Prediction of total healthcare cost following total shoulder arthroplasty utilizing machine learning.

BACKGROUND: Given the increase in demand in treatment of glenohumeral arthritis with anatomic total (aTSA) and reverse shoulder arthroplasty (RTSA), it is imperative to improve quality of patient care while controlling costs as private and federal insurers continue its gradual transition toward bundled payment models. Big data analytics with machine learning shows promise in predicting health care costs. This is significant as cost prediction may help control cost by enabling health care systems to appropriately allocate resources that help mitigate the cause of increased cost. METHODS: The Nationwide Readmissions Database (NRD) was accessed in 2018. The database was queried for all primary aTSA and RTSA by International Classification of Diseases, Tenth Revision (ICD-10) procedure codes: 0RRJ0JZ and 0RRK0JZ for aTSA and 0RRK00Z and 0RRJ00Z for RTSA. Procedures were categorized by diagnoses: osteoarthritis (OA), rheumatoid arthritis (RA), avascular necrosis (AVN), fracture, and rotator cuff arthropathy (RCA). Costs were calculated by utilizing the total hospital charge and each hospital's cost-to-charge ratio. Hospital characteristics were included, such as volume of procedures performed by the respective hospital for the calendar year and wage index, which represents the relative average hospital wage for the respective geographic area. Unplanned readmissions within 90 days were calculated using unique patient identifiers, and cost of readmissions was added to the total admission cost to represent the short-term perioperative health care cost. Machine learning algorithms were used to predict patients with immediate postoperative admission costs greater than 1 standard deviation from the mean, and readmissions. RESULTS: A total of 49,354 patients were isolated for analysis, with an average patient age of 69.9 ± 9.6 years. The average perioperative cost of care was $18,843 ± $10,165. In total, there were 4279 all-cause readmissions, resulting in an average cost of $13,871.00 ± $14,301.06 per readmission. Wage index, hospital volume, patient age, readmissions, and diagnosis-related group severity were the factors most correlated with the total cost of care. The logistic regression and random forest algorithms were equivalent in predicting the total cost of care (area under the receiver operating characteristic curve = 0.83). CONCLUSION: After shoulder arthroplasty, there is significant variability in cumulative hospital costs, and this is largely affected by readmissions. Hospital characteristics, such as geographic area and volume, are key determinants of overall health care cost. When accounting for this, machine learning algorithms may predict cases with high likelihood of increased resource utilization and/or readmission.

Biceps Tenodesis Has Greater Expected Value Than Repair for Isolated Type II SLAP Tears: A Meta-analysis and Expected-Value Decision Analysis.

PURPOSE: To use an expected-value decision analysis to determine the optimal treatment decision between repair and biceps tenodesis (BT) for an isolated type II SLAP injury. METHODS: An expected-value decision analysis with sensitivity analysis was performed to systematically quantify the clinical decision. To determine outcome probabilities, a decision tree was constructed (repair vs BT) and a meta-analysis was conducted. To determine outcome utilities, we evaluated 70 patients with a chief complaint of shoulder pain regarding age, sex, Shoulder Activity Level, and visual analog scale score in terms of potential outcome preferences. Statistical fold-back analysis was performed to determine the optimal treatment. One-way sensitivity analysis determined the effect of changing the reinjury rate on the expected value of BT. RESULTS: The overall expected value was 8.66 for BT versus 7.19 for SLAP repair. One-way sensitivity analysis showed that BT was the superior choice if reinjury rates were expected to be lower than 28%. Meta-analysis of 23 studies and 908 patients revealed that the probability of a "well" outcome was significantly greater for BT (87.8%; 95% confidence interval [CI], 74.9%-94.6%; I2 = 0.0%) than for SLAP repair (62.9%; 95% CI, 55.9%-69.3%; I2 = 65.9%; P = .0023). The rate of reinjury was 1.5% for BT (95% CI, 0.05%-33.8%; I2 = 0.0%) and 6.4% for repair (95% CI, 4.2%-9.6%; I2 = 24%), which was not statistically significantly different (P = .411). A total of 50 participants (mean age, 25.4 years [standard deviation, 8.9 years]; 76% male patients; 50% overhead athletes) met the inclusion criteria. Forty-six percent of participants had a high Shoulder Activity Level score. CONCLUSIONS: Decision analysis showed that BT is preferred over repair for an isolated type II SLAP tear based on greater expected value of BT versus repair. Meta-analysis showed more frequent favorable outcomes with BT. Surgeons can use this information to tailor discussions with patients. LEVEL OF EVIDENCE: Level IV, meta-analysis of Level I-IV studies.

Relationship Between Clinical Scapular Assessment and Scapula Resting Position, Shoulder Strength, and Baseball Pitching Kinematics and Kinetics.

BACKGROUND: Scapular assessment is important in examining overhead athletes, but there is inconsistency in scapular clinical assessment and its relation to pathology. PURPOSE: To determine the relationship between clinical scapular assessment and biomechanical scapula resting position, shoulder strength, and pitching shoulder kinematics and kinetics. STUDY DESIGN: Descriptive laboratory study. METHODS: Two clinicians performed scapular assessments and graded the scapula as presence or absence of scapular dyskinesis. Shoulder external rotation (ER) and internal rotation (IR) strength were collected. The 3-dimensional biomechanics of the scapula resting position (upward/downward rotation, IR/ER, and anterior/posterior tilt) were assessed while participants stood at rest, and pitching kinematics (maximum shoulder ER, shoulder abduction, shoulder horizontal abduction, shoulder rotation velocity) and kinetics (maximum shoulder distraction force) were assessed when participants pitched off the portable pitching mound that was engineered to meet major league specifications. RESULTS: A total of 33 high school baseball pitchers (age, 16.3 ± 1.2 years; height, 184.0 ± 6.9 cm; weight, 76.8 ± 20.8 kg; hand dominance: left, 9 [27%]; right, 24 [73%]; pitch velocity, 34.7 ± 2.3 m/s) participated in this study. Of them, 15 participants had scapular dyskinesis, and 18 had normal scapulothoracic rhythm. No differences were observed for upward/downward rotation or anterior/posterior tilt, shoulder ER, shoulder abduction, or shoulder distraction force, based on the presence of scapular dyskinesis. Pitchers with scapular dyskinesis demonstrated significantly greater scapular resting IR position (effect size [ES], 0.80; 95% CI, 0.06 to 1.54; P = .020), greater nondominant shoulder ER to IR strength ratio (ES, 0.49; 95% CI, -0.02 to 1.00; P = .018), and decreased shoulder rotation velocity (ES, 14.66; 95% CI: 12.06 to 17.25; P = .016). Pitchers with greater anterior tilt demonstrated greater shoulder rotation velocity (r = -0.48; P = .006). CONCLUSION: Pitchers with scapular dyskinesis had greater scapular IR, greater nondominant shoulder ER to IR strength ratio, and reduced shoulder rotation velocity. CLINICAL RELEVANCE: Scapular assessment may be more influenced by differential IR than upward rotation or anterior tilt. Scapular dyskinesis has no competitive performance advantage among amateur athletes. Greater understanding is needed to decipher the critical threshold between beneficial and maladaptive scapular movement patterns.

Editorial Commentary: Early Operative Management of "Stable" Osteochondritis Dissecans Lesions Confers Greater Value in Skeletally Immature Patients.

The ideal treatment of juvenile osteochondritis dissecans (OCD) varies according to the chronicity of symptoms and radiographic classification. Traditionally, "stable" OCD lesions of the knee are managed conservatively with limited weight bearing and nonoperative care. However, this can require up to 6 to 12 months of observation, and success rates are estimated at only 59%. By contrast, recent data suggest that early subchondral drilling of OCD lesions may more consistently facilitate new vascular channels and remodeling of the compromised osteochondral unit. When considering overarching health care costs and probabilistic modeling, contemporary treatment paradigms may preferentially suggest early surgical treatment of OCD lesions for greater cost-effectiveness and an optimized timeline for a return to full activity. Additionally, surgery may be prioritized for larger lesions, atypical locations, closing physes, and/or the presence of mechanical symptoms.

Current Resident and Faculty Mentorship Satisfaction and Important Mentee Functions in Orthopedic Surgery: An American Orthopedic Association North American Traveling Fellowship Project.

OBJECTIVE: While mentorship remains important in orthopedic training, few studies have delineated specific priorities for creating successful mentorship programs and reciprocal satisfaction among contemporary trainees and faculty. The purpose of this study was to define beneficial mentor qualities along with specific mentee characteristics to facilitate improved mentoring relationships in orthopedic surgery. DESIGN: This is a cross-sectional study with a 16 multi-item self-reported survey. SETTING: This study was conducted at 11 tertiary orthopedic surgery training programs during the 2017 American Orthopaedic Association (AOA) North American Traveling Fellowship Tour. PARTICIPANTS: Eighty orthopedic resident trainees and 90 academic faculty members completed the survey. RESULTS: Around 55.0% of residents and 48.9% of faculty acknowledged a formal mentorship program at their institution. Furthermore, 61.3% of residents and 61.1% of faculty reported having a current mentor. The top 3 qualities valued by residents were a mentor who modeled work-life balance, remained in touch with contemporary issues in training, and provided timely counseling. Faculty valued a mentor who accepted their goals and priorities, provided counseling, and enhanced exposure in their subspecialty. Surveyed faculty were more satisfied than their corresponding residents with how their mentor promoted them, enhanced their exposure, was a friend, and protected them from exploitative collaborations. Mentee participation was considered the most important variable for a successful mentor relationship, while mentee acknowledgement of their mentors was the least prioritized quality. CONCLUSIONS: Faculty had a higher overall satisfaction with their mentoring relationships in orthopedic surgery. Residents reported more favorable results when their mentor was a role model of work-life balance. For optimal success, mentors identified active participation and openness to feedback as the most important quality for a mentee to display. These qualities contribute to a heightened sense of satisfaction among mentors and mentees and can be utilized to further guide development of both formal and informal programs for residents and faculty.

Orthopaedic Residency Training Structure: Implications on Quantity and Quality of Scholarship.

The objective of this analysis was to compare the efficiency of scholarly activity withinmilitary orthopaedic training programs. The authors obtained the lists of abstracts accepted for presentation at the 2009 through 2014 Society of Military Orthopaedic Surgeons (SOMOS) annual meetings. Data were extracted for each individual presentation. Three primary groups were compared: a traditional program, a research program, and a hybrid program. The hybrid program produced the highest percentage of the presentations (28.6%). The traditional program contributed the most presentations (3.32) and publications (2.16) per resident and had the highest publication rate (87.7%) and the shortest time to publication (14.4 months). The research program published in the highest average impact journals (3.2). The addition of a research year does not improve the number of academic presentations or published papers but may improve the impact factor of the journals in which the projects are published. (Journal of Surgical Orthopaedic Advances 28(3):175-179, 2019).

The 2017 American Orthopaedic Association North American Traveling Fellowship.

Initially established in 1967, the American Orthopaedic Association (AOA) North American Traveling Fellowship was designed to promote leadership development, network creation, and knowledge exchange among emerging leaders in orthopaedic surgery, and it remains one of the AOA's flagship tours. In 2017, the fellows visited 10 academic medical centers on the West Coast of Canada and the United States, participating in leadership, academic, clinical, and team-building activities. On the tour, we formed countless new friendships and collaborations, including exceptionally strong ones with each other. Because the 5 fellows came from diverse social, ethnic, religious, political, educational, and clinical backgrounds, the group discussions were lively and engaging. We all agree that the friendships that were made, the experiences that were encountered, and the lessons that were learned during the tour are priceless and will never be forgotten.

Open reduction and internal fixation (ORIF) versus ORIF and primary subtalar arthrodesis for complex displaced intraarticular calcaneus fractures: An expected value decision analysis.

OBJECTIVES: To determine the optimal patient-oriented treatment between open reduction and internal fixation (ORIF) with or without primary subtalar arthrodesis (PSTA) for patients with displaced intraarticular calcaneus fractures (DIACFs, OTA 82-C3 and C4). DESIGN: Expected value decision analysis. SETTING: Academic military treatment facility. PARTICIPANTS: One hundred randomly selected volunteers. INTERVENTION: Hypothetical clinical scenario involving ORIF versus ORIF with PSTA. MAIN OUTCOME MEASUREMENTS: Decision analysis was used to elucidate the superior treatment option based on expected patient values, composed of: the product of the average outcome probabilities established by previously published studies and the average ascribed patient utility values for each outcome probability. One-way sensitivity analysis was performed to quantify the amount of change required for the inferior treatment to equal or surpass the superior option. RESULTS: Expected values for ORIF and ORIF with PSTA were 8.96 and 18.06, respectively, favoring ORIF with PSTA. One-way sensitivity analysis was performed by artificially decreasing the rate of secondary fusion following isolated ORIF thus increasing its overall expected value. Adjusting the rate of secondary fusion to 0%, the expected value of ORIF with PSTA nearly doubled that of ORIF (18.06 vs 9.45). Similarly, when adjusting the moderate and severe complication rates following ORIF with PSTA to 100%, the expected value of ORIF with PSTA still exceeded that of ORIF (15.45 vs 8.96, and 13.52 vs 8.96, respectively). CONCLUSION: Expected value decision analysis favors ORIF with PSTA as the optimal treatment for complex DIACF.

Anterior Cruciate Ligament Graft Removal Versus Retention in the Setting of Septic Arthritis After Reconstruction: A Systematic Review and Expected Value Decision Analysis.

PURPOSE: To provide further guidance on the optimal decision between anterior cruciate ligament (ACL) graft removal versus retention in the setting of septic arthritis following reconstruction using an expected value decision analysis. METHODS: A systematic review and expected value decision analysis and sensitivity analyses were performed to quantify the clinical decision. A decision tree was created with 5 outcomes of interest: nonoperative complications, revision surgery, early reoperation, late reoperation, and "well." Pooled probabilities of each outcome were generated through a systematic literature review. We included only peer-reviewed studies, published in English, with at least 6 months of follow-up. One hundred randomly selected volunteers were given descriptions of the clinical scenario, the 2 treatment options, and outcomes of interest. Patients younger than 18 and older than 50 years and those previously treated for either ACL injury or septic arthritis, or both, were excluded from the analysis to minimize bias. These hypothetical patients indicated preferences for each outcome on a visual analog scale and responses were averaged to generate overall "utility values." Fold-back analysis summed products of pooled outcomes probabilities with respective averaged utility values. The resulting overall expected values for graft removal and debridement were compared, with the highest expected value considered to be superior. We then performed 1-way sensitivity analyses to mitigate sample bias. RESULTS: Fold-back analysis revealed graft removal to be strongly favored over retention, with overall expected values of 17.2 and 8.64, respectively. The most important contributor to the difference in overall expected values was late reoperation (8.59 vs 2.50 for removal and retention, respectively). Despite adjustments made to the rates of revision and early reoperation during the 1-way sensitivity analyses, graft removal remained the optimal strategy. CONCLUSIONS: This expected value decision analysis revealed that ACL graft removal was strongly favored by patients over graft retention in the setting of postoperative septic arthritis when consideration was given to the probabilities of wellness, nonoperative complications, revision surgery, early reoperation, and late reoperation. Sensitivity analysis revealed that although variation in rates of other outcomes did not impact this preference, the rate of late reoperation had a substantial impact. Only a sizable increase in the probability of late reoperation (from 0% to 60%) after graft removal would cause potential patients to favor graft retention. LEVEL OF EVIDENCE: Level IV, systematic review and decision analysis.

The Arthroscopy Association of North America Advanced Arthroscopy Traveling Fellowship: A 10-Year History.

In its brief 10-year existence, the Arthroscopy Association of North America Advanced Arthroscopy Traveling Fellowship has quickly established itself as the paramount educational experience for aspiring young surgeons in sports medicine and arthroscopy. The Traveling Fellowship is structured as a 10-day experience with visits to 3 host sites and culminates at the AANA Annual Meeting. With 4 selected fellows and an honorary "Godfather," the Traveling Fellowship affords a unique and invaluable opportunity to forge enduring friendships and rare mentorships with established leaders in the field of Arthroscopy. Potential applicants can anticipate not only developing their surgical acumen and aspects of clinical practice, but also assimilating key leadership skills, pearls on work-life balance, and a broader commitment to life-long education. The Dr. Don Johnson AANA Traveling Fellowship Alumni Group, named in honor of the two-time godfather and AANA Past President, represent an emerging class of leaders within AANA who are poised to contribute immensely to its mission of continuing medical education and collaboration.

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.