Physicians for Social Justice, Diversity and Equity: Take Action and Lead.

Physicians are in a position to take action and lead to actively mitigate against bias and discrimination. Social justice, diversity, and racial, gender, and SGM (sexual and gender minority) equity are sensitive issues. Few orthopaedic surgeons are minorities or female, and orthopaedic surgery is not perceived to be an inclusive specialty. This is an obstacle to equitable diverse hiring. As it takes almost 30 years to advance from preschool to orthopaedic fellowship graduation, we should advocate for educational equity beginning in early childhood. We should serve as role models for young people of all backgrounds and suggest that if they are dedicated and study hard, someday they too could become orthopaedic surgeons and researchers. Wherever possible, each of us in our own way and position should take a leadership role to resolve the disparities in our profession.

Letters to the Editor Highlight Current Controversies.

In 2018, Letters to the Editor of Arthroscopy were heated and helped point out the broiling topics in our field including ankle arthroscopy distraction technique versus no-distraction and dorsiflexion, knee anterolateral ligament reconstruction versus lateral extraarticular tenodesis, hip labral primary repair versus primary reconstruction, and shoulder stabilization technique cost-effectiveness.

Medical Device and Pharmaceutical Industry Employees as Medical Research Publication Authors.

As an editorial policy, medical device and pharmaceutical industry employees are generally permitted to publish original scientific research in Arthroscopy journal but are not permitted to publish systematic reviews. All authors complete the International Committee of Medical Journal Editors Form for Disclosure of Potential Conflicts of Interest, which are thoughtfully considered by our reviewers and editors and readers. In accord with the American Academy of Orthopaedic Surgeons, we believe that "manufacturers of medical devices, biologics, drugs, and other items use(d) in the care of the patient…play an important role in…the development of new technologies. This collaborative effort ensures that patients have the best outcomes through the invention and testing of new technology, research, and evaluation of existing technology." Our peer-review process mitigates against bias including but not limited to commercial bias in the interpretation of scientific research data. In the end, our goal is to publish the best science, and as above, industry plays "an important role in…(t)his collaborative effort."

Cost-Effective Medical Care Optimizes Value Over Time.

Researchers are encouraged to consider value (cost in addition to outcome) when analyzing the results of arthroscopic and related treatments. Given increasing health care costs, value calculations are critical, particularly in cases of clinical equipoise-uncertainty as to which of various treatment options is optimal. Value calculations must not be shortsighted, and rigor is required to determine direct costs as well as more obscure indirect costs. In addition, sometimes the published literature is ambiguous or conflicting with regard to outcomes. Thus, investigations of cost-effectiveness require sensitivity analyses, where a range of possible results for cost-effectiveness (i.e., the dependent variable) could be reported based on a range of values for the independent variables (costs or outcomes). What is more, value analyses should not be shortsighted; costs and outcomes must be considered over the long term. Ultimately, the most cost-effective treatments may be preferred.

Editorial Commentary: Arthroscopic Training and Proficiency Assessment Are Hot Topics.

Methods to measure operative skill are improving in quality. Arthroscopic surgical training and arthroscopic proficiency assessment are hot topics.

Cost-effectiveness analysis of primary arthroscopic stabilization versus nonoperative treatment for first-time anterior glenohumeral dislocations.

PURPOSE: The purpose of this study was to compare the cost-effectiveness of initial observation versus surgery for first-time anterior shoulder dislocation. METHODS: The clinical scenario of first-time anterior glenohumeral dislocation was simulated using a Markov model (where variables change over time depending on previous states). Nonoperative outcomes include success (no recurrence) and recurrence; surgical outcomes include success, recurrence, and complications of infection or stiffness. Probabilities for outcomes were determined from published literature. Costs were tabulated from Medicare Current Procedural Terminology data, as well as hospital and office billing records. We performed microsimulation and probabilistic sensitivity analysis running 6 models for 1,000 patients over a period of 15 years. The 6 models tested were male versus female patients aged 15 years versus 25 years versus 35 years. RESULTS: Primary surgery was less costly and more effective for 15-year-old boys, 15-year-old girls, and 25-year-old men. For the remaining scenarios (25-year-old women and 35-year-old men and women), primary surgery was also more effective but was more costly. However, for these scenarios, primary surgery was still very cost-effective (cost per quality-adjusted life-year, <$25,000). After 1 recurrence, surgery was less costly and more effective for all scenarios. CONCLUSIONS: Primary arthroscopic stabilization is a clinically effective and cost-effective treatment for first-time anterior shoulder dislocations in the cohorts studied. By use of a willingness-to-pay threshold of $25,000 per quality-adjusted life-year, surgery was more cost-effective than nonoperative treatment for the majority of patients studied in the model. LEVEL OF EVIDENCE: Level II, economic and decision analysis.

Allograft versus autograft decision for anterior cruciate ligament reconstruction: an expected-value decision analysis evaluating hypothetical patients.

PURPOSE: The purpose of this study was to determine the optimal decision between autograft and allograft for patients undergoing anterior cruciate ligament (ACL) reconstruction. METHODS: An expected-value decision analysis with sensitivity analysis was performed to systematically quantify the clinical decision. We evaluated 100 randomly selected individuals aged 16 to 70 years with regard to the following variables: age, sex, activity level (International Knee Documentation Committee form), and visual analog scale regarding potential outcome preferences. Patients with prior ACL injury were excluded. A decision tree was constructed (allograft v autograft potential outcomes), and a literature review determined probabilities of potential outcomes. Statistical fold-back analysis calculated optimal treatment. Sensitivity analysis determined the effect of changing the outcome probabilities on the decision. RESULTS: Of the subjects, 88 met the study inclusion criteria. The mean age was 44 years (range, 16 to 66 years), 67% of subjects were female, and the mean activity level was moderate. The expected value for autograft reconstruction was 11.22 versus 8.42 for allograft. Increasing the probability of complications associated with autograft (sensitivity analysis) decreased the expected value of autograft reconstruction. Significant limitations include that (1) decision analysis does not investigate actual patients in whom discussion of graft options between doctor and patient highly influences the decision and (2) patient decision largely depends on the information provided. CONCLUSIONS: Decision analysis shows that autograft is preferred over allograft for ACL surgical reconstruction. CLINICAL RELEVANCE: Patients' aversion to allograft tissue in general, and specific aversion to risk of disease transmission, results in a decision for ACL autograft, independent of expected outcomes.

Current concepts in clinical research: web-based, automated, arthroscopic surgery prospective database registry.

In 2011, postsurgical patient outcome data may be compiled in a research registry, allowing comparative-effectiveness research and cost-effectiveness analysis by use of Health Insurance Portability and Accountability Act-compliant, institutional review board-approved, Food and Drug Administration-approved, remote, Web-based data collection systems. Computerized automation minimizes cost and minimizes surgeon time demand. A research registry can be a powerful tool to observe and understand variations in treatment and outcomes, to examine factors that influence prognosis and quality of life, to describe care patterns, to assess effectiveness, to monitor safety, and to change provider practice through feedback of data. Registry of validated, prospective outcome data is required for arthroscopic and related researchers and the public to advocate with governments and health payers. The goal is to develop evidence-based data to determine the best methods for treating patients.

Cost-effectiveness analysis of the most common orthopaedic surgery procedures: knee arthroscopy and knee anterior cruciate ligament reconstruction.

PURPOSE: The purpose of this study was to determine the cost-effectiveness of knee arthroscopy and anterior cruciate ligament (ACL) reconstruction. METHODS: Retrospective analysis of prospectively collected data from a single-surgeon, institutional review board-approved outcomes registry included 2 cohorts: surgically treated knee arthroscopy and ACL reconstruction patients. Our outcome measure is cost-effectiveness (cost of a quality-adjusted life-year [QALY]). The QALY is calculated by multiplying difference in health-related quality of life, before and after treatment, by life expectancy. Health-related quality of life is measured by use of the Quality of Well-Being scale, which has been validated for cost-effectiveness analysis. Costs are facility charges per the facility cost-to-charges ratio plus surgeon fee. Sensitivity analyses are performed to determine the effect of variations in costs or outcomes. RESULTS: There were 93 knee arthroscopy and 35 ACL reconstruction patients included at a mean follow-up of 2.1 years. Cost per QALY was $5,783 for arthroscopy and $10,326 for ACL reconstruction (2009 US dollars). Sensitivity analysis shows that our results are robust (relatively insensitive) to variations in costs or outcomes. CONCLUSIONS: Knee arthroscopy and knee ACL reconstruction are very cost-effective.

Operative versus nonoperative treatment of anterior cruciate ligament rupture in patients aged 40 years or older: an expected-value decision analysis.

PURPOSE: Our purpose was to determine the optimal treatment of anterior cruciate ligament (ACL) rupture in patients aged 40 years or older. METHODS: Our method was expected-value decision analysis with sensitivity analysis, which is a systematic tool for quantitating clinical decisions. We evaluated 100 randomly selected individuals aged 40 years or older with regard to the following variables: age, gender, activity level (International Knee Documentation Committee form), and visual analog scale regarding potential outcome preferences. Patients with prior knee injury or surgery were excluded. A decision tree was constructed (operative v nonoperative potential outcomes). Literature review determined probabilities of outcomes. Statistical fold-back analysis calculated optimal treatment. Sensitivity analysis determined the effect of changing the outcome probabilities on the decision. RESULTS: This study included 69 patients (31 with prior knee injury or surgery were excluded). The mean age was 53 years (range, 40 to 80 years), 48% were men, and the activity level was normally distributed (with a slight lower activity skew as anticipated for an older population). The expected value for operative treatment was 7.99 versus 1.86 for nonoperative treatment. Increasing the probability of surgical complications (sensitivity analysis) decreased the expected value of operative treatment but not below the expected value of nonoperative treatment. CONCLUSIONS: Decision analysis shows that surgery is the optimal treatment of ACL rupture in patients aged 40 years or older. A limitation is that, by convention, decision analysis does not investigate actual patients with the condition. CLINICAL RELEVANCE: Individuals aged 40 years or older are extremely averse to accepting potential knee instability during pivoting and thus prefer ACL surgery despite the risk of surgical complications.

Ex vivo comparison of mechanical versus thermal chondroplasty: assessment of tissue effect at the surgical endpoint.

PURPOSE: The purpose of this study was to evaluate tissue effect (tissue removal plus underlying cell death) of two chondroplasty techniques: mechanical debridement (MD) using a rotary shaver blade and thermal chondroplasty using radiofrequency energy (RFE). METHODS: Forty-eight human chondromalacic cartilage samples were treated with either MD or RFE. Pre- and post-treatment arthroscopic images of the cartilage surface were recorded. Samples were incubated with cell viability stain and visualized with confocal laser microscopy to determine tissue effect. Smoothing was quantitated by three surgeons using a visual analog scale (VAS) as well as a subjective rating regarding whether smoothing was "arthroscopically acceptable." RESULTS: Tissue effect at the surgical endpoint of arthroscopically acceptable smoothing was 385 microm for MD versus 236 microm for RFE, a significant difference (P < .0001). Mean post-treatment VAS for MD was 2.8 points less smooth than for RFE (P < .0001). Overall, arthroscopically acceptable smoothing was achieved in 90% of RFE samples compared to 49% of MD samples. CONCLUSIONS: Our results shown that chondroplasty using a RFE probe results in greater smoothing of chondromalacic cartilage in fewer treatment passes and with decreased total tissue effect than MD using a rotary shaver blade. CLINICAL RELEVANCE: If safety and efficacy can be shown in vivo, thermal chondroplasty may represent an alternative for treatment of symptomatic chondromalacia.