highest healthcare expenditure. METHODS: An observational cohort study was conducted using the IBM Watson Health MarketScan databases from January 1, 2017 to December 31, 2019. The primary outcome was the cost of payments for nonoperative procedures which included (i) physical therapy (PT), (ii) bracing, (iii) intra-articular injections: professional fee, hyaluronic acid (IA-HA), and corticosteroids (IA-CS), (iv) medication: nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and acetaminophen, and (v) knee-specific imaging. RESULTS: Among the 24,492 patients included in the study, the total payments per patient for nonoperative care were $3,735 ± 3,049 in the highest payment quartile (Q4) and $137 ± 70 in the lowest payment quartile (Q1). Per-patient-per-month costs generally increased across quartiles for procedures. Comparing Q4 to Q1, the largest changes in prevalence were found in IA-HA (348×), bracing (10×), and PT (7×). Patients who were prescribed IA-HA and PT had a 28.3-times and 4.8-times greater likelihood, respectively, to be a higher-paying patient. CONCLUSION: Unequal healthcare costs in the nonoperative treatment of late-stage knee OA are driven by differences in prevalent management strategies. Overall healthcare expenditure may be reduced if only guideline-concordant treatments are used.

Effect of body mass and midsole hardness on kinetic and perceptual variables during basketball landing manoeuvres.

This study investigated the effects of body mass and shoe midsole hardness on kinetic and perceptual variables during the performance of three basketball movements: (1) the first and landing steps of layup, (2) shot-blocking landing and (3) drop landing. Thirty male basketball players, assigned into "heavy" (n = 15, mass 82.7 ± 4.3 kg) or "light" (n = 15, mass 63.1 ± 2.8 kg) groups, performed five trials of each movement in three identical shoes of varying midsole hardness (soft, medium, hard). Vertical ground reaction force (VGRF) during landing was sampled using multiple wooden-top force plates. Perceptual responses on five variables (forefoot cushioning, rearfoot cushioning, forefoot stability, rearfoot stability and overall comfort) were rated after each movement condition using a 150-mm Visual Analogue Scale (VAS). A mixed factorial analysis of variance (ANOVA) (Body Mass × Shoe) was applied to all kinetic and perceptual variables. During the first step of the layup, the loading rate associated with rearfoot contact was 40.7% higher in the "heavy" than "light" groups (P = .014) and 12.4% higher in hard compared with soft shoes (P = .011). Forefoot peak VGRF in a soft shoe was higher (P = .011) than in a hard shoe during shot-block landing. Both "heavy" and "light" groups preferred softer to harder shoes. Overall, body mass had little effect on kinetic or perceptual variables.