Early Surgery for Partial Tears of the Ulnar Collateral Ligament May Be More Cost-Effective and Result in Longer Playing Careers Than Nonoperative Management for High-Level Baseball Pitchers: A Decision-Analytic Markov Model-Based Analysis.

BACKGROUND: Nonoperative management versus early reconstruction for partial tears of the medial ulnar collateral ligament (MUCL) remains controversial, with the most common treatment options for partial tears consisting of rest, rehabilitation, platelet-rich plasma (PRP), and/or surgical intervention. However, whether the improved outcomes reported for treatments such as MUCL reconstruction (UCLR) or nonoperative management with a series of PRP injections justifies their increased upfront costs remains unknown. PURPOSE: To compare the cost-effectiveness of an initial trial of physical therapy alone, an initial trial of physical therapy plus a series of PRP injections, and early UCLR to determine the preferred cost-effective treatment strategy for young, high-level baseball pitchers with partial tears of the MUCL and with aspirations to continue play at the next level (ie, collegiate and/or professional). STUDY DESIGN: Economic and decision analysis; Level of evidence, 2. METHODS: A Markov chain Monte Carlo probabilistic model was developed to evaluate the outcomes and costs of 1000 young, high-level, simulated pitchers undergoing nonoperative management with and without PRP versus early UCLR for partial MUCL tears. Utility values, return to play rates, and transition probabilities were derived from the published literature. Costs were determined based on the typical patient undergoing each treatment strategy at the authors' institution. Outcome measures included costs, acquired playing years (PYs), and the incremental cost-effectiveness ratio (ICER). RESULTS: The mean total costs resulting from nonoperative management without PRP, nonoperative management with PRP, and early UCLR were $22,520, $24,800, and $43,992, respectively. On average, early UCLR produced an additional 4.0 PYs over the 10-year time horizon relative to nonoperative management, resulting in an ICER of $5395/PY, which falls well below the $50,000 willingness-to-pay threshold. Overall, early UCLR was determined to be the preferred cost-effective strategy in 77.5% of pitchers included in the microsimulation model, with nonoperative management with PRP determined to be the preferred strategy in 15% of pitchers and nonoperative management alone in 7.5% of pitchers. CONCLUSION: Despite increased upfront costs, UCLR is a more cost-effective treatment option for partial tears of the MUCL than an initial trial of nonoperative management for most high-level baseball pitchers.

Availability of Consumer Prices for Arthroscopic Meniscus Surgery.

The purpose is to examine the availability of consumer pricing information for arthroscopic meniscal surgery in the United States. Secondary objectives were comparing the price of meniscal repair to meniscectomy and regional pricing differences. Orthopaedic sports medicine clinics were sorted by state and randomly selected from American Orthopaedic Society for Sports Medicine's online directory. Following standardized script, each clinic was called a maximum of three times to obtain pricing information for meniscal surgery. A total of 1,008 distinct orthopaedic sport medicine practices were contacted. Six (6%) clinics were able to provide complete bundle pricing, and 183 (18.2%) clinics were able to provide physician-only fees for either meniscectomy or meniscal repair. Physician-only fees and bundle pricing were significantly less for meniscal repairs as compared to meniscectomies. There were no geographic regional differences in pricing for physician-only fees. There is a paucity of information regarding price transparency for arthroscopic meniscal surgery. (Journal of Surgical Orthopaedic Advances 32(2):083-087, 2023).

Platelet-Rich Plasma and Marrow Venting May Serve as Cost-Effective Augmentation Techniques for Isolated Meniscal Repair: A Decision-Analytical Markov Model-Based Analysis.

PURPOSE: To evaluate the cost-effectiveness of 3 isolated meniscal repair (IMR) treatment strategies: platelet-rich plasma (PRP)-augmented IMR, IMR with a marrow venting procedure (MVP), and IMR without biological augmentation. METHODS: A Markov model was developed to evaluate the baseline case: a young adult patient meeting the indications for IMR. Health utility values, failure rates, and transition probabilities were derived from the published literature. Costs were determined based on the typical patient undergoing IMR at an outpatient surgery center. Outcome measures included costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER). RESULTS: Total costs of IMR with an MVP were $8,250; PRP-augmented IMR, $12,031; and IMR without PRP or an MVP, $13,326. PRP-augmented IMR resulted in an additional 2.16 QALYs, whereas IMR with an MVP produced slightly fewer QALYs, at 2.13. Non-augmented repair produced a modeled gain of 2.02 QALYs. The ICER comparing PRP-augmented IMR versus MVP-augmented IMR was $161,742/QALY, which fell well above the $50,000 willingness-to-pay threshold. CONCLUSIONS: IMR with biological augmentation (MVP or PRP) resulted in a higher number of QALYs and lower costs than non-augmented IMR, suggesting that biological augmentation is cost-effective. Total costs of IMR with an MVP were significantly lower than those of PRP-augmented IMR, whereas the number of additional QALYs produced by PRP-augmented IMR was only slightly higher than that produced by IMR with an MVP. As a result, neither treatment dominated over the other. However, because the ICER of PRP-augmented IMR fell well above the $50,000 willingness-to-pay threshold, IMR with an MVP was determined to be the overall cost-effective treatment strategy in the setting of young adult patients with isolated meniscal tears. LEVEL OF EVIDENCE: Level III, economic and decision analysis.

Understanding risk for early dislocation resulting in reoperation within 90 days of reverse total shoulder arthroplasty: extreme rare event detection through cost-sensitive machine learning.

BACKGROUND: Reliable prediction of postoperative dislocation after reverse total shoulder arthroplasty (RSA) would inform patient counseling as well as surgical and postoperative decision making. Understanding interactions between multiple risk factors is important to identify those patients most at risk of this rare but costly complication. To better understand these interactions, a game theory-based approach was undertaken to develop machine learning models capable of predicting dislocation-related 90-day readmission following RSA. MATERIAL & METHODS: A retrospective review of the Nationwide Readmissions Database was performed to identify patients who underwent RSA between 2016 and 2018 with a subsequent readmission for prosthetic dislocation. Of the 74,697 index procedures included in the data set, 740 (1%) experienced a dislocation resulting in hospital readmission within 90 days. Five machine learning algorithms were evaluated for their ability to predict dislocation leading to hospital readmission within 90 days of RSA. Shapley additive explanation (SHAP) values were calculated for the top-performing models to quantify the importance of features and understand variable interaction effects, with hierarchical clustering used to identify cohorts of patients with similar risk factor combinations. RESULTS: Of the 5 models evaluated, the extreme gradient boosting algorithm was the most reliable in predicting dislocation (C statistic = 0.71, F2 score = 0.07, recall = 0.84, Brier score = 0.21). SHAP value analysis revealed multifactorial explanations for dislocation risk, with presence of a preoperative humerus fracture; disposition involving discharge or transfer to a skilled nursing facility, intermediate care facility, or other nonroutine facility; and Medicaid as the expected primary payer resulting in strong, positive, and unidirectional effects on increasing dislocation risk. In contrast, factors such as comorbidity burden, index procedure complexity and duration, age, sex, and presence or absence of preoperative glenohumeral osteoarthritis displayed bidirectional influences on risk, indicating potential protective effects for these variables and opportunities for risk mitigation. Hierarchical clustering using SHAP values identified patients with similar risk factor combinations. CONCLUSION: Machine learning can reliably predict patients at risk for postoperative dislocation resulting in hospital readmission within 90 days of RSA. Although individual risk for dislocation varies significantly based on unique combinations of patient characteristics, SHAP analysis revealed a particularly at-risk cohort consisting of young, male patients with high comorbidity burdens who are indicated for RSA after a humerus fracture. These patients may require additional modifications in postoperative activity, physical therapy, and counseling on risk-reducing measures to prevent early dislocation after RSA.

Patient-Reported Outcomes Measurement Information System (PROMIS) Instruments Correlate Better With Legacy Measures in Knee Cartilage Patients at Postoperative Than at Preoperative Assessment.

PURPOSE: To define the psychometric properties of the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), Pain Interference (PI), and Depression computer adaptive tests (CATs) in patients undergoing knee cartilage surgical procedures. METHODS: The PROMIS PF, PI, and Depression CATs were administered preoperatively and at 6 months alongside legacy knee patient-reported outcome measures (PROMs) in patients undergoing knee cartilage surgical procedures. Statistical analysis consisted of the time to completion, psychometric analysis for correlative strengths, absolute and relative floor and ceiling effects, and Cohen effect size. RESULTS: Our study included 250 patients (57.2% male patients), averaging 1.87, 1.53, and 1.91 minutes for completion of the PF, PI, and Depression CATs, respectively. Preoperatively, the PROMIS PF and PI CATs showed wide ranges of correlation coefficients with respect to function (r = 0.14-0.72 and r = 0.29-0.77, respectively) and health-related quality-of-life PROMs (r = 0.64-0.70). At 6 months, the PROMIS PF CAT (r = 0.82-0.93) and PI CAT (r = 0.77-0.93) both exhibited excellent correlations with respect to legacy function and health-related quality-of-life PROMs except for the Marx Activity Rating Scale (r = 0.36-0.44). None of the PROMIS instruments exhibited any significant floor or ceiling effects. CONCLUSIONS: The PROMIS PF, PI, and Depression CATs performed better with respect to legacy PROMs in the postoperative period than the preoperative period. In addition, the PROMIS PF and PI measures performed best with respect to the International Knee Documentation Committee questionnaire, and no floor or ceiling effects were identified for the PROMIS instruments. The PROMIS instruments may be more suited to track outcomes postoperatively than to establish preoperative baselines in cartilage surgery patients. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Cost analysis of Tommy John surgery for Major League Baseball teams.

BACKGROUND: The economic loss following ulnar collateral ligament reconstruction (UCLR) in Major League Baseball (MLB) pitchers has not been evaluated. The purpose of this study is to quantify the financial impact of UCLR on MLB teams. We hypothesize that MLB teams incur significant losses annually as a result of salaries paid to injured players following reconstruction. METHODS: Public records were accessed to identify MLB pitchers from January 1, 2004, to December 31, 2014, who had undergone UCLR. Contract terms and time away from competition were used to approximate economic loss. Successful return was considered when a pitcher returned to play in at least 1 Minor League Baseball (MiLB) or MLB game. RESULTS: One hundred ninety-four MLB pitchers underwent UCLR from 2004 to 2014, missing on average 180.2 days of the MLB regular season. Cost of recovery (COR) amounted to $395 million, averaging $1.9 million per player. Starting pitchers accounted for the largest total COR at $239.6 million, whereas closers had the largest economic loss per player ($3.9 million/player). Only 77% of pitchers returned to MLB play. CONCLUSION: UCLR has a substantial economic impact on MLB teams. Starting pitchers represented a majority of team cost, but closers represented higher costs per pitcher.

The Impact of Workers' Compensation on Patient-Reported Outcomes Measurement Information System Upper Extremity and Legacy Outcome Measures in Patients Undergoing Arthroscopic Rotator Cuff Repair.

PURPOSE: To examine the preoperative performance of the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) Computer Adaptive Test (CAT) with respect to legacy scores in patients receiving rotator cuff repair (RCR). In addition, to define the impact of Workers' Compensation (WC) status on both performance and floor and ceiling effects. METHODS: The PROMIS UE CAT was administered preoperatively alongside legacy patient-reported outcome measures (PROMs) to patients undergoing isolated arthroscopic RCR from November 2017 to September 2018. Performance was assessed using Spearman correlation coefficients, and floor and ceiling effects were examined. RESULTS: One hundred twenty-two patients (WC, n = 32; non-WC, n = 90; 62.3% male, 53.6 ± 11.5 years) were included. PROMs assessing physical function (r = 0.41-0.77) correlated more strongly to the PROMIS UE CAT than did multidomain or mental health PROMs (r = 0.25-0.61). In WC patients, the PROMIS UE CAT demonstrated diminished correlative strength relative to shoulder function PROMs. WC patients also demonstrated relative floor effects for Single Assessment Numerical Evaluation (SANE; 18.8%) and Constant-Murley (15.6%) and relative ceiling effects for the Brief Resilience Scale (53.1%), Short Form 12 Mental Component Score (50%), and Veterans Rand 12 Mental Component Score (53.1%) and were more likely to report the minimum SANE score (P < .01) and the maximum Brief Resilience Scale score (P < .01). No absolute or relative floor/ceiling effects for the PROMIS UE CAT were found. CONCLUSIONS: Compared with a non-WC cohort, WC patients have significantly lower preoperative PROMIS UE CAT scores, are more likely to report the absolute minimum and maximum scores for various PROMs, and demonstrated relative floor and ceiling effects for PROMs assessing mental health. The absence of significant floor/ceiling effects for the PROMIS UE CAT may suggest improved outcome discrimination and may support the adoption of PROMIS UE for the assessment of functional status in WC patients with rotator cuff pathology. LEVEL OF EVIDENCE: Level III, retrospective comparative trial.

Assessment of Elbow Torque and Other Parameters During the Pitching Motion: Comparison of Fastball, Curveball, and Change-up.

PURPOSE: To assess the precision of a new wearable device in detecting medial elbow torque during the pitching motion in competitive baseball pitchers and to determine the differences in torque across pitch types and thrower demographic characteristics. METHODS: High school and collegiate baseball pitchers were recruited from August 1, 2016, to January 31, 2017, through direct request by athletic trainers and coaches. Body dimensions and throwing arm measurements of the participants were collected. The sensor was positioned directly over the medial elbow and pitchers were instructed to throw 8 fastballs, 8 curveballs, and 8 change-ups in a standard, randomized sequence. The sensor reported elbow torque, arm speed, arm slot, and shoulder rotation, whereas a radar gun measured peak ball velocity. Precision was calculated by measuring outlier rate, and mixed model regression analysis was performed to detect differences in throwing biomechanics among pitch types. RESULTS: In total, 37 competitive baseball pitchers were included in the study. The device had a precision of 96.9% for fastballs, 96.9% for curveballs, and 97.9% for change-ups. The device was sensitive enough to distinguish pitches according to elbow torque, arm speed, arm slot, and shoulder rotation. Fastballs caused the greatest relative torque across the medial elbow (average = 45.56 N m), compared with change-ups (43.77 N m; P = .006) and curveballs (43.83 N m; P = .01). Ball velocity contributed most to medial elbow torque (P = .003), followed by elbow circumference (P = .021), where smaller elbow circumference predicted greater medial elbow torque. CONCLUSIONS: The sensor is a precise and reproducible device for measuring torque across the medial elbow, as well as additional parameters of arm speed, arm slot, and shoulder rotation. Torque was significantly relatively higher in fastballs than curveballs and change-ups. LEVEL OF EVIDENCE: Level III, comparative study.

Patient Perceptions of Reimbursement for Arthroscopic Meniscectomy and Anterior Cruciate Ligament Reconstruction.

Historically, patient perceptions of surgeon reimbursement have been exaggerated compared with actual reimbursement. There is limited information about patient perceptions of physician reimbursement for arthroscopic meniscectomy and anterior cruciate ligament (ACL) reconstruction. This study evaluated patient perceptions of physician reimbursement for these procedures and compared perceptions of health care reform between urban and suburban clinics. Surveys were given to 231 consecutive patients, and patients were asked how much they believed a surgeon should be reimbursed for arthroscopic meniscectomy and ACL reconstruction as well as their perception of actual Medicare reimbursement to physicians. Patients were then informed of the actual reimbursement rates and asked additional questions about health care reform. Survey responses were compared in an urban setting vs a suburban setting. On average, patients reported that surgeons should receive $8096 for meniscectomy and $11,794 for ACL reconstruction. Patients estimated that Medicare paid physicians $5442 for meniscectomy and $6667 for ACL reconstruction. In addition, 65% of patients believed that reimbursement for meniscectomy was too low, and 57% of patients believed that reimbursement for ACL reconstruction was too low. Fewer than 2% of patients believed that surgeon salaries should be cut, and 75% believed that orthopedic surgeons should be paid more for subspecialty training. No differences were found in patients' perceptions of reimbursement or health care reform between urban and suburban settings. Patients perceived that the values of meniscectomy and ACL reconstruction were substantially higher than current Medicare reimbursement values and that surgeon salaries should not be cut. [Orthopedics. 2016; 39(5):e904-e910.].

Pain Assessment After Anterior Cruciate Ligament Reconstruction: Bone-Patellar Tendon-Bone Versus Hamstring Tendon Autograft.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction is a common outpatient procedure that is accompanied by significant postoperative pain. PURPOSE: To determine differences in acute pain levels between patients undergoing ACL reconstruction with bone-patellar tendon-bone (BTB) versus hamstring tendon (HS) autograft. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 70 patients who underwent primary ACL reconstruction using either BTB or HS autografts consented to participate. The primary outcome of the study was postoperative pain levels (visual analog scale), which were collected immediately after surgery and for 3 days postoperatively. Secondary outcome measures included opioid consumption (intravenous morphine equivalents), hours slept, patient satisfaction, reported breakthrough pain, and calls to the physician. RESULTS: Patients treated with BTB had increased pain when compared with those treated with HS in the acute postoperative period (mean ± SD: day 0, 6.0 ± 1.7 vs 5.2 ± 2.0 [P = .066]; day 1, 5.9 ± 1.7 vs 4.9 ±1.7 [P = .024]; day 2, 5.2 ± 1.9 vs 4.1 ± 2.0 [P = .032]; day 3, 4.8 ± 2.1 vs 3.9 ± 2.3 [P = .151]). There were also significant increases in reported breakthrough pain (day 0, 76% vs 43% [P = .009]; day 1, 64% vs 35% [P = .003]) and calls to the physician due to pain (day 1, 19% vs 0% [P = .041]) in the BTB group. There were no significant differences in narcotic requirements or sleep disturbances. Overall, the BTB group reported significantly less satisfaction with pain management on days 0 and 1 (P = .024 and .027, respectively). CONCLUSION: A significant increase in acute postoperative pain was found when performing ACL reconstruction with BTB compared with HS. Patients treated with BTB were more likely to have breakthrough pain, decreased satisfaction with their pain management, and to contact their physician due to pain. These findings suggest a difference in early postoperative pain between the 2 most common graft options for ACL reconstruction. Patients should be informed of the differences in acute postoperative pain when deciding on graft choice with their physician.