Clinical outcomes and return to dance after total hip arthroplasty or hip resurfacing in professional dancers.

Aims: Professional dancers represent a unique patient population in the setting of hip arthroplasty, given the high degree of hip strength and mobility required by their profession. We sought to determine the clinical outcomes and ability to return to professional dance after total hip arthroplasty (THA) or hip resurfacing arthroplasty (HRA). Methods: Active professional dancers who underwent primary THA or HRA at a single institution with minimum one-year follow-up were included in the study. Primary outcomes included the rate of return to professional dance, three patient-reported outcome measures (PROMs) (modified Harris Hip Score (mHHS), Hip disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR), and Lower Extremity Activity Scale (LEAS)), and postoperative complications. Results: A total of 49 hips in 39 patients (mean age 56 years (SD 13); 80% female (n = 39)) were included. Mean follow-up was 4.9 years (SD 5.1). Of these 49 hips, 37 THAs and 12 HRAs were performed. In all, 96% of hips returned to professional dance activities postoperatively. With regard to PROMs, there were statistically significant improvements in mHHS, HOOS-JR, and LEAS from baseline to ≥ one year postoperatively. There were complications in 7/49 hips postoperatively (14%), five of which required revision surgery (10%). There were no revisions for instability after the index procedure. Two complications (5.4%) occurred in hips that underwent THA compared with five (42%) after HRA (p = 0.007), though the difference by procedure was not significantly different when including only contemporary implant designs (p = 0.334). Conclusion: Active professional dancers experienced significant improvements in functional outcome scores after THA or HRA, with a 96% rate of return to professional dance. However, the revision rate at short- to mid-term follow-up highlights the challenges of performing hip arthroplasty in this demanding patient population. Further investigation is required to determine the results of THA versus HRA using contemporary implant designs in these patients.

The Risk Assessment and Prediction Tool (RAPT) Score Predicts Discharge Destination, Length of Stay, and Postoperative Mobility After Total Joint Arthroplasty.

BACKGROUND: Predicting an arthroplasty patient's discharge disposition, length of stay (LOS), and physical function is helpful because it allows for preoperative patient optimization, expectation management, and discharge planning. The goal of this study was to evaluate the ability of the Risk Assessment and Prediction Tool (RAPT) score to predict discharge destination, LOS, and postoperative mobility in patients undergoing primary total knee arthroplasty (TKA) and total hip arthroplasty (THA). METHODS: Primary unilateral TKAs (n = 9,064) and THAs (n = 8,649) performed for primary osteoarthritis at our institution from 2018 to 2021 (excluding March to June 2020) were identified using a prospectively maintained institutional registry. We evaluated the associations between preoperative RAPT score and (1) discharge destination, (2) LOS, and postoperative mobility as measured by (3) successful ambulation on the day of surgery and (4) Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" score. RESULTS: On multivariable analyses adjusting for multiple covariates, every one-point increase in RAPT score among TKA patients was associated with a 1.82-fold increased odds of home discharge (P < .001), 0.22 days shorter LOS (P < .001), 1.13-fold increased odds of ambulating on postoperative day 0 (P < .001), and 0.25-point higher Activity Measure for Post-Acute Care score (P < .001). Similar findings were seen among THAs. A RAPT score of 8 or higher was the most sensitive and specific cutoff to predict home discharge. CONCLUSION: Among nearly 18,000 TKA and THA patients, RAPT score was predictive of discharge disposition, LOS, and postoperative mobility. A RAPT score of 8 or higher was the most sensitive and specific cutoff to predict discharge to home. In contrast to prior studies of the RAPT score which have grouped TKAs and THAs together, this study ran separate analyses for TKAs and THAs and found that THA patients seemed to perform better than TKA patients with equal RAPT scores, suggesting that RAPT may behave differently between TKAs and THAs, particularly in the intermediate risk RAPT range.

Reasons and Risk Factors for Failed Same-Day Discharge After Primary Total Knee Arthroplasty.

BACKGROUND: As ambulatory total knee arthroplasty (TKA) becomes increasingly common, unplanned admission after surgery presents a challenge for the health care system. Studies evaluating the reasons and risk factors for this occurrence are limited. We sought to evaluate the reasons for unplanned admission after surgery and identify risk factors associated with this occurrence. METHODS: Patients registered in an institutional ambulatory joint arthroplasty program who underwent a TKA from 2017-2020 were retrospectively reviewed. The criteria for enrollment include candidates for unilateral TKA between the ages of 18 and 70 years, with a body mass index (BMI) of less than 35, and appropriate social and material support at home. Patients who had certain comorbidities including coronary artery disease, valvular heart disease, and opioid dependence were not eligible. A total of 274 patients who underwent TKA with planned same-day discharge (SDD) were identified in the medical record and reviewed. In this cohort, 140 patients (51.1%) were discharged on the day of surgery and 134 patients (48.9%) required a minimum 1-night admission. Demographics, comorbidities, and perioperative data were collected. Factors associated with failed SDD were identified using multivariate logistic regression. RESULTS: The most common reasons for failed SDD were failure to meet ambulation goals (25%) and logistical issues related to a late-day case (19%). Risk factors for failed SDD include general anesthesia (odds ratio (OR) 12.60, P = .047), procedure start time after 11:00 am (OR 5.16, P < .001), highest postoperative pain score >8 (visual analogue scale, OR 5.78, P = .001). Willingness to accept a higher pain threshold before discharge (visual analogue scale 4 to 10) was associated with successful SDD (OR 3.0, P < .001). Age and American Society of Anesthesiologists (ASA) classification were not associated with failed SDD. CONCLUSIONS: The most common reasons for failed SDD were related to logistical issues and postoperative mobilization. Risk factors for failed SDD involve case timing and pain control. Modifiable perioperative factors may play an important role in successful SDD after TKA.

A Systematic Review of Propensity Score Matching in the Orthopedic Literature.

Background: Propensity score matching (PSM) is a statistical technique used to reduce bias in observational studies by controlling for measured confounders. Given its complexity and popularity, it is imperative that researchers comprehensively report their methodologies to ensure accurate interpretation and reproducibility. Purpose: This systematic review sought to define how often PSM has been used in recent orthopedic research and to describe how such studies reported their methods. Secondary aims included analyzing study reproducibility, bibliometric factors associated with reproducibility, and associations between methodology and the reporting of statistically significant results. Methods: PubMed and Embase databases were queried for studies containing "propensity score" and "match*" published in 20 orthopedic journals prior to 2020. All studies meeting inclusion criteria were used for trend analysis. Articles published between 2017 and 2019 were used for analysis of reporting quality and reproducibility. Results: In all, 261 studies were included for trend analysis, and 162 studies underwent full-text review. The proportion of orthopedic studies using PSM significantly increased over time. Seventy-one (41%) articles did not provide justification for covariate selection. The majority of studies illustrated covariate balance through P values. We found that 19% of the studies were fully reproducible. Most studies failed to report the use of replacement (67.3%) or independent or paired statistical methods (34.0%). Studies reporting standardized mean differences to illustrate covariate balance were less likely to report statistically significant results. Conclusion: Despite the increased use of PSM in orthopedic research, observational studies employing PSM have largely failed to adequately report their methodology.

Ambulatory total hip arthroplasty: Causes for failure to launch and associated risk factors.

AIMS: The volume of ambulatory total hip arthroplasty (THA) procedures is increasing due to the emphasis on value-based care. The purpose of the study is to identify the causes for failed same-day discharge (SDD) and perioperative factors leading to failed SDD. METHODS: This retrospective cohort study followed pre-selected patients for SDD THA from 1 August 2018 to 31 December 2020. Inclusion criteria were patients undergoing unilateral THA with appropriate social support, age 18 to 75 years, and BMI < 37 kg/m2. Patients with opioid dependence, coronary artery disease, and valvular heart disease were excluded. Demographics, comorbidities, and perioperative data were collected from the electronic medical records. Possible risk factors for failed SDD were identified using multivariate logistic regression. RESULTS: In all, 278 patients were identified with a mean age of 57.1 years (SD 8.1) and a mean BMI of 27.3 kg/m2 (SD 4.5). A total of 96 patients failed SDD, with the most common reasons being failure to clear physical therapy (26%), dizziness (22%), and postoperative nausea and vomiting (11%). Risk factors associated with failed SDD included smokers (odds ratio (OR) 6.24; p = 0.009), a maximum postoperative pain score > 8 (OR 4.76; p = 0.004), and procedures starting after 11 am (OR 2.28; p = 0.015). A higher postoperative tolerable pain goal (numerical rating scale 4 to 10) was found to be associated with successful SDD (OR 2.7; p = 0.001). Age, BMI, surgical approach, American Society of Anesthesiologists grade, and anaesthesia type were not associated with failed SDD. CONCLUSION: SDD is a safe and viable option for pre-selected patients interested in rapid recovery THA. The most common causes for failure to launch were failing to clear physical thereapy and patient symptomatology. Risk factors associated with failed SSD highlight the importance of preoperative counselling regarding smoking cessation and postoperative pain to set reasonable expectations. Future interventions should aim to improve patient postoperative mobilization, pain control, and decrease symptomatology.Cite this article: Bone Jt Open 2022;3(9):684-691.

No Effect of Surgical Approach on Discharge Outcomes in Outpatient Total Hip Arthroplasty.

Background: The interest in ambulatory total hip arthroplasty (THA) has increased recently due to a national focus on value-based care and improved rapid recovery protocols. Purpose: We sought to determine if surgical approach had an effect on discharge outcomes in outpatient THA. Methods: We performed a retrospective cohort study examining patients who underwent unilateral THA at a single institution using a standardized perioperative care pathway who were discharged home within 24 hours. In total, we compared 106 patients who underwent THA using the direct anterior approach (ATHA) and 90 patients who underwent THA using the posterior approach (PTHA). Univariate and multivariable analyses were used to compare time to ambulation, length of surgery, readmissions, and 90-day complications. Results:Time to ambulation in the ATHA and PTHA groups was 3.9 hours and 4.1 hours, respectively, and time to discharge was 5.9 hours and 6.0 hours, respectively. Length of surgery was shorter in the ATHA group than in the PTHA group (78 minutes vs 86 minutes, respectively). Complications occurred in 3 patients (3%) in the ATHA group vs 4 patients (4%) in PTHA group. In both groups, early ambulation (within 5 hours) predicted earlier time to discharge. Surgical approach was not associated with time to ambulation or time to discharge on multivariable analysis. Conclusion: In this retrospective study, outpatient THA was feasible in a well-selected population of patients undergoing anterior or posterior approaches. Further study is warranted.

Multimodal Thromboprophylaxis in Patients With a History of Venous Thromboembolism Undergoing Primary and Revision Knee Arthroplasty.

Background: Patients with a history of venous thromboembolism (VTE) undergoing total knee arthroplasty (TKA) are at a high risk of postoperative VTE. Purpose: In this high-risk population, we sought to evaluate the safety and efficacy of multimodal thromboprophylaxis. The regimen consisted of discontinuation of procoagulant medications, VTE risk stratification, regional anesthesia, rapid mobilization, perioperative use of pneumatic compression devices, vigorous ankle dorsiflexion during the recovery period, and chemoprophylaxis tailored to the patient's risk of VTE. Methods: We conducted a retrospective chart review of 141 consecutive patients with a history of VTE who underwent 177 elective TKA procedures between 2005 and 2019 by 2 arthroplasty surgeons at a single institution. The patients had a history of deep venous thrombosis (DVT) (n = 127; 72%), pulmonary embolism (PE) (n = 20; 11%), or both (n = 30; 17%). Postoperative chemoprophylaxis included aspirin (n = 20; 11%), anticoagulation (n = 135; 77%), or a combination of aspirin and anticoagulation (n = 21; 12%). Complications within 120 days, including VTE events, wound complications, bleeding, and unplanned readmissions, were recorded, as was 1-year mortality. Results: Five patients (2.8%) developed symptomatic DVT (3 distal, 2 proximal), and 4 patients (2.3%) developed symptomatic PE. The most common postdischarge complications were wound infection (n = 6; 3.4%) and stiffness requiring manipulation under anesthesia (n = 5; 2.8%). There was 1 emergency room visit and 13 unplanned readmissions; 3 patients developed intra-articular hematomas or prolonged wound drainage and recovered uneventfully. All patients were alive 1 year after surgery. Conclusion: The findings of this retrospective study suggest that multimodal prophylaxis may be safe and effective in patients with a history of VTE undergoing primary and revision TKA. More rigorous study is warranted.

Telerehabilitation has similar clinical and patient-reported outcomes compared to traditional rehabilitation following total knee arthroplasty.

PURPOSE: Telehealth rehabilitation (telerehab) is an increasingly popular cost-saving alternative to traditional rehabilitation after total joint arthroplasty. We compared the safety and efficacy of an institutional telerehab program to conventional "face-to-face" rehabilitation in a sample of patients undergoing total knee arthroplasty (TKA). METHODS: A retrospective matched cohort study was performed. Medicare patients who utilized telerehab following unilateral TKA were matched in a 1:3 ratio to those utilizing conventional rehabilitation. Patients were matched on sex, body mass index (BMI, ± 5 kg/m2), preoperative extension (± 10 degrees), preoperative flexion (± 10 degrees), and Risk Assessment and Prediction Tool (RAPT) score (± 2 points). Ninety-day unplanned healthcare encounters, 120-day manipulations under anesthesia (MUAs), and 6-week and 3-month changes in the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR), pain visual analog scale (VAS), Veterans RAND 12 (VR-12), and Lower-Extremity Activity Scale (LEAS) were compared between groups. RESULTS: Eighty-two telerehab patients and 244 conventional rehab patients were included. After matching, there were no differences in 90-day unplanned healthcare encounters or 120-day MUA rates between groups. There were no differences in 6-week or 3-month changes in KOOS-JR, VAS pain, or VR-12 mental or physical sub-scores between groups. Telerehab patients had a greater improvement in LEAS score at 3 months compared to the conventional group (mean difference 1.9, P = 0.03). CONCLUSION: In a matched cohort study of 326 TKA patients, telerehab patients had similar rates of unplanned healthcare encounters and MUAs and similar patient-reported outcomes compared to conventional PT patients, suggesting that telerehab can be an equally effective alternative to conventional PT following TKA. LEVEL OF EVIDENCE: III.

Predicting Total Knee Arthroplasty Outpatient Discharge: Surgeons versus Insurance Companies.

BACKGROUND: Insurance companies are increasingly making unilateral determinations of admission status for primary total knee arthroplasty (TKA). These determinations may differ from those based on surgeon-derived criteria for outpatient knee replacement. The goal of this study is to determine if insurance company determinations of outpatient status are as reliable as surgeon-derived criteria in predicting outpatient discharge after TKA. METHODS: We retrospectively reviewed 709 patients who were preoperatively authorized for outpatient TKA. Patients were stratified into 2 groups: "outpatient per surgeon" (appropriate for outpatient surgery per institutional protocols) or "outpatient per insurance" (appropriate for inpatient surgery per institutional protocols but denied inpatient status by insurance). The primary endpoint of this study was the conversion rate of outpatient to inpatient stay. Univariate logistic regression was performed to compare the odds of conversion to inpatient stay between outpatient per surgeon and outpatient per insurance procedures and other covariates. RESULTS: The cohort included 434 outpatient per insurance (61.2%) and 275 outpatient per surgeon (38.8%) patients. Surgeons accurately predicted outpatients' discharge 92.0% of the time, while insurance companies did so 81.3% of time (P < .001). Outpatient per insurance procedures (odds ratio [OR] 2.20, P = .003) and body mass index >35 kg/m2 (OR 1.82, P = .026) had higher odds of being converted to inpatient. Males had higher odds (OR 1.52, P < .001) of being discharged as outpatient. CONCLUSION: Determining inpatient versus outpatient status is a complex decision involving both clinical and social factors. Surgeons accurately predicted outpatient discharge 92% of the time. Moreover, outpatient per insurance procedures were twice as likely to be converted to inpatient status. Therefore, insurance companies should leave deciding admission status up to both the patient and surgeon.

Particulated Juvenile Articular Cartilage and Matrix-Induced Autologous Chondrocyte Implantation Are Cost-Effective for Patellar Chondral Lesions.

PURPOSE: To compare the cost-effectiveness of nonoperative management, particulated juvenile allograft cartilage (PJAC), and matrix-induced autologous chondrocyte implantation (MACI) in the management of patellar chondral lesions. METHODS: A Markov model was used to evaluate the cost-effectiveness of three strategies for symptomatic patellar chondral lesions: 1) nonoperative management, 2) PJAC, and 3) MACI. Model inputs (transition probabilities, utilities, and costs) were derived from literature review and an institutional cohort of 67 patients treated with PJAC for patellar chondral defects (mean age 26 years, mean lesion size 2.7 cm2). Societal and payer perspectives over a 15-year time horizon were evaluated. The principal outcome measure was the incremental cost-effectiveness ratio (ICER) using a $100,000/quality-adjusted life year (QALY) willingness-to-pay threshold. Sensitivity analyses were performed to assess the robustness of the model and the relative effects of variable estimates on base case conclusions. RESULTS: From a societal perspective, nonoperative management, PJAC, and MACI cost $4,140, $52,683, and $83,073 and were associated with 5.28, 7.22, and 6.92 QALYs gained, respectively. PJAC and MACI were cost-effective relative to nonoperative management (ICERs $25,010/QALY and $48,344/QALY, respectively). PJAC dominated MACI in the base case analysis by being cheaper and more effective, but this was sensitive to the estimated effectiveness of both strategies. PJAC remained cost-effective if PJAC and MACI were considered equally effective. CONCLUSIONS: In the management of symptomatic patellar cartilage defects, PJAC and MACI were both cost-effective compared to nonoperative management. Because of the need for one surgery instead of two, and less costly graft material, PJAC was cheaper than MACI. Consequently, when PJAC and MACI were considered equally effective, PJAC was more cost-effective than MACI. Sensitivity analyses accounting for the lack of robust long-term data for PJAC or MACI demonstrated that the cost-effectiveness of PJAC versus MACI depended heavily on the relative probabilities of yielding similar clinical results. LEVEL OF EVIDENCE: III, economic and decision analysis.

Analysis of Hand Surgery Questions on Orthopedic In-training Examination From 2014 to 2019.

BACKGROUND: The orthopedic in-training examination (OITE) continues to evolve over time. It is important for orthopedic residents and residency programs to have an up-to-date understanding of the content and resources being used on the OITE to study and tailor curricula accordingly. This study presents an updated analysis of the OITE hand domain from 2014 to 2019. METHODS: All OITE questions related to hand surgery from 2014 to 2019 were analyzed for topic, subtopic, taxonomy, imaging modalities, and bibliometric factors related to cited references. RESULTS: Of the 1600 OITE questions, there were 113 hand surgery questions (7.1%) over a 6-year period. The most commonly tested topics were nerve (n = 22; 19%), fracture/dislocation (n = 21; 19%), and tendon/ligament (n = 19; 17%). Complex clinical management questions were the most common taxonomic category (n = 66; 58%). Two hundred fifty-two references were cited, the most common of which were from the Journal of Hand Surgery (American Volume) (n = 76; 30%), Journal of the American Academy of Orthopaedic Surgeons (n = 27; 11%), and Hand Clinics (n = 21; 8%). Publication lag decreased over the study period (P = .009). Twenty-five questions (22%) used imaging modalities, and 21 (19%) used clinical photos. Compared with a prior analysis from 2002 to 2006, there were more questions related to nerves (19.5% vs 9.8%, P = .041). CONCLUSIONS: Residents and residency programs can benefit from an updated understanding of OITE hand surgery content and resources. The current analysis identifies high-yield topics and resources that can guide resident preparation for the OITE.

Hip Resurfacing vs Total Hip Arthroplasty in Patients Younger than 35 Years: A Comparison of Revision Rates and Patient-Reported Outcomes.

BACKGROUND: Hip resurfacing arthroplasty (HRA) and total hip arthroplasty (THA) are two treatment options for end-stage degenerative hip conditions. The objective of this single-center retrospective cohort study was to compare implant survival and patient-reported outcomes (PROs) in young patients (≤35 years) who underwent HRA or THA. METHODS: All patients aged 35 years or younger who underwent HRA or THA with a single high-volume arthroplasty surgeon between 2004 and 2015 were reviewed. The sample included 33 THAs (26 patients) and 76 HRAs (65 patients). Five-year implant survival and minimum 2-year PROs were compared between patient cohorts. RESULTS: Three patients in the THA group (9%) were revised within 5 years for instability (n = 1), squeaking (n = 1), or squeaking with a ceramic liner fracture (n = 1). No patients who underwent HRA were revised. The University of California, Los Angeles, activity score, modified Harris Hip score, and Hip Dysfunction and Osteoarthritis Outcome Scores for Joint Replacement increased by 74%, 64%, and 49%, respectively, among all patients. Compared to the HRA cohort, patients who underwent THA had lower preoperative and postoperative University of California, Los Angeles, activity, modified Harris Hip score, and Hip Dysfunction and Osteoarthritis Outcome Scores for Joint Replacement scores, yet there were no differences in the absolute improvements in any of the three measures between the two groups. CONCLUSIONS: Excellent functional outcomes were seen in young patients undergoing either HRA or THA. Although young patients undergoing THA started at lower preoperative baseline and postoperative PROs than patients undergoing HRA, both groups improved by an equal amount after surgery, suggesting that both HRA and THA afford a similar degree of potential improvement in a young population.

Increased Comorbidity Burden Among Hip Fracture Patients During the COVID-19 Pandemic in New York City.

BACKGROUND: The coronavirus disease 19 (COVID-19) pandemic had a devastating effect on New York City in the spring of 2020. Several global reports suggested worse early outcomes among COVID-positive patients with hip fractures. However, there is limited data comparing baseline comorbidities among patients treated during the pandemic relative to those treated in non-pandemic conditions. MATERIALS AND METHODS: A multicenter retrospective cohort study was performed at two Level 1 Trauma centers and one orthopedic specialty hospital to assess demographics, comorbidities, and outcomes among 67 hip fracture patients treated (OTA/AO 31, 32.1) during the peak of the COVID-19 pandemic in New York City (March 20, 2020 to April 24, 2020), including 9 who were diagnosed with COVID-19. These patients were compared to a cohort of 76 hip fracture patients treated 1 year prior (March 20, 2019 to April 24, 2019). Baseline demographics, comorbidities, treatment characteristics, and respiratory symptomatology were evaluated. The primary outcome was inpatient mortality. RESULTS: Relative to patients treated in 2019, patients with hip fractures during the pandemic had worse Charlson Comorbidity Indices (median 5.0 vs 6.0, P = .03) and American Society of Anesthesiologists (ASA) scores (mean 2.4 vs 2.7, P = .04). Patients during the COVID-19 pandemic were more likely to have decreased ambulatory status (P<.01) and a smoking history (P = .04). Patients in 2020 had longer inpatient stays (median 5 vs 7 days, P = .01), and were more likely to be discharged home (61% vs 9%, P<.01). Inpatient mortality was significantly increased during the COVID-19 pandemic (12% vs 0%, P = .002). CONCLUSIONS: Patients with hip fractures during the COVID-19 pandemic had worse comorbidity profiles and decreased functional status compared to patients treated the year prior. This information may be relevant in negotiations regarding reimbursement for cost of care of hip fracture patients with COVID-19, as these patients may require more expensive care.

Telemedicine in an Outpatient Arthroplasty Setting During the COVID-19 Pandemic: Early Lessons from New York City.

Background: The early months of the coronavirus disease 19 (COVID-19) pandemic in New York City led to a rapid transition of non-essential in-person health care, including outpatient arthroplasty visits, to a telemedicine context. Questions/Purposes: Based on our initial experiences with telemedicine in an outpatient arthroplasty setting, we sought to determine early lessons learned that may be applicable to other providers adopting or expanding telemedicine services. Methods: A cross-sectional study was performed by surveying all patients undergoing telemedicine visits with 8 arthroplasty surgeons at 1 orthopedic specialty hospital in New York City from April 8 to May 19, 2020. Descriptive statistics were used to analyze demographic data, satisfaction with the telemedicine visit, and positive and negative takeaways. Results: In all, 164 patients completed the survey. The most common reasons for the telemedicine visit were short-term (less than 6 months), postoperative appointment (n = 88; 54%), and new patient consultation (n = 32; 20%). A total of 84 patients (51%) noted a reduction in expenses versus standard outpatient care. Several positive themes emerged from patient feedback, including less anxiety and stress related to traveling (n = 82; 50%), feeling more at ease in a familiar environment (n = 54; 33%), and the ability to assess postoperative home environment (n = 13; 8%). However, patients also expressed concerns about the difficulty addressing symptoms in the absence of an in-person examination (n = 28; 17%), a decreased sense of interpersonal connection with the physician (n = 20; 12%), and technical difficulties (n = 14; 9%). Conclusions: Patients were satisfied with their telemedicine experience during the COVID-19 pandemic; however, we identified several areas amenable to improvement. Further study is warranted.

Surgical Treatment of Iatrogenic Nerve Injury Following Arthroscopic Capsulolabral Repair.

PURPOSE: Case reports of nerve injuries following arthroscopic capsulolabral repair emphasize the proximity of major nerves to the glenoid. This study describes preoperative localization using nerve-sensitive magnetic resonance imaging in a small cohort of patients with iatrogenic nerve injuries following arthroscopic capsulolabral repair and the outcomes of nerve repair in these patients. METHODS: Cases of iatrogenic nerve injury following arthroscopic capsulolabral repair referred to 2 surgeons from January 2017 to December 2019 were identified. Clinical charts, electrodiagnostic testing, magnetic resonance imaging studies, and operative reports were reviewed. RESULTS: Four cases of iatrogenic nerve injury were identified. The time to presentation to our institution ranged from 2 weeks to 8 years. The axillary nerves in 3 cases were tethered by a suture at the inferior glenoid, whereas 1 case had a suture tied around the radial and median nerves inferior to the glenohumeral joint capsule. One case underwent excision and nerve transfer, 1 underwent excision and nerve repair, and 2 underwent suture removal and neurolysis. Open and arthroscopic approaches, including a recently described approach to the axillary nerve in the "blind zone," were used. Three cases demonstrated good recovery of all affected motor and sensory functions after surgery. At the 10-month follow-up, 1 case had persistent weakness, but there was evidence of axonal regeneration on electrodiagnostic testing. CONCLUSIONS: Arthroscopic capsulolabral repair places regional nerves, particularly the axillary nerve, at risk owing to their proximity to the joint capsule and inferior glenoid. Patients with neuropathic pain in the distribution of affected nerves with corresponding sensorimotor loss following arthroscopic capsulolabral surgery should undergo focused magnetic resonance imaging with nerve-sensitive sequences and electrodiagnostic testing to localize the injury. The use of multiple surgical windows to the axillary nerve in the "blind zone" enables full visualization for neurolysis, suture removal, and nerve repair or transfer. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Cost-Effectiveness Analysis of Nonoperative Management Versus Early Drilling for Stable Osteochondritis Dissecans Lesions of the Knee in Skeletally Immature Patients.

PURPOSE: To evaluate the cost-effectiveness of a trial of nonoperative management versus early drilling in the treatment of skeletally immature patients with stable osteochondritis dissecans (OCD) of the knee. METHODS: A decision tree model was used to compare the cost-effectiveness of a trial of nonoperative management versus early drilling (within 6 weeks of the first office visit) from payer and societal perspectives over a 3-year time horizon. Relevant transition probabilities, costs (in 2019 US dollars based on Medicare reimbursement), health state utilities, and times to healing were derived from the literature. The principal outcome measure was the incremental cost-effectiveness ratio (ICER). One- and 2-way sensitivity analyses were performed on pertinent model parameters to validate the robustness of the base-case results using a conservative willingness-to-pay (WTP) threshold of $50,000 per quality-adjusted life-year (QALY). The Consolidated Health Economic Evaluation Reporting Standards checklist for reporting economic evaluations was used. RESULTS: In the base-case analysis from a payer perspective, early drilling was more effective (2.51 versus 2.27 QALYs), more costly ($4,655 versus $3,212), and overall more cost-effective (ICER $5,839/QALY) relative to nonoperative management. In the base-case analysis from a societal perspective, early drilling dominated nonoperative management owing to its increased effectiveness (2.51 versus 2.27 QALYs) and decreased cost ($13,098 versus $18,149). These results were stable across broad ranges on sensitivity analysis. Based on 1-way threshold analyses from a payer perspective, early drilling remained cost-effective as long it cost less than $19,840, the disutility of surgery was greater than -0.40, or the probability of successful early drilling was greater than 0.62. CONCLUSIONS: Although the traditional approach to stable OCD lesions of the knee in skeletally immature patients has been a trial of nonoperative management, our data suggest that early drilling may be cost-effective from both payer and societal perspectives. LEVEL OF EVIDENCE: III, economic and decision analysis.