Comparison of Long-Term Healthcare Cost and Utilisation of Nonoperative and Surgical Management of Thumb CMC Arthritis.

Background: Thumb carpometacarpal joint (CMC) osteoarthritis is the most symptomatic hand arthritis but the long-term healthcare burden for managing this condition is unknown. We sought to compare total healthcare cost and utilisation for operative and nonoperative treatments of thumb CMC arthritis. Methods: We conducted a retrospective longitudinal analysis using a large nationwide insurance claims database. A total of 18,705 patients underwent CMC arthroplasty (trapeziectomy with or without ligament reconstruction tendon interposition) or steroid injections between 1 October 2015 and 31 December 2018. Primary outcomes, healthcare utilisation and costs were measured from 1 year pre-intervention to 3 years post-intervention. Generalised linear mixed effect models adjusted for potentially confounding factors such as the Elixhauser comorbidity score with propensity score matching were applied to evaluate the association between the primary outcomes and treatment type. Results: A total of 13,646 patients underwent treatment through steroid injections, and 5,059 patients underwent CMC arthroplasty. At 1 year preoperatively, the surgery group required $635 more healthcare costs (95% CI [594.28, 675.27]; p < 0.001) and consumed 42% more healthcare utilisation (95% CI [1.38, 1.46]; p < 0.0001) than the steroid injection group. At 3 years postoperatively, the surgery group required $846 less healthcare costs (95% CI [-883.07, -808.51], p < 0.0001) and had 51% less utilisation (95% CI [0.49, 0.53]; p < 0.0001) annually. Cumulatively over 3 years, the surgical group on average was $4,204 costlier than its counterpart secondary to surgical costs. Conclusions: CMC arthritis treatment incurs high healthcare cost and utilisation independent of other medical comorbidities. At 3 years postoperatively, the annual healthcare cost and utilisation for surgical patients were less than those for patients who underwent conservative management, but this difference was insufficient to offset the initial surgical cost. Level of Evidence: Level III (Therapeutic).

Does psychological distress predict risk of orthopaedic surgery and postoperative opioid prescribing in patients with hip pain? A retrospective study.

BACKGROUND: Clinicians and public health professionals have allocated resources to curb opioid over-prescription and address psychological needs among patients with musculoskeletal pain. However, associations between psychological distress, risk of surgery, and opioid prescribing among those with hip pathologies remain unclear. METHODS: Using a retrospective cohort study design, we identified patients that were evaluated for hip pain from January 13, 2020 to October 27, 2021. Patients' surgical histories and postoperative opioid prescriptions were extracted via chart review. Risk of hip surgery within one year of evaluation was analyzed using multivariable logistic regression. Multivariable linear regression was employed to predict average morphine milligram equivalents (MME) per day of opioid prescriptions within the first 30 days after surgery. Candidate predictors included age, gender, race, ethnicity, employment, insurance type, hip function and quality of life on the International Hip Outcome Tool (iHOT-12), and psychological distress phenotype using the OSPRO Yellow Flag (OSPRO-YF) Assessment Tool. RESULTS: Of the 672 patients, n = 350 (52.1%) underwent orthopaedic surgery for hip pain. In multivariable analysis, younger patients, those with TRICARE/other government insurance, and those with a high psychological distress phenotype had higher odds of surgery. After adding iHOT-12 scores, younger patients and lower iHOT-12 scores were associated with higher odds of surgery, while Black/African American patients had lower odds of surgery. In multivariable analysis of average MME, patients with periacetabular osteotomy (PAO) received opioid prescriptions with significantly higher average MME than those with other procedures, and surgery type was the only significant predictor. Post-hoc analysis excluding PAO found higher average MME for patients undergoing hip arthroscopy (compared to arthroplasty or other non-PAO procedures) and significantly lower average MME for patients with public insurance (Medicare/Medicaid) compared to those with private insurance. Among those only undergoing arthroscopy, older age and having public insurance were associated with opioid prescriptions with lower average MME. Neither iHOT-12 scores nor OSPRO-YF phenotype assignment were significant predictors of postoperative mean MME. CONCLUSIONS: Psychological distress characteristics are modifiable targets for rehabilitation programs, but their use as prognostic factors for risk of orthopaedic surgery and opioid prescribing in patients with hip pain appears limited when considered alongside other commonly collected clinical information such as age, insurance, type of surgery pursued, and iHOT-12 scores.

Cost-effectiveness and cost-utility of the ball-and-socket trapeziometacarpal prosthesis compared to trapeziectomy and ligament reconstruction: study protocol for a randomized controlled clinical trial.

BACKGROUND: Trapeziometacarpal (TMC) osteoarthritis (OA) is a common cause of pain and weakness during thumb pinch leading to disability. There is no consensus about the best surgical treatment in unresponsive cases. The treatment is associated with costs and the recovery may take up to 1 year after surgery depending on the procedure. No randomized controlled trials have been conducted comparing ball and socket TMC prosthesis to trapeziectomy with ligament reconstruction. METHODS: A randomized, blinded, parallel-group superiority clinical trial comparing trapeziectomy with abductor pollicis longus (APL) arthroplasty and prosthetic replacement with Maïa® prosthesis. Patients, 18 years old and older, with a clinical diagnosis of unilateral or bilateral TMC OA who fulfill the trial's eligibility criteria will be invited to participate. The diagnosis will be made by experienced hand surgeons based on symptoms, clinical history, physical examination, and complementary imaging tests. A total of 106 patients who provide informed consent will be randomly assigned to treatment with APL arthroplasty and prosthetic replacement with Maïa® prosthesis. The participants will complete different questionnaires including EuroQuol 5D-5L (EQ-5D-5L), the Quick DASH, and the Patient Rated Wrist Evaluation (PRWE) at baseline, at 6 weeks, and 3, 6, 12, 24, 36, 48, and 60 months after surgical treatment. The participants will undergo physical examination, range of motion assessment, and strength measure every appointment. The trial's primary outcome variable is the change in the visual analog scale (VAS) from baseline to 12 months. A long-term follow-up analysis will be performed every year for 5 years to assess chronic changes and prosthesis survival rate. The costs will be calculated from the provider's and society perspective using direct and indirect medical costs. DISCUSSION: This is the first randomized study that investigates the effectiveness and cost-utility of trapeziectomy and ligament reconstruction arthroplasty and Maïa prosthesis. We expect the findings from this trial to lead to new insights into the surgical approach to TMC OA. TRIAL REGISTRATION: ClinicalTrials.gov NCT04562753. Registered on June 15, 2020.

Assessment of upper airway changes after interpositional arthroplasty: a cephalometric analysis.

This prospective cohort study examined the changes in airway area and soft tissue parameters following interpositional arthroplasty for temporomandibular joint (TMJ) ankylosis. Ten patients with TMJ ankylosis underwent surgery, and preoperative and postoperative skeletal and soft tissue measurements were obtained. A significant rise in soft tissue parameters was observed following surgery, although only minor changes in skeletal parameters were seen. The nasoropharyngeal area, oral area, soft palate area, and tongue area were examined. After the surgery, increases in values were observed in the nasoropharyngeal area (from 3482.4 mm2 to 3618.7 mm2), the oral area (from 2731.8 mm2 to 2840.8 mm2), the soft palate area (from 204.9 mm2 to 217.3 mm2), and the tongue area (from 2577.5 mm2 to 2600.8 mm2). These findings suggest that interpositional arthroplasty can improve airway area and soft tissue dimensions, affecting the stomatognathic system's aesthetic and functional aspects. Further research is needed to validate these results and assess long-term stability.

3D-printed antibiotic-loaded bone cement spacers as adjunctive therapy for hip periprosthetic infection after arthroplasty: A clinical assessment.

OBJECTIVE: To explore the effect of three-dimensional (3D) printing to create personalized antibiotic-loaded bone cement (ALBC) spacers to assist in treatment of periprosthetic infection after total hip arthroplasty (THA). METHODS: The data of 40 patients with postoperative infection after THA were analysed retrospectively. The patients were divided into two groups: the 3D-printing group (age 47-78 years, n = 20) and the conventional group (age 57-78 years, n = 20). In stage I surgery, 3D-printed silicone moulds were used to create ALBC spacers for the 3D-printing group, while traditional manual methods were used to create spacers for the conventional group. After the infection was controlled, both groups underwent conventional hip revision surgery (stage II surgery). All patients were evaluated using the Harris Hip Score (HHS) (primary outcome) for hip function. RESULTS: All 40 patients had follow-up data from 3 months after stage I surgery and 12 months after stage II surgery. The intergroup difference in HHS was 11.25 points [97.5% confidence interval (CI) 7.92-14.58; P < 0.01] at 3 months after stage I surgery, and 9.15 points (97.5% CI 4.82-13.48; P < 0.01) at 12 months after stage II surgery. The overall difference between the two groups was 9.55 points (97.5% CI 5.83-13.27; P < 0.01), which was significant (P < 0.05). CONCLUSION: During the follow-up period, the hip function of the 3D-printing group was superior to that of the conventional group following the treatment of infections after THA.

A prospective study of lumbar facet arthroplasty in the treatment of degenerative spondylolisthesis and stenosis: cost-effective assessment from the Total Posterior Spine system (TOPSTM) IDE Study: 2-year model revision and sensitivity analyses based on 305 subjects.

BACKGROUND CONTEXT: A previous cost-effectiveness analysis published in 2022 found that the Total Posterior Spine (TOPSTM) system was dominant over transforaminal lumbar interbody fusion (TLIF). This analysis required updating to reflect a more complete dataset and pricing considerations. PURPOSE: To evaluate the cost-effectiveness of TOPSTM system as compared with TLIF based on an updated and complete FDA investigational device exemption (IDE) data set. STUDY DESIGN/SETTING: Cost-utility analysis of the TOPSTM system compared to TLIF. PATIENT SAMPLE: A multicenter, FDA IDE, randomized control trial (RCT) investigated the efficacy of TOPSTM compared to TLIF with a current population of n=305 enrolled and n=168 with complete 2-year follow-up. OUTCOME MEASURES: Cost and quality adjusted life years (QALYs) were calculated to determine our primary outcome measure, the incremental cost-effectiveness ratio. Secondary outcome measures included: net monetary benefit as well at willingness-to-pay (WTP) thresholds. METHODS: The primary outcome of cost-effectiveness is determined by incremental cost-effectiveness ratio. A Markov model was used to simulate the health outcomes and costs of patients undergoing TOPSTM or TLIF over a 2-year period. alternative scenario sensitivity analysis, one-way sensitivity analysis, and probabilistic sensitivity analysis were conducted to assess the robustness of the model results. RESULTS: The updated base case result demonstrated that TOPSTM was immediately and longitudinally dominant compared with the control with an incremental cost-effectiveness ratio of -9,637.37 $/QALY. The net monetary benefit was correspondingly $2,237, both from the health system's perspective and at a WTP threshold of 50,000 $/QALY at the 2-year time point. This remained true in all scenarios tested. The Alternative Scenario Sensitivity Analysis suggested cost-effectiveness irrespective of payer type and surgical setting. To remain cost-effective, the cost difference between TOPSTM and TLIF should be no greater than $1,875 and $3,750 at WTP thresholds of $50,000 and 100,000 $/QALY, respectively. CONCLUSIONS: This updated analysis confirms that the TOPSTM device is a cost-effective and economically dominant surgical treatment option for patients with lumbar stenosis and degenerative spondylolisthesis compared to TLIF in all scenarios examined.

Health Care Costs Following Anterior Cervical Discectomy and Fusion or Cervical Disc Arthroplasty.

STUDY DESIGN: Observational cohort study. OBJECTIVE: To describe the postoperative costs associated with both anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) in the two-year period following surgery. SUMMARY OF BACKGROUND DATA: CDA has become an increasingly common alternative to ACDF for the treatment of cervical disc disorders. Although a number of studies have compared clinical outcomes between both procedures, much less is known about the postoperative economic burden of each procedure. MATERIALS AND METHODS: By analyzing a commercial insurance claims database (Marketscan, Merative), patients who underwent one-level or two-level ACDF and CDA procedures between January 1, 2017 and December 31, 2017 were identified and included in the study. The primary outcome was the cost of payments for postoperative management in the two-year period following ACDF or CDA. Identified postoperative interventions included in the study were: (i) physical therapy, (ii) pain medication, (iii) injections, (iv) psychological treatment, and (iv) subsequent spine surgeries. RESULTS: Totally, 2304 patients (age: 49.0±9.4 yr; male, 50.1%) were included in the study. In all, 1723 (74.8%) patients underwent ACDF, while 581 (25.2%) underwent CDA. The cost of surgery was similar between both groups (ACDF: $26,819±23,449; CDA: $25,954±20,620; P =0.429). Thirty-day, 90-day, and two-year global costs were all lower for patients who underwent CDA compared with ACDF ($31,024 vs. $34,411, $33,064 vs. $37,517, and $55,723 vs. $68,113, respectively). CONCLUSION: Lower two-year health care costs were found for patients undergoing CDA compared with ACDF. Further work is necessary to determine the drivers of these findings and the associated longer-term outcomes.

An evaluation of factors influencing the adoption and usage of robotic surgery in lower limb arthroplasty amongst orthopaedic trainees: a clinical survey.

BACKGROUND: The rise of robotics in orthopaedic training, driven by the demand for better training outcomes and patient care, presents specific challenges for junior trainees due to its novelty and steep learning curve. This paper explores how orthopaedic trainees perceive and adopt robotic-assisted lower limb arthroplasty. METHODS: The study utilised the UTUAT model questionnaire as the primary data collection tool, employing targeted questions on a five-point Likert scale to efficiently gather responses from a large number of participants. Data analysis was conducted using partial least squares (PLS), a well-established method in previous technology acceptance research. RESULT: The findings indicate a favourable attitude amongst trainees towards adopting robotic technology in orthopaedic training. They acknowledge the potential advantages of improved surgical precision and patient outcomes through roboticassisted procedures. Social factors, including the views of peers and mentors, notably influence trainees' decision-making. However, the availability of resources and expert mentors did not appear to have a significant impact on trainees' intention to use robotic technology. CONCLUSION: The study contributes to the understanding of factors influencing trainees' interest in robotic surgery and emphasises the importance of creating a supportive environment for its adoption.

Motivations and Barriers for Women Orthopaedic Surgeons Considering Arthroplasty Fellowship.

BACKGROUND: Arthroplasty is one of the least gender-diverse orthopaedic subspecialties. While previous studies have looked at factors influencing fellowship choices for women, few studies have attempted to understand the decision for or against arthroplasty specifically. Working to better understand fellowship choice is a critical step in the process of increasing women recruitment. METHODS: An anonymous survey was distributed using REDCap to women orthopaedic surgeons and trainees through listservs, social media groups, and residency programs. Surgeons who had decided on a specific subspecialty or already completed fellowship were included. Responses were obtained from 164 surgeons (72 arthroplasty surgeons, 92 other subspecialties). Chi-squared and Fisher's Exact tests were then performed. RESULTS: The most important factor for those who chose arthroplasty was enjoyment of the surgeries. The biggest concerns from those in the arthroplasty group about the field were work-life balance, ability to become pregnant and/or have a healthy pregnancy, and sex bias from referring physicians. Of those who ultimately chose another subspecialty, 30.4% considered arthroplasty "a little" and 8.7% considered it "strongly." The most important dissuaders for the group that considered arthroplasty were concerns about "boy's club" culture, concerns about the physicality of the surgeries, and a lack of mentors. CONCLUSION: While the decision to choose a career path is multifactorial, our hope is that through the identification of modifiable factors we can increase women representation in arthroplasty. Increasing mentorship, implementing practical solutions to improve work-life balance, supporting healthy pregnancies, and mitigating the physical demands of surgery could help address current disparities.

Neutrophil to Lymphocyte Ratio as an Indicator of Periprosthetic Joint Infection: A Retrospective Cohort Study.

INTRODUCTION: Periprosthetic joint infection (PJI) after total joint arthroplasty (TJA) is a serious complication posing notable clinical implications for patients and substantial economic burdens. Neutrophil to lymphocyte ratio (NLR) is an emerging biomarker of inflammation, which may better predict PJI. The objective of this review was to evaluate NLR changes in patients with confirmed PJI, to compare NLR between an aseptic revision and a revision for PJI, and to establish whether an NLR of 2.45 is an appropriate cutoff for predicting infection. METHODS: A retrospective review of patients who underwent revision TJA for PJI at a single center between January 1, 2005, and December 31, 2018, was performed and compared with an aseptic cohort who underwent aseptic revision TJA. NLR was calculated from complete blood counts performed at index surgery and at the time of revision surgery. Receiver operating characteristic curves were analyzed, along with sensitivity, specificity, and positive and negative likelihood ratios. RESULTS: There were 89 patients included in each cohort. Mean NLR in patients who underwent revision for PJI was 2.85 (± 1.27) at the time of index surgery and 6.89 (± 6.64) at the time of revision surgery ( P = 0.017). Mean NLR in patients undergoing revision for PJI (6.89) was significantly higher than aseptic revisions (3.17; P < 0.001). DISCUSSION: In patients who underwent revision surgery for PJI, NLR was markedly elevated at time of revision compared with the time of index surgery. Because it is a cost-effective and readily available test, these findings suggest that NLR may be a useful triage test in the diagnosis of PJI. LEVEL OF EVIDENCE: Level III Diagnostic Study.

Emergency Department Visits Following Patellofemoral Arthroplasty.

BACKGROUND: Readmissions are a typical postoperative metric; however, postoperative emergency department (ED) utilization also negatively affects patient care. Few studies have explored this metric after patellofemoral arthroplasty (PFA); thus, we investigated the incidence, timing, predictive factors, and reasons for ED utilization within 90 days after PFA. METHODS: Using the 2010 to 2021 PearlDiver M151Ortho data set, a national billing claims database containing information of over 151 million US orthopaedic patients across all payer types, the study examined weekly ED visits up to 90 days after PFA and conducted univariate and multivariate analyses to identify predictive factors. RESULTS: Of 7765 PFA patients, 11.2% (922) had ED visits within 90 days, with 46.7% (431) occurring in the first 3 weeks. Independent predictors of ED utilization included younger age (OR 1.40 per decade decrease), higher Elixhauser Comorbidity Index (OR 1.44 per 2-point increase), surgery in the South or Midwest (OR 1.27 and 1.31), and Medicaid insurance (OR 1.74). Postoperative pain accounted for 50.6% of visits. CONCLUSIONS: 11.2% of PFA patients visited the ED within 90 days, primarily for postoperative pain. Younger, more comorbid, and Medicaid-insured patients were most likely to use the ED. This study suggests the need for targeted perioperative pain management to reduce ED utilization after PFA.

Assessment and trends in the methodological quality of the top 50 most cited articles in shoulder arthroplasty.

INTRODUCTION: Shoulder arthroplasty is increasingly frequent, and the associated literature is abundant. Citation rate is often considered a good means of assessing impact and scientific value. However, analysis of methodological quality is also essential in evidence-based medicine. OBJECTIVES: (1) To identify the 50 most cited articles on shoulder arthroplasty, and (2) to assess the correlation between citation rate and methodological quality. The study hypothesis was that there is no correlation between citation rate and methodological quality. METHOD: Articles were retrieved from PubMed and Google Scholar, identifying the 50 most cited articles on shoulder arthroplasty via the keywords "shoulder joint replacement", "shoulder arthroplasty", "anatomic shoulder prothesis", "reverse shoulder prothesis", and "glenohumeral arthritis". Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-Randomized Studies (MINORS) were calculated. RESULTS: Mean citation rate for the 50 articles was 312.4±169.5 (range, 151-841.5), with a mean citation density of 18.8±10.6 (range, 4.7-46.7). 56% of the studies (28/50) were retrospective case series with level of evidence IV. There was no correlation between citation rate and methodological quality. DISCUSSION: The 50 most cited articles on shoulder arthroplasty mostly showed low levels of methodological quality. There was no correlation between citation rate and methodological quality: the literature needs to be read with a critical eye. LEVEL OF EVIDENCE: IV.

Trends in costs, reimbursements, and surgeon payments for cervical disc arthroplasty cost of care from 2009 to 2019.

OBJECTIVE: The use of cervical disc arthroplasty (CDA) continues to increase in the Medicare population. As healthcare costs continue to rise, payors have begun to implement bundled payment structures for spine surgery. While Medicare has steadily decreased reimbursements for cervical fusions, Medicare reimbursements for CDA have not been studied. The purpose of this study was to assess trends in 1) hospital costs and reimbursement, 2) physician reimbursement, and 3) potential cost drivers for CDA in a Medicare population. METHODS: This is a retrospective longitudinal study of CDA in Medicare patients. The Medicare Provider Analysis and Review Limited Data Sets for 2009, 2014, and 2019 were used for this study. Patients undergoing elective CDA were included. Corresponding Inpatient Prospective Payment System files were used to calculate cost through cost-to-charge ratios. Physician fees were obtained from the Medicare Physician Fee Schedule Look-Up Tool. All financial data were adjusted for inflation to 2019 values based on the Consumer Price Index for All Urban Consumers. Demographic, comorbidity, surgical, and hospital trends were assessed. Trends in revenue center-level charges were also assessed. RESULTS: Adjusted for inflation, from 2009 to 2019, mean total hospital charges for elective CDA increased from $64,609 ± $45,787 to $111,874 ± $78,611 (73% increase, p < 0.001) and the mean total cost for index hospital admission increased from $19,665 ± $13,414 to $24,682 ± $13,818 (26% increase, p < 0.001). Over the same period, Medicare reimbursement increased from a mean of $11,154 ± $11,684 to $12,879 ± $13,613 (15% increase, p = 0.003), while total reimbursement increased from a mean of $15,005 ± $15,684 to $15,547 ± $15,829 (4% increase, p = 0.040). The mean hospital profit decreased from -$4076 ± $14,041 to -$9023 ± $16,084 (-121%, p < 0.001). Surgeon reimbursement for CDA decreased from a mean of $1850 ± $165 (2009) to $1722 ± $138 (2019) (7% decrease, p < 0.001). On multivariate analysis, increasing year of surgery (p < 0.001), increasing age (p = 0.001), increasing length of stay (p < 0.001), rural hospital setting (p = 0.027), and hospital geography (p < 0.001) were independently associated with cost of care. Medical/surgical supplies and operating room charges increased 71.6% (p < 0.001) and 98.5% (p < 0.001) and accounted for 41.1%-42.5% and 30.6%-35.1% of total charges, respectively. CONCLUSIONS: From 2009 to 2019, costs of care for elective inpatient CDA increased disproportionately to reimbursement. Hospitals operated at increasing losses and surgeon reimbursement decreased. Cost of care was independently associated with year of surgery, increasing age, length of stay, hospital setting, and hospital geography. The main charge drivers were medical/surgical supplies and operating room charges. These results may have implications for the future financial feasibility of inpatient CDA for Medicare patients and targets to improve the value of CDA. Further study is necessary to provide fair reimbursement for CDA in Medicare patients and prevent financially based bias against use of CDA in Medicare patients.

Assessment of progression and clinical relevance of stress-shielding around press-fit radial head arthroplasty.

Aims: The aim of this study was to analyze how proximal radial neck resorption (PRNR) starts and progresses radiologically in two types of press-fit radial head arthroplasties (RHAs), and to investigate its clinical relevance. Methods: A total of 97 patients with RHA were analyzed: 56 received a bipolar RHA (Group 1) while 41 received an anatomical implant (Group 2). Radiographs were performed postoperatively and after three, six, nine, and 12 weeks, six, nine, 12, 18, and 24 months, and annually thereafter. PRNR was measured in all radiographs in the four radial neck quadrants. The Mayo Elbow Performance Score (MEPS), the abbreviated version of the Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), and the patient-assessed American Shoulder and Elbow Surgeons score - Elbow (pASES-E) were used for the clinical assessment. Radiological signs of implant loosening were investigated. Results: The mean follow-up was six years (2 to 14). PRNR started after a mean of 7.5 weeks (SD 2.1) and progressed significantly during the first two years, by the end of which the bone resorption stabilized. PRNR was detected in 81% (n = 45) of patients in Group 1 and 88% (n = 36) in Group 2. The final mean PRNR was 3.0 mm (SD 2.3) in Group 1 and 3.7 mm (SD 2.5) in Group 2. The mean MEPS, QuickDASH, and pASES-E were 95.9 (SD 11.5), 4.4 (SD 9.2), and 94.8 (SD 10.9) in Group 1 and 92.2 (SD 16.2), 9.9 (SD 21.5), and 90.8 (SD 15) in Group 2, respectively. No significant differences were observed between groups in the clinical and radiological outcomes. No correlations were found between PRNR and the clinical results. Conclusion: PRNR after press-fit RHA is a common radiological finding that develops in the first 24 months before stabilizing definitively. PRNR does not affect the clinical results or implant survival in the mid term.

Socioeconomic Challenges in the Rural Patient Population in Need of Total Joint Arthroplasty.

Many challenges exist for the rural patient in need of joint arthroplasty. Optimization for surgery is more difficult due to factors such as deprivation, education, employment, household income, and access to proper surgical institutions. Rural individuals have less access to primary care and even less access to surgical specialists, creating a distinct subset of patients who endure higher costs, poorer outcomes, and lack of care. Reducing socioeconomic disparities in rural communities will require policy initiatives addressing the components of socioeconomic status (income, education, and occupation). Hopefully remote patient technologies can help with access and timely addressing of modifiable risk factors.

Social Determinants of Health Disparities Are Associated With Increased Costs, Revisions, and Infection in Patients Undergoing Arthroscopic Rotator Cuff Repair.

PURPOSE: The purpose of this study was to use a national claims database to assess the impact of pre-existing social determinants of health disparities (SDHD) on postoperative outcomes following rotator cuff repair (RCR). METHODS: A retrospective review of the Mariner Claims Database was used to capture patients undergoing primary RCR with at least 1 year of follow-up. These patients were divided into two cohorts based on the presence of a current or previous history of SDHD, encompassing educational, environmental, social, or economic disparities. Records were queried for 90-day postoperative complications, consisting of minor and major medical complications, emergency department (ED) visits, readmission, stiffness, and 1-year ipsilateral revision surgery. Multivariate logistic regression was employed to assess the impact of SDHD on the assessed postoperative outcomes following RCR. RESULTS: 58,748 patients undergoing primary RCR with a SDHD diagnosis and 58,748 patients in the matched control group were included. A previous diagnosis of SDHD was associated with an increased risk of ED visits (OR 1.22, 95% CI 1.18-1.27; P < .001), postoperative stiffness (OR 2.53, 95% CI 2.42-2.64; P < .001), and revision surgery (OR 2.35, 95% CI 2.13-2.59; P < .001) compared to the matched control group. Subgroup analysis revealed educational disparities had the greatest risk for 1-year revision (OR 3.13, 95% CI 2.53-4.05; P < .001). CONCLUSIONS: The presence of a SDHD was associated with an increased risk of revision surgery, postoperative stiffness, emergency room visits, medical complications, and surgical costs following arthroscopic RCR. Overall, economic and educational SDHD were associated with the greatest risk of 1-year revision surgery. LEVEL OF EVIDENCE: III, retrospective cohort study.

The Influence of Workers' Compensation Status on Patient-Reported Outcomes after Cervical Disc Arthroplasty at an Ambulatory Surgical Center.

INTRODUCTION: Workers' compensation (WC) status tends to negatively affect patient outcomes in spine surgery. This study aims to evaluate the potential effect of WC status on patient-reported outcomes (PROs) after cervical disc arthroplasty (CDR) at an ambulatory surgical center (ASC). METHODS: A single-surgeon registry was retrospectively reviewed for patients who had undergone elective CDR at an ASC. Patients with missing insurance data were excluded. Propensity score-matched cohorts were generated by the presence or lack of WC status. PROs were collected preoperatively and at 6-week, 12-week, 6-month, and 1-year time points. PROs included the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), visual analog scale (VAS) neck and arm pain, and Neck Disability Index. PROs were compared within and between groups. Minimum clinically important difference (MCID) achievement rates were compared between groups. RESULTS: Sixty-three patients were included, with 36 without WC (non-WC) and 27 with WC. The non-WC cohort demonstrated postoperative improvement in all PROs at all time points, with the exception of VAS arm past the 12-week point ( P ≤ 0.030, all). The WC cohort demonstrated postoperative improvement in VAS neck at 12-week, 6-month, and 1-year time points ( P ≤ 0.025, all). The WC cohort improved in VAS arm and Neck Disability Index at the 12-week and 1-year points as well ( P ≤ 0.029, all). The non-WC cohort reported superior PRO scores in every PRO at one or more postoperative time points ( P ≤ 0.046, all). The non-WC cohort demonstrated higher rates of minimum clinically important difference achievement in PROMIS-PF at 12 weeks ( P ≤ 0.024). CONCLUSION: Patients with WC status undergoing CDR at an ASC may report inferior pain, function, and disability outcomes compared with those with private or government-provided insurance. Perceived inferior disability in WC patients persisted into the long-term follow-up period (1 year). These findings may aid surgeons in setting realistic preoperative expectations with patients at risk of inferior outcomes.

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.

A real-world analysis of hybrid CDA and ACDF compared to multilevel ACDF.

BACKGROUND: Multilevel anterior cervical discectomy and fusion (mACDF) is the gold standard for multilevel spinal disease; although safe and effective, mACDF can limit regular spinal motion and contribute to adjacent segment disease (ASD). Hybrid surgery, composed of ACDF and cervical disc arthroplasty, has the potential to reduce ASD by retaining spinal mobility. This study examined the safety of hybrid surgery by utilizing administrative claims data to compare real-world rates of subsequent surgery and post-procedural hospitalization within populations of patients undergoing hybrid surgery versus mACDF for multilevel spinal disease. METHODS: This observational, retrospective analysis used the MarketScan Commercial and Medicare Database from July 2013 through June 2020. Propensity score matched cohorts of patients who received hybrid surgery or mACDF were established based on the presence of spinal surgery procedure codes in the claims data and followed over a variable post-period. Rates of subsequent surgery and post-procedural hospitalization (30- and 90-day) were compared between hybrid surgery and mACDF cohorts. RESULTS: A total of 430 hybrid surgery patients and 2,136 mACDF patients qualified for the study; average follow-up was approximately 2 years. Similar rates of subsequent surgery (Hybrid: 1.9 surgeries/100 patient-years; mACDF: 1.8 surgeries/100 patient-years) were observed for the two cohorts. Hospitalization rates were also similar across cohorts at 30 days post-procedure (Hybrid: 0.67% hospitalized/patient-year; mACDF: 0.87% hospitalized/patient-year). At 90 days post-procedure, hybrid surgery patients had slightly lower rates of hospitalization compared to mACDF patients (0.23% versus 0.42% hospitalized/patient-year; p < 0.05). CONCLUSIONS: Findings of this real-world, retrospective cohort study confirm prior reports indicating that hybrid surgery is a safe and effective intervention for multilevel spinal disease which demonstrates non-inferiority in relation to the current gold standard mACDF. The use of administrative claims data in this analysis provides a unique perspective allowing the inclusion of a larger, more generalizable population has historically been reported on in small cohort studies.