Treatment for Symptomatic SLAP Tears in Middle-Aged Patients Comparing Repair, Biceps Tenodesis, and Nonoperative Approaches: A Cost-Effectiveness Analysis.

PURPOSE: To evaluate the cost-effectiveness of nonoperative management, primary SLAP repair, and primary biceps tenodesis for the treatment of symptomatic isolated type II SLAP tear. METHODS: A microsimulation Markov model was constructed to compare 3 strategies for middle-aged patients with symptomatic type II SLAP tears: SLAP repair, biceps tenodesis, or nonoperative management. A failed 6-month trial of nonoperative treatment was assumed. The principal outcome measure was the incremental cost-effectiveness ratio in 2017 U.S. dollars using a societal perspective over a 10-year time horizon. Treatment effectiveness was expressed in quality-adjusted life-years (QALY). Model results were compared with estimates from the published literature and were subjected to sensitivity analyses to evaluate robustness. RESULTS: Primary biceps tenodesis compared with SLAP repair conferred an increased effectiveness of 0.06 QALY with cost savings of $1,766. Compared with nonoperative treatment, both biceps tenodesis and SLAP repair were cost-effective (incremental cost-effectiveness ratio values of $3,344/QALY gained and $4,289/QALY gained, respectively). Sensitivity analysis showed that biceps tenodesis was the preferred strategy in most simulations (52%); however, for SLAP repair to become cost-effective over biceps tenodesis, its probability of failure would have to be lower than 2.7% or the cost of biceps tenodesis would have to be higher than $14,644. CONCLUSIONS: When compared with primary SLAP repair and nonoperative treatment, primary biceps tenodesis is the most cost-effective treatment strategy for type II SLAP tears in middle-aged patients. Primary biceps tenodesis offers increased effectiveness when compared with both primary SLAP repair and nonoperative treatment and lower costs than primary SLAP repair. LEVEL OF EVIDENCE: Level III, economic decision analysis.

The outcomes of total hip arthroplasty in patients with and without multiple sclerosis: a retrospective cohort study.

BACKGROUND: Multiple sclerosis (MS) is a neuroinflammatory disease with debilitating manifestations that may predispose patients to hip fracture and osteoarthritis, and may affect recovery from total hip arthroplasty (THA). With increased longevity of MS patients and growth in demand for arthroplasty in this population, it is important to understand outcomes of THA in patients with MS. AIM: We sought to compare outcomes of THA among persons with MS and without MS. METHODS: International Classification of Diseases, Ninth Revision Procedure Coding System (ICD-9-PCS) codes for hip arthroplasty (815.1) were used to identify all patients in the New York Statewide Planning and Research Cooperative System (SPARCS) database who underwent THA between 2000 and 2014. Patients with MS, the primary exposure, were identified using ICD-9-Clinical Modification (CM) code 340. The study outcomes of length of stay (days), discharge disposition, index admission mortality, 90-day readmission, 1-year revision arthroplasty, and 1-year all-cause mortality were evaluated using multivariable regression analyses inclusive of basic demographics, admission source, disposition, payer, comorbidity, and socioeconomic status (SES). RESULTS: Compared to patients without MS, those with MS had marginally longer lengths of stay (mean ratio [MR] 1.05; 95% confidence interval [CI], 1.01-1.10; p = 0.0142), higher risk for institutional discharge disposition (odds ratio [OR] 2.03; 95% CI, 1.54-2.70; p < 0.0001) and higher risk of readmission for revision hip arthroplasty (OR 2.60; 95% CI, 1.07-6.35; p = 0.035). However, MS patients had similar risk for 90-day readmission and one-year all-cause mortality as compared with non-MS patients. CONCLUSIONS: Although patients with MS who underwent THA had a 90-day complication risk that was similar to those without MS, the risk for requiring revision surgery was more than 2-fold higher. Additional studies are needed to understand the reasons for revision surgery and for developing strategies to mitigate the risk of complications.

Metabolic Bone Disorders Are Predictors for 2-year Adverse Outcomes in Patients Undergoing 2-3 Level Anterior Cervical Discectomy and Fusion for Cervical Radiculopathy or Myelopathy.

STUDY DESIGN: Retrospective cohort study utilizing the New York statewide planning and research cooperative system. STUDY OBJECTIVE: To investigate postoperative complications of patients with metabolic bone disorders (MBDs) who undergo 2-3 levels of anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: MBDs and cervical degenerative pathologies, including cervical radiculopathy (CR) and cervical myelopathy (CM), are prevalent in the aging population. Complications with ACDF procedures can lead to increased hospitalization times, more expensive overhead, and worse patient outcomes. METHOD: Patients with CM/CR who underwent an ACDF of 2-3 vertebrae from 2009 to 2011 with a minimum 2-year follow-up were identified. Patients diagnosed with 1 or more MBD at baseline were compared with a control cohort without any MBD diagnosis. Cohorts were compared for demographics, hospital-related parameters, and 2-year medical, surgical, and overall complications. Binary multivariate logistic regression was used to identify independent predictors. RESULTS: A total of 22,276 patients were identified (MBD: 214; no-MBD: 22,062). Among MBD patients, the majority had vitamin D deficiency (n = 194, 90.7%). MBD patients were older (53.0 vs 49.7 y, P < 0.001), and with higher Deyo index (1.0 vs 0.5, P < 0.001). MBD patients had higher rates of medical complications, including anemia (6.1% vs 2.3%), pneumonia (4.7% vs 2.1%), hematoma (3.3% vs 0.7%), infection (2.8% vs 0.9%), and sepsis (3.7% vs 0.9%), as well as overall medical complications (23.8% vs 9.6%) (all, P ≤0.033). MBD patients also experienced higher surgical complications, including implant-related (5.7% vs 1.9%), wound infection (4.2% vs 1.2%), and wound disruption (0.9% vs 0.2%), and overall surgical complications (9.8% vs 3.2%) (all, P ≤0.039). Regression analysis revealed that a baseline diagnosis of MBD was independently associated with an increased risk of 2-year surgical complications (odds ratio = 2.10, P < 0.001) and medical complications (odds ratio = 1.84, P = 0.001). CONCLUSIONS: MBD as a comorbidity was associated with an increased risk of 2-year postoperative complications after 2-3 level ACDF for CR or CM.

Impact of Admission Source on Shoulder Arthroplasty.

BACKGROUND: The purpose of this study was to determine the relationship between admission source and postoperative length of stay (LOS), index admission hospital charges, and discharge disposition, in patients undergoing shoulder arthroplasty. METHODS: The New York Statewide Planning and Research Cooperative System (SPARCS) was used to identify all patients that underwent elective shoulder arthroplasty from 1994 through 2015. Patients were grouped into institutionalized (INS) versus non-institutionalized (n-INS) groups based on admission source. The two groups were compared regarding demographics, Charleston comorbidity index (CCI), postoperative blood transfusion requirement, LOS, and total charges. RESULTS: A total of 33,248 patients were identified (32,875 n-INS, 373 INS). Patientsin the INS cohort were significantly older (71.9 versus 68.1 years) and had a higher CCI (1.3 vs. 0.7). The mean LOS in the INS group was nearly 1 week longer(9.5 days vs. 2.8 days) and had a significantly higher postoperative blood transfusion rate (37.5% vs. 9.2%, odds ratio: 5.9). The mean total hospital charges in the INS group were also significantly higher ($63,988 vs. $36,826). DISCUSSION: Institutionalized patients undergoing shoulder arthroplasty have a protracted postoperative hospital course and this ultimately resulted in poorer outcomes and increased resource utilization.

The Impact of Isolated Baseline Cannabis Use on Outcomes Following Thoracolumbar Spinal Fusion: A Propensity Score-Matched Analysis.

Background: There is limited literature evaluating the impact of isolated cannabis use on outcomes for patients following spinal surgery. This study sought to compare 90-day complication, 90-day readmission, as well as 2-year revision rates between baseline cannabis users and non-users following thoracolumbar spinal fusion (TLF) for adult spinal deformity (ASD). Methods: The New York Statewide Planning and Research Cooperative System (SPARCS) database was queried between January 2009 and September 2013 to identify all patients who underwent TLF for ASD. Inclusion criteria were age ≥18 years and either minimum 90-day (for complications and readmissions) or 2-year (for revisions) follow-up surveillance. Cohorts were created and propensity score-matched based on presence or absence of isolated baseline cannabis use. Baseline demographics, hospital-related parameters, 90-day complications and readmissions, and two-year revisions were retrieved. Multivariate binary stepwise logistic regression identified independent outcome predictors. Results: 704 patients were identified (n=352 each), with comparable age, sex, race, primary insurance, Charlson/Deyo scores, surgical approach, and levels fused between cohorts (all, p>0.05). Cannabis users (versus non-users) incurred lower 90-day overall and medical complication rates (2.4% vs. 4.8%, p=0.013; 2.0% vs. 4.1%, p=0.018). Cohorts had otherwise comparable complication, revision, and readmission rates (p>0.05). Baseline cannabis use was associated with a lower risk of 90-day medical complications (OR=0.47, p=0.005). Isolated baseline cannabis use was not associated with 90-day surgical complications and readmissions, or two-year revisions. Conclusion: Isolated baseline cannabis use, in the absence of any other diagnosed substance abuse disorders, was not associated with increased odds of 90-day surgical complications or readmissions or two-year revisions, though its use was associated with reduced odds of 90-day medical complications when compared to non-users undergoing TLF for ASD. Further investigations are warranted to identify the physiologic mechanisms underlying these findings. Level of Evidence: III.

Is the incidence of paediatric stress fractures on the rise? Trends in New York State from 2000 to 2015.

The purpose of this study is to analyze trends in the epidemiology of paediatric stress fractures. The New York Statewide Planning and Research Cooperative System database was queried for stress fractures in children between the ages of 6 and 18 years. After checking for monotonicity of the data, Spearman's correlation coefficient was calculated. Multivariate regressions were used to test for associations between demographic variables and risk of stress fracture. Analysis of 11 475 386 outpatient visits between 2000 and 2015 showed that the annual incidence of paediatric stress fractures increased from 1.37 cases per 100 000 outpatient visits in 2006 to 5.32 per 100 000 visits in 2015 (ρ = 0.876, P < 0.01). The mean age at the time of injury was 14.4 ± 2.8 years. Children younger than 14 years accounted for 33.6% of the cohort. Age, male sex, white ethnicity, and private insurance were statistically significant predictors of stress fractures in a multivariate model. This study is the first to document an increase in the annual incidence of paediatric stress fractures.

Reverse Total Shoulder Arthroplasty with a Superior Augmented Glenoid Component for Favard Type-E1, E2, and E3 Glenoids.

BACKGROUND: Uncorrected superior glenoid wear in patients managed with reverse total shoulder arthroplasty (rTSA) can result in increased complications, including baseplate failure. The present study quantifies the clinical and radiographic outcomes of patients with Favard type-E1, E2, and E3 glenoid deformity who were managed with rTSA with use of a superior or superior/posterior augmented glenoid baseplate. METHODS: We retrospectively reviewed the records for 68 patients with shoulder arthritis and Favard type-E1, E2, or E3 glenoid deformity who were managed with primary rTSA and a 10° superior augmented or 10° superior/8° posterior augmented baseplate. The mean duration of follow-up was 40 months (range, 24 to 85 months). Outcomes were assessed preoperatively and at the latest follow-up with shoulder range of motion and use of outcome scores including the Simple Shoulder Test (SST), University of California Los Angeles (UCLA) score, American Shoulder and Elbow Surgeons (ASES) score, Constant score, and Shoulder Pain and Disability Index (SPADI) score. Radiographs were evaluated preoperatively and at the time of the latest follow-up. Differences in preoperative and postoperative range of motion and outcome metrics were assessed with use of a 2-tailed Student t test. RESULTS: The majority of patients experienced clinically meaningful improvements in terms of pain and function following rTSA with a superior or superior/posterior augment, with 94% of patients rating themselves as "much better" (73.5%) or "better" (20.5%) at the time of the latest follow-up. At least 88% of the patients exceeded the minimum clinically important difference (MCID) threshold, and 75% of patients exceeded the substantial clinical benefit (SCB) threshold, for each of the clinical outcome metrics and range of motion. Five complications were reported (prevalence, 7.4%), including acromial stress fracture (2 patients), posttraumatic scapular neck fracture (1 patient), chronic shoulder pain (1 patient), and aseptic glenoid loosening (1 patient). CONCLUSIONS: The present short-term clinical and radiographic study demonstrated that shoulder arthropathy with superior glenoid wear patterns (Favard types E1, E2, and E3) can be successfully treated with rTSA with a superior or superior/posterior augmented baseplate. Longer-term clinical and radiographic follow-up is necessary to confirm that these promising short-term results are durable. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Factors Predicting Hemodynamic Interventions During Inpatient Admission After Shoulder Arthroplasty.

BACKGROUND: We sought to identify the influence of shoulder arthroplasty (SA) type (primary anatomic, primary reverse, revision) and indication (fracture, arthritis) on the risk of postoperative packed red blood cell transfusion (pRBCT) and intravenous fluid bolus (IVFB). METHODS: Patients who underwent SA from 2013 through 2016 at our institution were categorized into four groups: primary anatomic (pTSA; N = 298), primary reverse (pRTSA; N = 292), revision (RevSA; N = 133), and shoulder arthroplasty for fracture (SAF; N = 58). Basic demographics, intraoperative metrics, preoperative lab values, and postoperative interventions (pRBCT and IVFB) were retrieved from electronic records. RESULTS: There were 781 SAs, of which 176 cases involved at least one postoperative intervention: pRBCT (6.3%) or IVFB (18.8%). Compared to pTSA, the odds of pRBCT in pRTSA, revSA, and SAF were: 3.0 (95% CI 0.9-10.0), 3.4 (95% CI 0.9-2.7), and 8.6 (95% CI 2.2-32.9), respectively. Independent risk factors for pRBCT included increasing age (p = 0.003), underweight body mass index (p = 0.019), Charlson Comorbidity Index ≥ 3 (p = 0.002), inpatient discharge to higher level of care (p = 0.011), estimated blood loss (p = 0.003), and preoperative hemoglobin (p ≤ 0.001). Also, compared to pTSA, the odds for IVFB in pRTSA, revSA, and SAF were: 2.8 (95% CI 1.7-4.6), 2.2 (95% CI 1.2-4.0), and 4.7 (95% CI 2.2-9.9), respectively. Other independent risk factors for IVFB included female sex (0.002), CCI ≥ 3 (p = 0.017), and operative time (p = 0.047). CONCLUSION: Shoulder arthroplasty for fracture is an independent risk factor for higher risk of postoperative pRBCT and IVFB.

The Demographic and Geographic Trends of Meniscal Procedures in New York State: An Analysis of 649,470 Patients Over 13 years.

BACKGROUND: The purpose of this study was to examine the geographic and demographic variations and time trends of different types of meniscal procedures in New York State to determine whether disparities exist in access to treatment. METHODS: The New York Statewide Planning and Research Cooperative System (SPARCS) outpatient database was reviewed to identify patients who underwent elective, primary knee arthroscopy between January 1, 2003, and December 31, 2015, for 1 of the following diagnosis-related categories: Group 1, meniscectomy; Group 2, meniscal repair; and Group 3, meniscal allograft transplantation, with or without anterior cruciate ligament reconstruction (ACLR). The 3 groups of meniscal procedures were compared on geographic distribution, patient age, insurance, concomitant ACLR, and surgeon and hospital volume over the study period. RESULTS: A total of 649,470 patients who underwent knee arthroscopy between 2003 and 2015 were identified for analysis. Both meniscectomies and meniscal repairs had a scattered distribution throughout New York State, with allograft volume concentrated at urban academic hospitals. The majority of patients who underwent any meniscal procedure had private insurance, with Medicaid patients having the lowest rates of meniscal surgery. At high-volume hospitals, meniscal repairs and allografts are being performed with increasing frequency, especially in patients <25 years of age. Meniscal repairs are being performed concomitantly with ACLR with increasing frequency. CONCLUSIONS: Meniscal repairs and allografts are being performed at high-volume hospitals for privately insured patients with increasing frequency. Geographic access to these treatments, particularly allografts, is limited. CLINICAL RELEVANCE: Disparities in the availability of advanced meniscal treatment require further investigation and understanding to improve access to care.

Trends and Risk Factors for 1-Year Revision of the Latarjet Procedure: The New York State Experience During the Past Decade.

Little research has been conducted evaluating surgical trends during the past 10 years and subsequent procedure risk factors for patients undergoing bone-blocking procedures for the treatment of anterior shoulder instability. The Statewide Planning and Research Cooperative System database was queried between 2003 and 2014 to identify patients undergoing soft tissue or bone-blocking procedures for anterior shoulder instability in New York. Patient demographics and 1-year subsequent procedures were analyzed. Multivariate logistic regression analyses were conducted to identify 1-year subsequent procedure risk factors. From 2003 through 2014, a total of 540 patients had Latarjet procedures performed. During this period, the volume of Latarjet procedures increased by 950%, from 12 procedures in 2003 to 126 procedures in 2014. The volume of open Bankart repairs declined by 77%; arthroscopic Bankart repairs fluctuated, being up (328%) between 2003 and 2012 and then down (6%) between 2012 and 2014. Of the 540 patients, 2.4% (13 of 540) required intervention for recurrent shoulder instability events. Age older than 20 years and workers' compensation were identified as independent risk factors for reoperation. The number of bone-blocking procedures, such as the Latarjet, has increased by nearly 1000% during the past decade in New York. Only 2.4% (13 of 540) of the patients had subsequent shoulder instability interventions. [Orthopedics. 2018; 41(3):e389-e394.].