Proximal humeral fracture-dislocations: which patterns can be reduced in the emergency department?

BACKGROUND: Shoulder fracture-dislocations can represent a challenging management scenario in the emergency department (ED) because of concern for the presence of occult fractures that may displace during a reduction attempt. The alternative, a closed reduction attempt in the operating room, has the benefit of full paralysis but requires additional resource utilization. There is limited guidance in the literature about the risks of an initial reduction attempt in the ED as a function of fracture pattern to help guide physicians with this decision. METHODS: This was a retrospective case review of adult patients with shoulder dislocations and fracture-dislocations seen in the ED at a level 1 trauma center over a 10-year period. Imaging and medical records were reviewed to evaluate whether the reduction attempt was successful, unsuccessful without worsening, or unsuccessful with worsening alignment of any fractures, as well as the ultimate clinical outcome. RESULTS: We identified 165 patients with fracture-dislocations and 484 patients with simple dislocations during the same period. Of the patients with fracture-dislocations, 103 had greater tuberosity fractures, 12 had nondisplaced surgical neck fractures, and 50 had displaced surgical neck fractures. None of the patients with simple dislocations had displacement during an ED reduction attempt, including 100 patients aged >65 years. Of the 103 patients with greater tuberosity fracture-dislocations, only 1 had displacement of a humeral shaft fracture during ED reduction. Displacement occurred in 6 of 8 patients with nondisplaced neck fractures who underwent an initial ED reduction attempt vs. 1 of 4 patients who underwent the initial reduction attempt in the operating room. ED reduction was attempted in 25 of the 50 displaced humeral neck fracture-dislocations and was successful in 10 of these (40%). CONCLUSIONS: For patients with greater tuberosity fracture-dislocations, there is a low rate of displacement with a reduction attempt in the ED, but an ED reduction attempt in nondisplaced neck fractures is not recommended because of the high rate of displacement. For displaced neck fractures, closed reduction can be successful in select patients. Finally, these data confirm prior reports that closed reduction of simple shoulder dislocations in patients aged >65 years is safe in the ED.

Modern treatment of tibial shaft fractures: Is there a role today for closed treatment?

PURPOSE: The decision to attempt closed treatment on tibial shaft fractures can be challenging. At our institution, we attempt treatment of nearly all closed, isolated tibial shaft fractures. The purpose of this study was to report the results of 10 years of experience to develop a tool to identify patients for whom non-operative treatment of tibial shaft fractures may be a viable option METHOD: This was a retrospective review of patients with tibial shaft fracture seen at a level 1 trauma center over 10 years. Patients with closed, isolated injuries underwent sedation, closed reduction, long-leg casting, and outpatient follow-up. Patients were converted to surgery for inability to obtain or maintain acceptable alignment or patient intolerance. Radiographic characteristics and patient demographics were extracted. Logistic regression analysis was used to develop a model to predict which patient and injury characteristics determined success of nonoperative treatment. RESULTS: 334 patients were identified with isolated, closed tibial shaft fractures, who were reduced and treated in a long leg cast. 234 patients (70%) converted to surgical treatment due to inability to maintain alignment, patient intolerance, and nonunion. In a regression model, coronal/sagittal translation, sagittal angulation, fracture morphology, and smoking status were shown to be significant predictors of success of nonoperative treatment (p < 0.05). We developed a Tibial Operative Outcome Likelihood (TOOL) score designed to help predict success or failure of closed treatment. The TOOL score can be used to identify a subsegment of patients with injuries amenable to closed treatment (38% of injuries) with a nonoperative success rate over 60%. CONCLUSION: Non-operative treatment of tibial shaft fractures is feasible, although there is a relatively high conversion rate to operative treatment. However, it is possible to use injury characteristics to identify a cohort of patients with a higher chance of success with closed treatment, which is potentially useful in a resource-constrained setting or for patients who wish to avoid surgery. LEVEL OF EVIDENCE: Prognostic Level 3.

Clinical Practice Guidelines on Ordering Echocardiography Before Hip Fracture Repair Perform Differently from One Another.

BACKGROUND: Osteoporotic hip fractures typically occur in frail elderly patients with multiple comorbidities, and repair of the fracture within 48 h is recommended. Pre-operative evaluation sometimes involves transthoracic echocardiography (TTE) to screen for heart disease that would alter peri-operative management, yet TTE can delay surgery and is resource intensive. Evidence suggests that the use of clinical practice guidelines (CPGs) can improve care. It is unclear which guidelines are most useful in hip fracture patients. QUESTIONS/PURPOSES: We sought to evaluate the performance of the five commonly used CPGs in determining which patients with acute fragility hip fracture require TTE and to identify common features among high-performing CPGs that could be incorporated into care pathways. PATIENTS AND METHODS: We performed a retrospective study of medical records taken from an institutional database of osteoporotic hip fracture patients to identify those who underwent pre-operative TTE. History and physical examination findings were recorded; listed indications for TTE were compared against those given in five commonly used CPGs: those from the American College of Cardiology/American Heart Association (ACC/AHA), the British Society of Echocardiography (BSE), the European Society of Cardiology and the European Society of Anaesthesiology(ESC/ESA), the Association of Anaesthetists of Great Britain and Ireland (AAGBI), and the Scottish Intercollegiate Guidelines Network (SIGN). We then calculated the performance (sensitivity and specificity) of the CPGs in identifying patients with TTE results that had the potential to change peri-operative management. RESULTS: We identified 100 patients who underwent pre-operative TTE. Among those, the patients met criteria for TTE 32 to 66% of the time, depending on the CPG used. In 14% of those receiving TTE, the test revealed new information with the potential to change management. The sensitivity of the CPGs ranged from 71% (ESC/ESA and AAGBI) to 100% (ACC/AHA and SIGN). The CPGs' specificity ranged from 37% (BSE) to 74% (ESC/ESA). The more sensitive guidelines focused on a change in clinical status in patients with known disease or clinical concern regarding new-onset disease. CONCLUSIONS: In patients requiring fixation of osteoporotic hip fractures, TTE can be useful for identifying pathologies that could directly change peri-operative management. Our data suggest that established CPGs can be safely used to identify which patients should undergo pre-operative TTE with low risk of missed pathology.

Compilation and Analysis of Web-Based Orthopedic Personalized Predictive Tools: A Scoping Review.

Web-based personalized predictive tools in orthopedic surgery are becoming more widely available. Despite rising numbers of these tools, many orthopedic surgeons may not know what tools are available, how these tools were developed, and how they can be utilized. The aim of this scoping review is to compile and synthesize the profile of existing web-based orthopedic tools. We conducted two separate PubMed searches-one a broad search and the second a more targeted one involving high impact journals-with the aim of comprehensively identifying all existing tools. These articles were then screened for functional tool URLs, methods regarding the tool's creation, and general inputs and outputs required for the tool to function. We identified 57 articles, which yielded 31 unique web-based tools. These tools involved various orthopedic conditions (e.g., fractures, osteoarthritis, musculoskeletal neoplasias); interventions (e.g., fracture fixation, total joint arthroplasty); outcomes (e.g., mortality, clinical outcomes). This scoping review highlights the availability and utility of a vast array of web-based personalized predictive tools for orthopedic surgeons. Increased awareness and access to these tools may allow for better decision support, surgical planning, post-operative expectation management, and improved shared decision-making.

Estimates of Direct and Indirect Costs of Ankle Fractures: A Prospective Analysis.

BACKGROUND: The quantification of the costs of ankle fractures and their associated treatments has garnered increased attention in orthopaedics through cost-effectiveness analysis. The purpose of this study was to prospectively assess the direct and indirect costs of ankle fractures in operatively and nonoperatively treated patients. METHODS: A prospective, observational, single-center study was performed. Adult patients presenting for an initial consult for an ankle fracture were enrolled and were followed until recurring indirect costs amounted to zero. Patients completed a cost form at every visit that assessed time away from work and the money spent in the last week on transportation, household chores, and self-care due to an ankle fracture. Direct cost data were obtained directly from the hospital billing department. RESULTS: Sixty patients were included in this study. With regard to patient characteristics, the mean patient age was 46.5 years, 55% of patients were female, 10% of patients had diabetes, and 17% of patients were active smokers. Weber A fractures composed 12% of fractures, Weber B fractures composed 72% of fractures, and Weber C fractures composed 18% of fractures. Operatively treated patients (n = 37) had significantly higher total costs and direct costs compared with nonoperatively treated patients (p < 0.01). In all patients, losses from missed work accounted for the largest portion of total and indirect costs, with a mean percentage of 35.8% of the total cost. The mean period preceding return to work of the 39 employed patients was 11.2 weeks. Longer periods of return to work were significantly associated with surgical fixation and having less than a college-level education (p < 0.05). The mean time for recurring observed costs to cease was 19.1 weeks. CONCLUSIONS: In patients treated operatively and nonoperatively, the largest discrete cost component was a specific indirect cost. Indirect costs accounted for a mean of 41.3% of the total cost. Although the majority of the direct costs of ankle fractures are accrued in the period immediately following the injury, indirect cost components will regularly be incurred for nearly 5 months and often longer. To capture the full economic impact of these injuries, future research should include detailed reporting on an intervention's impact on the indirect costs of ankle fractures. LEVEL OF EVIDENCE: Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

Can we predict failure of percutaneous fixation of femoral neck fractures?

PURPOSE: This study evaluated a series of geriatric femoral neck fracture treated with closed reduction percutaneous pinning (CRPP) at a single level-1 trauma center to determine if there are any simple, reliable, radiographic characteristics that can be used to predict increased risk of post-operative failure in nondisplaced and valgus impacted fracture patterns. METHODS: We conducted a retrospective cohort study of all patients with femoral neck fractures (AO/OTA 31B) who underwent CRPP over a 12-year period at a single Level 1 trauma center. Failure was defined as radiographic failure within the first year after the index operation requiring revision surgery. Common patterns identified on initial review were the presence of a visible medial transcervical line (MTL) felt to indicate a tension-sided failure, a straight inferior calcar (SIC) indicating severe valgus impaction, and quality of intra-operative screw positioning. X-rays of patients were then reviewed for these characteristics in a blinded manner by three different trauma-fellowship trained orthopedic surgeons. Inter-rater reliability was calculated using Fleiss' Kappa Coefficient. Comparisons of failure rates between groups were made using a Fisher's Exact test. RESULTS: 139 patients who underwent CRPP for a femoral neck fracture and follow-up for at least 90 days were identified and reviewed. There were a total of 19 failures (13.6%) within one year. The patients with a varus fracture had a failure rate of 9/24 (37.5%). Of the valgus/nondisplaced fractures, MTL was identified in 42/115 (36%) patients. Inter-rater agreement was high for the presence of an MTL (84%, Kappa 0.69). Patients with an MTL had a fourfold increase in risk of failure (7/42=17% with an MTL vs. 3/73=4% without, p  0.03). The presence of a SIC and quality of screw placement were not predictive of failure. CONCLUSION: Varus femoral neck fractures fixed with CRPP have a high rate of failure (37.5%). Nondisplaced or valgus impacted fractures with the presence of a visible medial transcervical line on pre-operative radiographic imaging resulted in a fourfold increase in the risk of failure after CRPP. Identification of the MTL will help treating surgeons better council patients when making pre-operative decisions between arthroplasty and CRPP.

"Found Down" Compartment Syndrome: Experience from the Front Lines of the Opioid Epidemic.

BACKGROUND: With the worsening of the opioid epidemic, there has been an increasing number of cases in which patients are "found down" following a drug overdose and develop a crush injury resulting in muscle necrosis, rhabdomyolysis, and elevated compartment pressures in a unique presentation of compartment syndrome. The purpose of the present study is to summarize our experience at a trauma center in a region with a high endemic rate of opiate abuse to provide guidance for the management of patients with "found down" compartment syndrome. METHODS: We performed a retrospective review of the records of patients who had been found unconscious as the result of overdose, with findings that were concerning for compartment syndrome, and had been managed with fasciotomy or observation at the discretion of the surgeon. The patients were divided into 3 groups based on presentation (partial deficits, complete deficits, or unexaminable), and the operative findings, hospital course, laboratory values, and functional status were compared between the groups. RESULTS: Over 12 years, we identified 30 "found down" patients who had an examination that was concerning for compartment syndrome. Twenty-five patients were managed with fasciotomy; this group required an average of 4.2 operations and had a 20% infection rate and a 12% amputation rate. Lactate, creatine phosphokinase, and creatinine levels typically were elevated but did not correspond with muscle viability or return of function. At the time of initial debridement, 56% of patients had muscle that appeared nonviable, although muscle function returned in 28% of the patients who had questionable viability. Four patients had no motor or neurological function on initial examination, and none had meaningful return of function at the time of the latest follow-up. Of the 10 patients who had partial neurological deficits at the time of presentation and underwent fasciotomy, over half (70%) had some improvement in ultimate function. CONCLUSIONS: Patients who are "found down" following an opiate overdose with crush injuries resulting in compartment syndrome have a high surgical complication rate and poor recovery of function. The limited data from the present study suggest that those with absent function at the time of presentation are unlikely to gain function after fasciotomy, and the risk-benefit ratio of fasciotomy in this patient population may be different from that for patients with traumatic compartment syndrome. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Orthopaedic Faculty and Resident Sex Diversity Are Associated with the Orthopaedic Residency Application Rate of Female Medical Students.

BACKGROUND: The representation of women in orthopaedics in the United States remains among the lowest in all fields of medicine, and prior research has suggested that this underrepresentation may stem from lower levels of interest among female medical students. Of the many proposed reasons for this lack of interest, the male-dominated nature of the field is one of the most commonly cited. The purpose of this study was to determine the degree to which the representation of women among orthopaedic faculty and residents influences female medical students at that institution to apply for a residency in orthopaedics. METHODS: Using data provided by the Association of American Medical Colleges, we identified all U.S. medical schools that were affiliated with an orthopaedic surgery department and an orthopaedic surgery residency program (n = 107). For each institution, data on the representation of women among the orthopaedic faculty and residents from 2014 through 2016 were collected, as well as data on the proportion of female medical school graduates who applied to an orthopaedic residency program from 2015 through 2017. The association between institutional factors and the female medical student orthopaedic application rate was assessed. RESULTS: Of 22,707 women who graduated from medical school during the 3-year study period, 449 (1.98%) applied to an orthopaedic surgery residency program. Women who attended medical school at institutions with high orthopaedic faculty sex diversity were more likely to apply for a residency in orthopaedics (odds ratio [OR], 1.30; 95% confidence interval [CI], 1.04 to 1.64; p = 0.023), as were women who attended medical school at institutions with high orthopaedic resident sex diversity (OR, 1.30; 95% CI, 1.05 to 1.61; p = 0.019). CONCLUSIONS: In this study, we found that increased sex diversity among orthopaedic faculty and residents was associated with a greater likelihood that female medical students at that institution would apply for an orthopaedic residency. These results suggest that at least some of the factors currently impeding female medical student interest in orthopaedics may be modifiable. These findings may have important implications for efforts to improve the sex diversity of the field of orthopaedics going forward.

Creation of an Online Wiki Improves Post-Operative Surgical Protocol Adherence in Arthroplasty Patients.

BACKGROUND: Perioperative care pathways are tools used in high-volume clinical settings to standardize care, reduce variability, and improve outcomes. However, the mechanism by which the information is transmitted to other caregivers is often inconsistent and error-prone. At our institution, we developed an online, user-editable ("wiki") database to communicate post-operative protocols. The purpose of this study is to evaluate the hypothesis that implementation of the wiki would improve protocol adherence and reduce unintentional deviations inpatient care. METHODS: We conducted a retrospective review of patients who underwent primary lower extremity arthroplasty at our institution during three 6-month time periods including immediately before, 6 months after, and 2 years following introduction of the wiki. Adherence to defined perioperative care pathways (laboratory studies, post-operative imaging, perioperative antibiotics, and inpatient pain medications) was compared between the groups. RESULTS: After wiki implementation, adherence to protocols improved significantly for laboratory orders (P < .0001), imaging (P < .001), pain control regimen (P = .03), and overall protocol adherence (P < .001). Improvements were seen in some areas almost immediately, while others did not show improvements until 2 years after implementation. Costs associated with unnecessary testing were reduced by 82%. CONCLUSION: Development of an online wiki for tracking post-operative protocols improves care pathway adherence and reduces variability in care while lowering costs associated with unnecessary testing, although some benefits may not be immediately realized. Several practical barriers to implementing the wiki are also discussed, along with proposed solutions.

Clinical Practice Guidelines Decrease Unnecessary Echocardiograms Before Hip Fracture Surgery.

BACKGROUND: Preoperative assessment of geriatric patients with a hip fracture may include transthoracic echocardiography (TTE), which increases resource utilization and cost and may delay surgery. The purpose of this study was to evaluate preoperative TTE utilization at a single institution in order to determine (1) how often TTE is ordered in accordance with clinical practice guidelines (CPGs), (2) how frequently TTE reveals cardiac disease that may alter medical or anesthesia management, and (3) whether following CPGs reduces unnecessary TTE utilization without potentially missing important disease. METHODS: A retrospective review of data on 100 geriatric patients with a hip fracture who had undergone preoperative TTE was performed. Charts were reviewed to evaluate if TTE had been obtained in accordance with the published CPGs from the American College of Cardiology/American Heart Association (ACC/AHA). TTE reports were reviewed for the presence of disease that was important enough to cause modifications in anesthesia or perioperative management, including new left ventricular systolic or diastolic dysfunction, moderate or severe valvular disease, and pulmonary hypertension. Finally, the sensitivity and specificity of accordance with the ACC/AHA CPGs for predicting which patients would have TTE that identified important disease were calculated. RESULTS: The TTE was ordered in accordance with the published ACC/AHA CPGs for 66% of the patients. TTE revealed disease with the potential to modify anesthesia or medical management in 14% of the patients-for all of whom the TTE had been indicated according to ACC/AHA guidelines (i.e., the guidelines were 100% sensitive). In this study population, following the ACC/AHA guidelines could have prevented the performance of TTE in 34% of the patients without missing any disease (40% specificity). CONCLUSIONS: Preoperative TTE for patients with a hip fracture is frequently obtained outside the recommendations of established CPGs. Utilization of CPGs such as the ACC/AHA guidelines should be considered, as it may decrease variability in care and reduce unnecessary resource utilization without adversely affecting patient outcomes.

Allograft Augmentation of Hamstring Autograft for Younger Patients Undergoing Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Younger patients and those with smaller hamstring autograft diameters have been shown to be at significantly greater risk of graft failure after anterior cruciate ligament (ACL) reconstruction. To date, there is no information in the literature about the clinical success and/or cost-effectiveness of increasing graft diameter by augmenting with semitendinosus allograft tissue for younger patients. HYPOTHESIS: Hybrid hamstring grafts are a cost-effective treatment option because of a reduced rate of graft failure. STUDY DESIGN: Cohort study (economic and decision analysis); Level of evidence, 3. METHODS: We retrospectively identified patients younger than 18 years who had undergone ACL reconstruction by a single surgeon between 2010 and 2015. During this period, the operating surgeon's graft selection algorithm included the use of bone-patellar tendon-bone (BTB) autografts for the majority of patients younger than 18 years. However, hamstring autografts (hamstring) or hybrid hamstring autografts with allograft augment (hybrid) were used in skeletally immature patients and in those whom the surgeon felt might have greater difficulty with postoperative rehabilitation after BTB graft harvest. Patient demographics, graft type, graft diameter, the time the patient was cleared to return to activity, and the need for secondary surgical procedures were compared between the hamstring and hybrid groups. The clinical results were then used to assess the potential cost-effectiveness of hybrid grafts in this select group of young patients with an ACL injury or reconstruction. RESULTS: This study comprised 88 patients (hamstring group, n = 46; hybrid group, n = 42). The 2 groups did not differ in terms of age, sex, timing of return to activity, or prevalence of skeletally immature patients. Graft diameters were significantly smaller in the hamstring group (7.8 vs 9.9 mm; P < .001), which corresponded with a significantly greater rate of graft failure (13 of 46 [28.3%] vs 5 of 42 [11.9%]; P = .049). As a result of the reduced revision rate, the hybrid graft demonstrated incremental cost savings of US$2765 compared with the hamstring graft, and the hybrid graft was the preferred strategy in 89% of cases. CONCLUSION: Driven by increased graft diameters and the reduced risk of revision, hybrid grafts appear to be a more cost-effective treatment option in a subset of younger patients with an ACL injury.

The Effect of Ligament Injuries on Outcomes of Operatively Treated Distal Radius Fractures.

Various authors have documented wrist ligament injuries in patients with distal radius fractures (DRFs). We conducted a study to determine whether scapholunate interosseous ligament (SLIL), triangular fibrocartilage complex (TFCC), or chondral injuries directly assessed with arthroscopy predict DRF outcomes. Forty-two patients who underwent open reduction and internal fixation of DRFs were enrolled in the study. At time of fracture surgery, patients were arthroscopically evaluated for SLIL and TFCC injuries and chondral surface damage. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire was the primary outcome measure at 1 year. Analysis of variance was performed to evaluate for correlations between ligamentous/chondral injuries and DRF outcomes. Forty-five percent of patients had SLIL injuries, 50% had TFCC injuries, and 29% had articular cartilage injuries. There were no significant differences in DASH scores among the different injury groups and no significant differences in terms of secondary outcomes. SLIL and TFCC injuries occur in more than 70% of patients with operatively treated DRFs. These injuries appear not to have major negative effects on DRF outcomes up to 1 year after surgery.

How Should the Treatment Costs of Distal Radius Fractures Be Measured?

Distal radius fractures (DRFs) are common, but the best way to measure the total cost of treating these injuries is not known. We conducted a study to measure the total treatment cost of DRFs to identify which items should be measured, and for how long, to capture all major cost-drivers. Eighty-two patients with DRFs were included in this prospective, observational study. All costs, both direct and indirect, were measured. Direct costs were measured for each patient from internal billing records. Indirect costs were obtained with a customized questionnaire. The major contributors to overall cost were physician fees, operating room costs, occupational therapy, and missed work, which together accounted for 92% of total cost. Recurring indirect costs largely resolved within 3 months for nonoperative management and within 6 months for operative management. Physician fees, operating room costs, occupational therapy, and missed work are the major cost-drivers for DRFs and should be measured for at least 6 months after injury. Indirect costs, particularly those associated with missed work, represent a significant amount of the total overall cost.

ORIF or Arthroplasty for Displaced Femoral Neck Fractures in Patients Younger Than 65 Years Old: An Economic Decision Analysis.

BACKGROUND: The decision between open reduction and internal fixation (ORIF) and arthroplasty for a displaced femoral neck fracture in a patient ≤65 years old can be challenging. Both options have potential drawbacks; if a fracture treated with ORIF fails to heal it may require a revision operation, whereas a relatively young patient who undergoes arthroplasty may need revision within his/her lifetime. The purpose of this study was to employ decision analysis modeling techniques to generate evidence-based treatment recommendations in this clinical scenario. METHODS: A Markov decision analytic model was created to simulate outcomes after ORIF, total hip arthroplasty (THA), or hemiarthroplasty in patients who had sustained a displaced femoral neck fracture between the ages of 40 and 65 years. The variables in the model were populated with values from studies with high-level evidence and from national registry data reported in the literature. The model was used to estimate the threshold age above which THA would be the superior strategy. Results were tested using sensitivity analysis and probabilistic statistical analysis. RESULTS: THA was found to be a cost-effective option for a displaced femoral neck fracture in an otherwise healthy patient who is >54 years old, a patient with mild comorbidity who is >47 years old, and a patient with multiple comorbidities who is >44 years old. The average clinical outcomes of THA and ORIF were similar for patients 40 to 65 years old, although ORIF had a wider variability in outcomes based on the success or failure of the initial fixation. For all ages and cases, hemiarthroplasty was associated with worse outcomes and higher costs. CONCLUSIONS: Compared with ORIF, primary THA can be a cost-effective treatment for displaced femoral neck fractures in patients 45 to 65 years of age, with the age cutoff favoring THA decreasing as the medical comorbidity and risk of ORIF fixation failure increase. Hemiarthroplasty has worse outcomes at higher costs and is not recommended in this age group. LEVEL OF EVIDENCE: Economic and decision analysis Level III. See Instructions for Authors for a complete description of levels of evidence.

Percutaneous Trigger Finger Release: A Cost-effectiveness Analysis.

INTRODUCTION: Percutaneous trigger finger releases (TFRs) performed in the office setting are becoming more prevalent. This study compares the costs of in-hospital open TFRs, open TFRs performed in ambulatory surgical centers (ASCs), and in-office percutaneous releases. METHODS: An expected-value decision-analysis model was constructed from the payer perspective to estimate total costs of the three competing treatment strategies for TFR. Model parameters were estimated based on the best available literature and were tested using multiway sensitivity analysis. RESULTS: Percutaneous TFR performed in the office and then, if needed, revised open TFR performed in the ASC, was the most cost-effective strategy, with an attributed cost of $603. The cost associated with an initial open TFR performed in the ASC was approximately 7% higher. Initial open TFR performed in the hospital was the least cost-effective, with an attributed cost nearly twice that of primary percutaneous TFR. DISCUSSION: An initial attempt at percutaneous TFR is more cost-effective than an open TFR. Currently, only about 5% of TFRs are performed in the office; therefore, a substantial opportunity exists for cost savings in the future. LEVEL OF EVIDENCE: Decision model level II.

Revision Arthroscopic Repair Versus Latarjet Procedure in Patients With Recurrent Instability After Initial Repair Attempt: A Cost-Effectiveness Model.

PURPOSE: To compare the cost-effectiveness of arthroscopic revision instability repair and Latarjet procedure in treating patients with recurrent instability after initial arthroscopic instability repair. METHODS: An expected-value decision analysis of revision arthroscopic instability repair compared with Latarjet procedure for recurrent instability followed by failed repair attempt was modeled. Inputs regarding procedure cost, clinical outcomes, and health utilities were derived from the literature. RESULTS: Compared with revision arthroscopic repair, Latarjet was less expensive ($13,672 v $15,287) with improved clinical outcomes (43.78 v 36.76 quality-adjusted life-years). Both arthroscopic repair and Latarjet were cost-effective compared with nonoperative treatment (incremental cost-effectiveness ratios of 3,082 and 1,141, respectively). Results from sensitivity analyses indicate that under scenarios of high rates of stability postoperatively, along with improved clinical outcome scores, revision arthroscopic repair becomes increasingly cost-effective. CONCLUSIONS: Latarjet procedure for failed instability repair is a cost-effective treatment option, with lower costs and improved clinical outcomes compared with revision arthroscopic instability repair. However, surgeons must still incorporate clinical judgment into treatment algorithm formation. LEVEL OF EVIDENCE: Level IV, expected value decision analysis.

Cost-Effectiveness of Reverse Total Shoulder Arthroplasty Versus Arthroscopic Rotator Cuff Repair for Symptomatic Large and Massive Rotator Cuff Tears.

PURPOSE: To compare the cost-effectiveness within the United States health care system of arthroscopic rotator cuff repair versus reverse total shoulder arthroplasty in patients with symptomatic large and massive rotator cuff tears without cuff-tear arthropathy. METHODS: An expected-value decision analysis was constructed comparing the costs and outcomes of patients undergoing arthroscopic rotator cuff repair and reverse total shoulder arthroplasty for large and massive rotator cuff tears (and excluding cases of cuff-tear arthropathy). Comprehensive literature search provided input data to extrapolate costs and health utility states for these outcomes. The primary outcome assessed was that of incremental cost-effectiveness ratio (ICER) of reverse total shoulder arthroplasty versus rotator cuff repair. RESULTS: For the base case, both arthroscopic rotator cuff repair and reverse total shoulder were superior to nonoperative care, with an ICER of $15,500/quality-adjusted life year (QALY) and $37,400/QALY, respectively. Arthroscopic rotator cuff repair was dominant over primary reverse total shoulder arthroplasty, with lower costs and slightly improved clinical outcomes. Arthroscopic rotator cuff repair was the preferred strategy as long as the lifetime progression rate from retear to end-stage cuff-tear arthropathy was less than 89%. However, when the model was modified to account for worse outcomes when reverse shoulder arthroplasty was performed after a failed attempted rotator cuff repair, primary reverse total shoulder had superior outcomes with an ICER of $90,000/QALY. CONCLUSIONS: Arthroscopic rotator cuff repair-despite high rates of tendon retearing-for patients with large and massive rotator cuff tears may be a more cost-effective initial treatment strategy when compared with primary reverse total shoulder arthroplasty and when assuming no detrimental impact of previous surgery on outcomes after arthroplasty. Clinical judgment should still be prioritized when formulating treatment plans for these patients. LEVEL OF EVIDENCE: Level II, economic decision analysis.

Dedicated Perioperative Hip Fracture Comanagement Programs are Cost-effective in High-volume Centers: An Economic Analysis.

BACKGROUND: Osteoporotic hip fractures are common injuries typically occurring in patients who are older and medically frail. Studies have suggested that creation of a multidisciplinary team including orthopaedic surgeons, internal medicine physicians, social workers, and specialized physical therapists, to comanage these patients can decrease complication rates, improve time to surgery, and reduce hospital length of stay; however, they have yet to achieve widespread implementation, partly owing to concerns regarding resource requirements necessary for a comanagement program. QUESTIONS/PURPOSES: We performed an economic analysis to determine whether implementation of a comanagement model of care for geriatric patients with osteoporotic hip fractures would be a cost-effective intervention at hospitals with moderate volume. We also calculated what annual volume of cases would be needed for a comanagement program to "break even", and finally we evaluated whether universal or risk-stratified comanagement was more cost effective. METHODS: Decision analysis techniques were used to model the effect of implementing a systems-based strategy to improve inpatient perioperative care. Costs were obtained from best-available literature and included salary to support personnel and resources to expedite time to the operating room. The major economic benefit was decreased initial hospital length of stay, which was determined via literature review and meta-analysis, and a health benefit was improvement in perioperative mortality owing to expedited preoperative evaluation based on previously conducted meta-analyses. A break-even analysis was conducted to determine the annual case volume necessary for comanagement to be either (1) cost effective (improve health-related quality of life enough to be worth additional expenses) or (2) result in cost savings (actually result in decreased total expenses). This calculation assumed the scenario in which a hospital could hire only one hospitalist (and therapist and social worker) on a full-time basis. Additionally, we evaluated the scenario where the necessary staff was already employed at the hospital and could be dedicated to a comanagement service on a part-time basis, and explored the effect of triaging only patients considered high risk to a comanagement service versus comanaging all geriatric patients. Finally, probabilistic sensitivity analysis was conducted on all critical variables, with broad ranges used for values around which there was higher uncertainty. RESULTS: For the base case, universal comanagement was more cost effective than traditional care and risk-stratified comanagement (incremental cost effectiveness ratios of USD 41,100 per quality-adjusted life-year and USD 81,900 per quality-adjusted life-year, respectively). Comanagement was more cost effective than traditional management as long as the case volume was more than 54 patients annually (range, 41-68 patients based on sensitivity analysis) and resulted in cost savings when there were more than 318 patients annually (range, 238-397 patients). In a scenario where staff could be partially dedicated to a comanagement service, universal comanagement was more cost effective than risk-stratified comanagement (incremental cost effectiveness of USD 2300 per quality-adjusted life-year), and both comanagement programs had lower costs and better outcomes compared with traditional management. Sensitivity analysis was conducted and showed that the level of uncertainty in key variables was not high enough to change the core conclusions of the model. CONCLUSIONS: Implementation of a systems-based comanagement strategy using a dedicated team to improve perioperative medical care and expedite preoperative evaluation is cost effective in hospitals with moderate volume and can result in cost savings at higher-volume centers. The optimum patient population for a comanagement strategy is still being defined. LEVEL OF EVIDENCE: Level 1, Economic and Decision Analysis.

Reliability of a field-based drop vertical jump screening test for ACL injury risk assessment.

OBJECTIVES: There is an epidemic of anterior cruciate ligament (ACL) injuries in youth athletes. Poor neuromuscular control is an easily modifiable risk factor for ACL injury, and can be screened for by observing dynamic knee valgus on landing in a drop vertical jump test. This study aims to validate a simple, clinically useful population-based screening test to identify at-risk athletes prior to participation in organized sports. We hypothesized that both physicians and allied health professionals would be accurate in subjectively assessing injury risk in real-time field and office conditions without motion analysis data and would be in agreement with each other. METHODS: We evaluated the inter-rater reliability of risk assessment by various observer groups, including physicians and allied health professionals, commonly involved in the care of youth athletes. Fifteen athletes age 11-17 were filmed performing a drop vertical jump test. These videos were viewed by 242 observers including orthopaedic surgeons, orthopaedic residents/fellows, coaches, athletic trainers (ATCs), and physical therapists (PTs), with the observer asked to subjectively estimate the risk level of each jumper. Objective injury risk was calculated using normalized knee separation distance (measured using Dartfish, Alpharetta, GA), based on previously published studies. Risk assessments by observers were compared to each other to determine inter-rater reliability, and to the objectively calculated risk level to determine sensitivity and specificity. Seventy one observers repeated the test at a minimum of 6 weeks later to determine intra-rater reliability. RESULTS: Between groups, the inter-rater reliability was high, κ = 0.92 (95% CI 0.829-0.969, p < 0.05), indicating that no single group gave better (or worse) assessments, including comparisons between physicians and allied health professionals. With a screening cutoff isolated to subjects identified by observers as "high risk", the sensitivity was 63.06% and specificity 82.81%. Reducing the screening cutoff to also include jumpers identified as "medium risk" increased sensitivity to 95.04% and decreased the specificity to 46.07%. Intra-rater reliability was moderate, κ = 0.55 (95% CI 0.49-0.61, p < 0.05), indicating that individual observers made reproducible risk assessments. CONCLUSIONS: This study supports the use of a simple, field-based observational drop vertical jump screening test to identify athletes at risk for ACL injury. Our study shows good inter- and intra-rater reliability and high sensitivity and suggests that screening can be performed without significant training by physicians as well as allied health professionals, including: coaches, athletic trainers and physical therapists. Identification of these high-risk athletes may play a role in enrollment in appropriate preventative neuromuscular training programs, which have been shown to decrease the incidence of ACL injuries in this population.