Financial Implications of the Merit-Based Incentive Payment System for Surgical Health Care Professionals.

This study describes financial implications of the merit-based incentive payment system for surgical health care professionals.

Nonarthroplasty options for massive, irreparable rotator cuff tears have improvement in range of motion and patient-reported outcomes at short-term follow-up: a systematic review.

PURPOSE: To compare various nonarthroplasty treatment options for massive, irreparable rotator cuff tears, including allograft bridging/augmentation, debridement, partial repair, superior capsule reconstruction (SCR), subacromial balloon spacer, and tendon transfer. METHODS: A comprehensive search was conducted through the PubMed, MEDLINE, and EMBASE databases for all articles pertaining to nonarthroplasty treatment options for irreparable rotator cuff tears. Inclusion criteria included manuscripts published between 2009 and 2020 with at least 1 year follow-up and Level I-IV evidence. Articles were separated into six groups: debridement, arthroscopic and open repair, allograft bridging/augmentation, SCR, subacromial balloon spacer, and tendon transfer. Data points included range of motion (external rotation, abduction, forward flexion, and internal rotation), visual analog scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score, Constant score, rate of revision surgery, and rate of conversion to arthroplasty. RESULTS: A total of 83 studies and 3363 patients were included. All treatment options had statistically significant improvements in postoperative range of motion and patient-reported outcomes. Debridement had statistically significantly greater postoperative abduction and forward flexion range of motion, as well as better VAS pain scores, compared to the other treatment options. The SCR subgroup had the greatest improvement in ASES scores postoperatively. The overall revision rate was 7.2% among all surgical options, with the allograft bridging/augmentation group having the lowest rate of revision at 0-8.3%. The overall rate of conversion to arthroplasty was 7.2%, with debridement having the greatest rate of conversion at 15.4%. CONCLUSION: All six nonarthroplasty treatment options for irreparable rotator cuff tears resulted in statistically significant improvements in range of motion and patient-reported outcomes at 1 year follow-up or more, with low rates of revision and conversion to arthroplasty. Debridement had statistically significantly greater postoperative abduction and forward flexion range of motion, as well as better VAS pain scores, compared to the other treatment options. However, these conclusions should be interpreted with caution due to the heterogeneous nature of the data, lack of prospective randomized control trials, and short-term follow-up. The findings of this study highlight the complexity of irreparable, massive rotator cuff tears, and the need for an individualized approach when treating these patients. LEVEL OF EVIDENCE: Level IV.

A ratio estimating glenoid bone loss.

Background: Estimating glenoid bone loss when assessing the unstable shoulder can be challenging. The aim of this article was to describe a simple derived ratio to estimate glenoid bone loss. Methods: When the glenoid is damaged and bone is damaged because of instability, the anterior aspect of the glenoid loses its normal curvature and becomes flattened. In geometry, this represents a chord. There are 3 assumptions for the calculations: (1) the lower glenoid is a circle; (2) there is a relationship between the glenoid height and the diameter of the glenoid circle; and (3) the length of the measured bone loss of the glenoid is a chord. Two measurements are required: glenoid height and length of the glenoid defect. The calculations involved in the ratio are reviewed. Results: If the ratio of the length of the bone defect to the glenoid height is 0.5 (otherwise, 50% of the height), the estimated bone loss is 12%. Conclusion: Glenoid bone loss can be estimated by measuring the length of the glenoid and the length of the defect.

Treatment disparities in muscle-invasive bladder cancer: Evidence from a large statewide cancer registry.

OBJECTIVE: To identify patient-level factors that can lead to treatment disparities for muscle invasive bladder cancer, we examine factors associated with receipt of definitive therapy, type of definitive therapy, and neoadjuvant chemotherapy administration in a statewide cohort of muscle-invasive bladder cancer patients. MATERIALS AND METHODS: We identified 2,434 patients diagnosed with non-metastatic muscle-invasive bladder cancer between 2010 and 2015 using the Pennsylvania Cancer Registry. We divided the cohort into three subsamples to examine receipt of treatment: definitive therapy among all muscle-invasive bladder cancer patients (n = 1548), cystectomy (n = 1254) vs. trimodal therapy (n = 294), and neoadjuvant chemotherapy among radical cystectomy patients (n = 1156). Multivariable logistic regression models controlling for patient-level covariates, including insurance status, and socioeconomic disadvantage (based on Area Deprivation Index from census tract data) were estimated to examine factors associated with each treatment outcome. RESULTS: Only 64% of muscle-invasive bladder cancer patients underwent definitive therapy. Those receiving trimodal therapy were more likely to be covered by Medicare than those undergoing cystectomy. Uninsured patients were less likely to undergo definitive treatment and Medicare-insured patients were less likely to undergo cystectomy as their definitive therapy. Patients with greater socioeconomic disadvantage were less likely to receive definitive treatment, undergo cystectomy, or receive neoadjuvant chemotherapy. Over the course of the study period, there was increased neoadjuvant chemotherapy use, but a persistent gap by neighborhood socioeconomic status. CONCLUSIONS: Socioeconomic disadvantage and insurance status are patient-level factors associated with suboptimal treatment for muscle-invasive bladder cancer.

Diffusion and adoption of the surgical robot in urology.

Over the last two decades, robotic surgery has become a mainstay in hospital systems around the world. Leading this charge has been Intuitive Surgical Inc.'s da Vinci robotic system (Sunnyvale, CA, USA). Through its innovative technology and unique revenue model, Intuitive has installed 4,986 robotic surgical systems worldwide in the last two decades. The rapid rate of adoption and diffusion of the surgical robot has been propelled by many important industry-specific factors. In this review, we propose a model that explains the successful adoption of robotic surgery due to its three core groups: the surgeon, the hospital administrator, and the patient.

Statewide Price Variation for Generic Benign Prostatic Hyperplasia Medications.

OBJECTIVE: To examine the geographic and pharmacy-type variation in costs for generic benign prostatic hyperplasia (BPH) medications in order to improve drug price transparency and reduce health disparities. Medical therapy for BPH can be expensive, having significant implications for uninsured and underinsured patients. METHODS: We generated a 20% random sample of all pharmacies in Pennsylvania and queried each for the uninsured cash price of a 30-day prescription of tamsulosin 0.4mg daily, finasteride 5mg daily, oxybutynin immediate release 5mg TID and oxybutynin XL 10mg daily. Our primary objectives were to identify price variation based on pharmacy type (i.e., big chain and independent) and between geographic regions (predetermined by the Pennsylvania Health Care Cost Containment Council Database). We fit multivariable quantile regression models to test for an association between drug price and region after controlling for pharmacy type. RESULTS: Among 575 retail pharmacies contacted, 473 responded (82% response rate). The median cash price was significantly higher for big chain pharmacies than for independent pharmacies for tamsulosin ($66 vs. $15), finasteride ($68 vs. $15), oxybutynin immediate release ($49 vs. $35), and oxybutynin XL ($79 vs. $31) (all p < 0.05). When controlling for region, the median and 75th percentile price of all drugs was significantly higher for big chain pharmacies. When controlling for pharmacy type, regional variation was noted in all four drugs at the 75th percentile price and was greater for independent pharmacies. CONCLUSION: Compared to independent pharmacies, big chain pharmacies charged significantly more for generic BPH medications to uninsured patients. However, independent pharmacies demonstrated more regional variation in their pricing.

Risk factors for hardware removal following operative treatment of middle- and distal-third clavicular fractures.

BACKGROUND: The incidence of hardware removal (HWR) after operative fixation of clavicular fractures varies widely. Risk factors related to HWR remain incompletely understood. The aim of this study was to evaluate the incidence of and risk factors for HWR after plate fixation of middle- and distal-third clavicular fractures. We hypothesized that (1) the total HWR incidence would be <20%, (2) the HWR incidence of operatively treated distal- and middle-third clavicular fractures would not be statistically different, and (3) symptomatic implants would be the most common HWR indication. METHODS: We performed a multi-hospital retrospective study of skeletally mature patients who underwent plate fixation of middle- and distal-third clavicular fractures from November 2008 to November 2018. Data included patient demographic characteristics, mechanism of injury, operative records, hardware-related symptoms, subsequent HWR, and complications. RESULTS: A total of 103 patients (aged 16-75 years, 76.7% male patients) were included. Of the patients, 87 (84.5%) underwent plate fixation for midshaft clavicular fractures and 16 (15.5%) underwent plate fixation for distal-third clavicular fractures. HWR was performed in 13 patients (12.6%). A significantly higher percentage of HWR procedures were performed for distal clavicular fractures (50%) than for middle-third clavicular fractures (4.9%, P < .0001). An initial high-energy mechanism of injury was associated with HWR (P = .0025). The most common indication for HWR was symptomatic hardware (69.2%). The overall complication rate was 14.5%. CONCLUSION: The overall incidence of clavicular HWR was 12.6%. A distal fracture location was associated with a significantly higher incidence of HWR. An initial high-energy mechanism of injury was a significant risk factor for HWR. The primary indication for HWR was symptomatic hardware.

Utility of Clinical Risk Stratification in the Selection of Muscle-Invasive Bladder Cancer Patients for Neoadjuvant Chemotherapy: A Retrospective Cohort Study.

Introduction: Level I evidence supports the use of cisplatin-based neoadjuvant chemotherapy (NAC) for muscle-invasive bladder cancer prior to radical cystectomy (RC). On average, 30-40% of patients achieve a complete pathologic response (i.e., stage pT0) after receiving NAC. Some centers risk-stratify patients, suggesting that there may be a higher-risk population that would derive the most benefit from NAC. Recently, a risk-stratification model developed at M.D. Anderson Cancer Center (MDACC) specified criteria for clinical staging and patient selection for NAC. We applied this model to our own RC patient cohort and evaluated our own experience with clinical risk stratification and the effect of NAC on post treatment risk categories. Methods: We retrospectively reviewed the charts of consecutive patients who underwent RC at two institutions between 2004 and 2014 and noted whether or not they received NAC. We determined the clinical stage by reviewing the exam under anesthesia, transurethral resection biopsy (TURBT) pathology, and preoperative imaging. Patients with cT2-T4a node-negative disease were included. Those with sarcomatoid features or adenocarcinoma were excluded. Patients were classified as high risk if they had tumor-associated hydronephrosis, clinical stage≥T3b-T4a disease, variant histology (i.e., micropapillary or small cell), or lymphovascular invasion (LVI), as specified by the MDACC model. Variables were examined for associations with cancer-specific survival (CSS), overall survival (OS), and risk-category reclassification. Results: We identified 166 patients with a median follow-up time of 22.2 months. In all, 117 patients (70.5%) did not receive NAC, 68 (58.1%) of whom we classified as high risk. Among patients not receiving NAC, CSS and OS were significantly decreased in high-risk patients (log-rank test p = 0.01 for both comparisons). The estimated age-adjusted hazard ratios of high-risk classification for cancer-specific and overall death were 3.2 (95% CI: 1.2 to 8.6) and 2.2 (95% CI: 1.1 to 4.4), respectively. On post-RC final pathology, 23 (46.9%) low-risk patients were up-classified to high risk and 17 (25.0%) high-risk patients were down-classified. Complete pathologic responses (pT0) were achieved in 7 (6.0%) patients and partial responses (pT1, pTa, pTis) were achieved in 28 (23.9%) patients. Of the 49 patients who did receive NAC, 43 (87.8%) received cisplatin-based and six (12.2%) received carboplatin-based regimens. Applying the MDACC model, we categorized 41 (83.7%) patients as high risk prior to NAC treatment. On final pathology, 3 (37.5%) low-risk patients were up-classified and 17 (41.5%) high-risk patients were down-classified. Complete pathologic responses (pT0) were seen in 13 (26.5%) patients and partial responses were seen in 10 (20.4%) patients. Although the utilization of NAC was not statistically significantly associated with CSS or OS (log-rank test p > 0.05 for both comparisons), it was associated with a 1.2 times increased odds (95% CI: 0.4 to 2.1) of post-RC reclassification from high to low risk on age-adjusted logistic regression. Conclusions: We found similar results using the clinical risk-stratification model in our cohort and showed that the high-risk category was associated with lower CSS and OS. NAC was associated with a higher probability of risk reclassification from high to low risk.

Short-term complications of the Latarjet procedure.

BACKGROUND: Although the results of the Latarjet procedure have been reported previously, there is little literature regarding the early complications of this procedure. The purpose of this study was to report our experience with the Latarjet procedure for glenohumeral instability and to highlight the initial complications that may occur following this procedure. METHODS: Forty-seven patients (forty-eight shoulders) underwent the Latarjet procedure for anterior glenohumeral instability between January 2005 and January 2010. All shoulders had some osseous deficiency of the anterior glenoid rim or had undergone an unsuccessful prior soft-tissue Bankart repair. The minimum duration of patient follow-up was six months. RESULTS: Forty-five shoulders were available for follow-up. The overall complication rate was 25% (twelve of the original forty-eight shoulders). Complications were divided into three groups: infection, recurrent glenohumeral instability, and neurologic injury. A superficial infection developed in three shoulders (6%); in all cases, the infection resolved following irrigation and debridement and administration of antibiotics for up to four weeks. Four shoulders (8%) developed recurrent glenohumeral instability; this occurred within eight months in two shoulders and at nineteen and forty-two months postoperatively in the other two. Five procedures (10%) resulted in a neurologic injury. Two of these involved the musculocutaneous nerve, one involved the radial nerve, and two involved the axillary nerve. The three musculocutaneous and radial nerve injuries involved sensory neurapraxia that resolved fully within two months. Both of the patients with axillary nerve dysfunction continued to have persistent sensory disturbances and one continued to have residual weakness that had not yet resolved fully at the time of the final follow-up. CONCLUSIONS: The overall complication rate of 25% is higher than that reported in the literature. Although most of these complications resolved completely, two patients continued to have residual neurologic symptoms. Patients should be informed of the risk of complications associated with the Latarjet procedure, although most of the potential complications will resolve.

Posterior capsular rupture causing posterior shoulder instability: a case report.

We report the case of a 20-year-old male competitive football player who was treated for a midsubstance posterior capsule rupture after a posterior dislocation from falling onto his shoulder. Conservative management for 5 months after the injury failed to improve his subjective symptoms, with the primary symptom being activity-related posterior shoulder pain. Advanced imaging findings and physical examination were consistent with posterior instability, thought to be due to a posterior labral tear. At the time of a diagnostic arthroscopy, the patient was found to have an oval-shaped rupture of the capsule that was neither a reverse humeral avulsion of the glenohumeral ligament lesion nor a posterior labral tear. The capsular tear was repaired through an all-arthroscopic technique with nonabsorbable sutures. The patient returned to his previous competitive function, had no pain, and had full motion at final follow-up without recurrence of instability or pain symptoms.

Clinical outcomes of suprascapular nerve decompression.

BACKGROUND: While the incidence and prevalence of suprascapular neuropathy (SSN) remains largely unknown, the evaluation and treatment of SSN appears to be increasing. Despite multiple technique articles demonstrating nerve decompression, there has been no clinical evidence to support the efficacy of SSN decompression in the absence of rotator cuff disease. METHODS: Between October 2006 and February 2010, 27 patients underwent arthroscopic suprascapular nerve decompression at the suprascapular and/or spinoglenoid notch. Eighty-nine percent (24/27) of patients had preoperative positive electromyography and nerve conduction EMG/NCV studies documenting suprascapular nerve pathology. All patients had either a computed tomography (CT) arthrogram or magnetic resonance imaging (MRI) documenting rotator cuff integrity. All patients were evaluated with pre and postoperative subjective shoulder values (SSV) and American Shoulder and Elbow Society (ASES) self-assessment scores. Additionally, patients were questioned whether they would have the procedure again and approximately at what week they experienced noticeable pain relief. RESULTS: The 27 patients were followed for an average of 22.5 months (range, 3-44). Three patients were lost to follow-up. Seventy-one percent (17/24) of patients reported pain relief (VAS [Visual Analogue Scales] pain scale) that was statistically significant (P = .0001) at an average of 9.4 weeks from surgery. Seventy-five percent (18/24) and 71% (17/24) had statistically significant improvement in ASES (P = .0001) and SSV scores (P = .0014), respectively. Seventy-one percent (17/24) would have the surgery again. CONCLUSION: The present study demonstrates a large series of patients treated for SSN without rotator cuff pathology. Our results show statistically significant improvement in VAS, ASES, and SSV.

Postarthroscopic arthrofibrosis of the shoulder.

Arthrofibrosis after shoulder surgery may be challenging to treat. Certain factors, including diabetes and history of keloid formation, predispose patients to the development of postoperative arthrofibrosis. Etiologies include rotator cuff repair, labral repair, capsulorrhaphy, shoulder arthroplasty, and proximal humerus fracture fixation. Systematic evaluation with thorough history and physical examination is essential to determine the proper treatment and to counsel patients on expectations for recovery. Nonoperative treatment focused on physical therapy is the first step in management. Manipulation under anesthesia may be an effective treatment for failure of physical therapy regimens in idiopathic adhesive capsulitis, however it is less successful in cases of postsurgical adhesions. In cases of postoperative stiffness, treatment options include arthroscopic and open capsular releases. Adequate postoperative pain control and adherence to a rigorous physical therapy regimen are integral to the success of surgical release. Surgical treatment is effective in the majority of patients with postsurgical arthrofibrosis.

The strength and effects of humeral rotation on single- versus double-row repair techniques in small rotator cuff tears.

With advanced surgical techniques, instrumentation, and implants, arthroscopic rotator cuff repair has become increasingly popular. As the techniques continue to evolve, so do the methods by which the repairs are tested. Cyclic loading has shown to better replicate postoperative motion after cuff repair. Recently, cyclic loading with dynamic external rotation has been studied for large rotator cuff repairs. Our study applies this concept to small, isolated supraspinatus tears, comparing single- vs double-row repair techniques. A 1.5-cm rotator cuff tear was created in cadaveric specimens and repaired with single-and double-row repair techniques. With cyclic loading and dynamic external rotation, gap formation and ultimate pullout strength were determined and found to be equivalent. This study demonstrates no significant difference in single- vs double-row repairs for small, isolated supraspinatus tears when tested with cyclic loading and dynamic external rotation.

Recessed femoral interference screws in anterior cruciate ligament reconstruction.

There are multiple modes of femoral fixation for the treatment of the anterior cruciate ligament (ACL)-deficient knee. Femoral interference screws are commonly used and are often buried to accommodate a graft-tunnel mismatch. After performing ACL reconstructions and imaging the ACL in 3 cadaveric knee specimens, obvious graft excursion and impingement was seen with recessed femoral interference screw fixation. The consequences of impingement are well known, and when faced with a graft-tunnel mismatch, alternative modes of fixation are advised.