MRI-based 3-dimensional volumetric assessment of fatty infiltration and muscle atrophy in rotator cuff tears.

BACKGROUND: The Goutallier and Warner Classification systems are useful in determining rotator cuff reparability. Data are limited on how accurately the scapular-Y view used in both systems reflects the 3-dimensional (3-D) changes in fatty infiltration (FI) and muscle atrophy (MA). Tendon retraction in the setting of a cuff tear may also influence the perception of these changes. This study's objectives were to (1) measure the 3-D volume of the supraspinatus muscle in intact rotator cuffs, and with varying magnitudes of retraction; (2) measure the 3-D volume of FI in the supraspinatus muscle in these conditions; and (3) determine the influence of tendon retraction on measured FI and MA using the Goutallier and Warner Classification Systems. METHODS: Between August 2015 and February 2016, all shoulder magnetic resonance images (MRIs) at the Portland VA Medical Center were standardized to include the medial scapular border. MRIs and charts were reviewed for inclusion/exclusion criteria. Included MRIs were categorized into 4 groups based on rotator cuff retraction. Supraspinatus muscle and fossa were traced to create 3-D volumes. FI and MA were measured within the supraspinatus. The supraspinatus muscle was graded among 6 physicians using the Goutallier and Warner classification systems. These grades were compared to 3-D measured FI and MA. The influence of tendon retraction on the measured grades were also evaluated. RESULTS: One hundred nine patients met inclusion/exclusion criteria. Ten MRIs for each group (N = 40) were included for image analysis. Supraspinatus volume tracings were highly reproducible and consistent between tracers. Supraspinatus muscle volumes decreased while global FI and MA increased with greater degrees of tendon retraction. In muscles with less than 10% global fat, fat concentrated in the lateral third of the muscle. In muscle with more than 10% global fat content, it distributed more diffusely throughout the muscle from medial to lateral. In comparing the scapular-Y to a medial cut, there was no consistent trend in FI whereas MA was more accurate at the medial cut. CONCLUSION: Parasagittal imaging location did not significantly influence the Goutallier score; however, assessment of MA using the Warner score leads readers to perceive less MA medially regardless of the magnitude of tendon retraction. The pattern of FI within the supraspinatus muscle changes from a laterally based location around the muscle-tendon junction to a more diffuse, global infiltration pattern when the whole muscle fat content exceeds 10%.

Advances in the Functional Assessment of Patients with Sarcoma.

Functional assessment of patients with osteosarcoma may yield unique insights into the guide and advance treatment. A range of patient-reported outcomes has been validated, including general health and condition-specific measures as well as computer adaptive testing. Health state utility measures, which facilitate comparative-effectiveness research, are also available. Beyond these surveys, and laboratory-dependent gait analyses, is the potential for real-world evaluation through research-oriented and consumer-oriented accelerometers. Initial studies have shown promising validity of these activity trackers and may also have implications for traditional oncologic outcomes.

Radiographic parameter-driven decision tree reliably predicts aseptic mechanical failure of compressive osseointegration fixation.

Background and purpose - Compressive osseointegration fixation is an alternative to intramedullary fixation for endoprosthetic reconstruction. Mechanical failure of compressive osseointegration presents differently on radiographs than stemmed implants, therefore we aimed to develop a reliable radiographic method to determine stable integration.Patients and methods - 8 reviewers evaluated 11 radiographic parameters from 29 patients twice, 2 months apart. Interclass correlation coefficients (ICCs) were used to assess test-retest and inter-rater reliability. We constructed a fast and frugal decision tree using radiographic parameters with substantial test-retest agreement, and then tested using radiographs from a new cohort of 49 patients. The model's predictions were compared with clinical outcomes and a confusion matrix was generated.Results - 6 of 8 reviewers had non-significant intra-rater ICCs for ≥ one parameter; all inter-rater ICCs were highly reliable (p < 0.001). Change in length between the top of the spindle sleeve and bottom of the anchor plug (ICC 0.98), bone cortex hypertrophy (ICC 0.86), and bone pin hypertrophy (ICC 0.81) were used to create the decision tree. The sensitivity and specificity of the training cohort were 100% (95% CI 52-100) and 87% (CI 74-94) respectively. The decision tree demonstrated 100% (CI 40-100) sensitivity and 89% (CI 75-96) specificity with the test cohort.Interpretation - A stable spindle length and at least 3 cortices with bone hypertrophy at the implant interface predicts stable osseointegration; failure is predicted in the absence of bone hypertrophy at the implant interface if the pin sites show hypertrophy. Thus, our decision tree can guide clinicians as they follow patients with compressive osseo-integration implants.

Oncology Patients Are High Cost Outliers in Total Joint Replacement Bundled Payment Systems.

BACKGROUND: In 2016, the Centers for Medicare and Medicaid Services began its first mandatory bundled payment program, the Comprehensive Care for Joint Replacement (CJR) model, which covers a 90-day episode of care. This study determined whether oncology patients enrolled in the CJR bundle incur higher hospital costs than patients with osteoarthritis (OA). METHODS: A retrospective review of all patients enrolled in the CJR bundled payments system from April 1, 2016 to June 31, 2018 at a single academic medical center was conducted. To determine whether tumor patients had higher total episode costs, this group was compared to patients diagnosed with OA using a 2-tailed t-test. To adjust for moderators of total hospital costs, we used generalized linear regression with a log-link, including multiple variables abstracted from chart review. RESULTS: Three hundred fourteen patients met inclusion criteria (12 primary or metastatic tumors, 302 OA). Fifty-eight percent of tumor patients were over the target price vs 16% of OA patients. The mean tumor patient had $40,862 for total internal hospital costs compared to $16,356 in the OA group (P < .001). Length of stay was greater in the tumor group (6.75 vs 2.0 days, P < .001). A greater percentage of tumor patients were discharged to a skilled nursing facility (67% vs 27%, P = .006) with significantly higher skilled nursing facility episode costs ($18,852 vs $7731, P = .04). With adjustment for fracture status, tumor patients were 5.36 times more likely to exceed the CJR target price than OA patients (risk ratio 5.36, confidence interval 3.44-8.35, P < .001) and 50 times more likely to be outliers over the regional threshold than OA patients (risk ratio 50.33, confidence interval 16.33-155.19, P < .001). CONCLUSION: Oncology patients enrolled in the CJR bundled payment model incur significantly higher costs and have higher cost variability than patients with OA. We recommend that oncology patients be excluded from the CJR bundle.

Rapid Web-Based Platform for Assessment of Orthopedic Surgery Patient Care Milestones: A 2-Year Validation.

OBJECTIVE: To determine the validity, feasibility, and responsiveness of a new web-based platform for rapid milestone-based evaluations of orthopedic surgery residents. SETTING: Single academic medical center, including a trauma center and pediatrics tertiary hospital. PARTICIPANTS: Forty residents (PG1-5) in an orthopedic residency program and their faculty evaluators. METHODS: Residents and faculty were trained and supported in the use of a novel trainee-initiated web-based evaluation system. Residents were encouraged to use the system to track progress on patient care subcompetencies. Two years of prospectively collected data were reviewed from residents at an academic program. The primary outcome was Spearman's rank correlation between postgraduate year (PGY) and competency level achieved as a measure of validity. Secondary outcomes assessed feasibility, resident self-evaluation versus faculty evaluation, the distributions among subcompetencies, and responsiveness over time. RESULTS: Between February 2014 and February 2016, 856 orthopedic surgery patient care subcompetency evaluations were completed (1.2 evaluations per day). Residents promptly requested feedback after a procedure (median = 0 days, interquartile range: 0-2), and faculty responded within 2 days in 51% (median = 2 days, interquartile range: 0-13). Primary outcome showed a correlation between PGY and competency level (r = 0.78, p < 0.001), with significant differences in competency among PGYs (p < 0.001 by Kruskal-Wallis rank sum test). Self-evaluations by residents substantially agreed with faculty-assigned competency level (weighted Cohen's κ = 0.72, p < 0.001). Resident classes beginning the study as PGY1, 2, and 3 separately demonstrated gains in competency over time (Spearman's rank correlation 0.39, 0.60, 0.59, respectively, each p < 0.001). There was significant variance in the number of evaluations submitted per subcompetency (median = 43, range: 6-113) and competency level assigned (p < 0.01). CONCLUSIONS: Rapid tracking of trainee competency with milestone-based evaluations in a learner-centered mobile platform demonstrated validity, feasibility, and responsiveness. Next Accreditation System-mandated data may be efficiently collected and used for trainee and program self-study.

Assessment of objective ambulation in lower extremity sarcoma patients with a continuous activity monitor: rationale and validation.

In addition to patient reported outcome measures, accelerometers may provide useful information on the outcome of sarcoma patients treated with limb salvage. The StepWatch (SW) Activity Monitor (SAM) is a two-dimensional accelerometer worn on the ankle that records an objective measure of walking performance. The purpose of this study was to validate the SW in a cross-sectional population of adult patients with lower extremity sarcoma treated with limb salvage. The main outcome was correlation of total steps with the Toronto Extremity Salvage Score (TESS). In a sample of 29 patients, a mean of 12 days of SW data was collected per patient (range 6-16), with 2767 average total steps (S.D. 1867; range 406-7437). There was a moderate positive correlation between total steps and TESS (r = 0.56, P = 0.002). Patients with osseous tumors walked significantly less than those with soft tissue sarcoma (1882 versus 3715, P < 0.01). This study supports the validity of the SAM as an activity monitor for the objective assessment of real world physical function in sarcoma patients.

Effect of insurance status on the rate of surgery following a meniscal tear.

BACKGROUND: Uninsured and underinsured Americans face barriers to access to medical care. The objective of this study was to characterize the effect of insurance status on whether patients with a torn meniscus proceed to elective arthroscopic knee surgery. METHODS: The records from January 2003 through April 2006 at a single academic orthopaedic surgery institution in Massachusetts were retrospectively reviewed to identify patients diagnosed with a meniscal tear and to determine whether surgery had been performed within six months after the diagnosis. Six categories of insurance were identified: private insurance, Workers' Compensation, Medicare, Medicaid, Uncompensated Care Pool, and self pay. A comparison of the proportions of insured and uninsured patients who underwent surgery was the primary outcome measure. RESULTS: A total of 1127 patients were identified, and 446 (40%) of them underwent surgery within six months after an office visit. The patients with and without surgery had similar age and sex distributions. When patients were divided, according to their insurance status, into insured and uninsured groups, no significant difference was found in the rate of surgery (p = 0.23). However, subgroup analysis revealed significant differences among the six insurance categories. Logistic regression analysis showed that patients in the self-pay group had a lower rate of surgery than those with private insurance (odds ratio, 0.33; 95% confidence interval, 0.14 to 0.75; p = 0.008), whereas patients receiving Workers' Compensation (odds ratio, 1.93; 95% confidence interval, 1.05 to 3.55; p = 0.034) and those receiving Medicaid (odds ratio, 1.63; 95% confidence interval, 1.09 to 2.42; p = 0.016) had higher surgical rates than those with private insurance. CONCLUSIONS: The rate of elective arthroscopic knee surgery for meniscal tears varied significantly for some insurance categories at this single academic institution in Massachusetts. Further work is necessary to clarify the patient and surgeon factors influencing these disparities in clinical decision-making.

'To prove this is the industry's best hope': big tobacco's support of research on the genetics of nicotine addiction.

BACKGROUND: New molecular techniques focus a genetic lens upon nicotine addiction. Given the medical and economic costs associated with smoking, innovative approaches to smoking cessation and prevention must be pursued; but can sound research be manipulated by the tobacco industry? METHODOLOGY: The chronological narrative of this paper was created using iterative reviews of primary sources (the Legacy Tobacco Documents), supplemented with secondary literature to provide a broader context. The empirical data inform an ethics and policy analysis of tobacco industry-funded research. FINDINGS: The search for a genetic basis for smoking is consistent with industry's decades-long plan to deflect responsibility away from the tobacco companies and onto individuals' genetic constitutions. Internal documents reveal long-standing support for genetic research as a strategy to relieve the tobacco industry of its legal responsibility for tobacco-related disease. CONCLUSIONS: Industry may turn the findings of genetics to its own ends, changing strategy from creating a 'safe' cigarette to defining a 'safe' smoker.