Measurement of value in rotator cuff repair: patient-level value analysis for the 1-year episode of care.

BACKGROUND: Rotator cuff repair (RCR) is one of the most common elective orthopedic procedures, with predictable indications, techniques, and outcomes. As a result, this surgical procedure is an ideal choice for studying value. The purpose of this study was to perform patient-level value analysis (PLVA) within the setting of RCR over the 1-year episode of care. METHODS: Included patients (N = 396) underwent RCR between 2009 and 2016 at a single outpatient orthopedic surgery center. The episode of care was defined as 1-year following surgery. The Western Ontario Rotator Cuff index was collected at both the initial preoperative baseline assessment and the 1-year postoperative mark. The total cost of care was determined using time-driven activity-based costing (TDABC). Both PLVA and provider-level value analysis were performed. RESULTS: The average TDABC cost of care was derived at $5413.78 ± $727.41 (95% confidence interval, $5341.92-$5485.64). At the patient level, arthroscopic isolated supraspinatus tears yielded the highest value coefficient (0.82; analysis-of-variance F test, P = .01). There was a poor correlation between the change in the 1-year Western Ontario Rotator Cuff score and the TDABC cost of care (r2 = 0.03). Provider-level value analysis demonstrated significant variation between the 8 providers evaluated (P < .01). CONCLUSION: RCR is one of the most common orthopedic procedures, yet the correlations between cost of care and patient outcomes are unknown. PLVA quantifies the ratio of functional improvement to the TDABC-estimated cost of care at the patient level. This is the first study to apply PLVA over the first-year episode of care. With health care transitioning toward value-based delivery, PLVA offers a quantitative tool to measure the value of individual patient care delivery over the entire episode of care.

The pathogenesis and management of cuff tear arthropathy.

Massive rotator cuff tears may lead to the development of cuff tear arthropathy (CTA). Although this pathology has been recognized for more than 150 years, treatment strategies have continued to evolve. During the last decade, there has been increased understanding of the molecular and cellular changes that govern rotator cuff tear outcomes and development of new treatment strategies to repair or reconstruct the rotator cuff. These have included an expansion of the use of arthroscopic double-row transosseous-equivalent repairs and the development of superior capsule reconstruction. However, the greatest change in the management of CTA has been the expansion of the use of reverse total shoulder arthroplasty, which has become the standard of care for patients who do not have a repair option and when nonoperative management has failed. This review article summarizes the current literature on the management of CTA, including nonoperative, repair, reconstruction, and replacement options, with a focus on literature in the last 5 years.

Risk factors for failing to achieve improvement after anatomic total shoulder arthroplasty for glenohumeral osteoarthritis.

BACKGROUND: Although anatomic total shoulder arthroplasty (TSA) successfully improves pain and function, not all patients improve clinically. This study was conducted to determine patient-related factors for failure to achieve improvement after primary TSA for osteoarthritis at 2 years postoperatively. METHODS: This prospective study reviewed an institutional shoulder registry for consecutive patients who underwent primary TSA for osteoarthritis from 2007 to 2013 with baseline and 2-year postoperative American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form scores. A failed outcome was defined as (1) a failure to reach the ASES minimal clinically important difference of 16.1 points or (2) revision surgery within 2 years of the index procedure, or both. Univariate and multivariable analyses of clinical and demographic patient factors were performed using logistic regression. RESULTS: Of 459 arthroplasties that met inclusion criteria, 411 were deemed successful by the aforementioned criteria, and 48 (10.5%) failed to achieve a desirable outcome. Clinical risk factors associated with failure included previous surgery to the shoulder (P = .047), presence of a torn rotator cuff (P = .025), and presence of diabetes (P = .036), after adjusting for age, sex, race, and body mass index. A higher preoperative ASES score at baseline was associated with failure (P < .001). CONCLUSION: Previous shoulder surgery, a rotator cuff tear requiring repair during TSA, presence of diabetes, surgery on the nondominant arm, and a higher baseline ASES score were associated with a higher risk of failing to achieve improvement after anatomic TSA.

Buprenorphine, Clonidine, Dexamethasone, and Ropivacaine for Interscalene Nerve Blockade: A Prospective, Randomized, Blinded, Ropivacaine Dose-Response Study.

OBJECTIVE: This study investigated interscalene block for shoulder arthroplasty with various ropivacaine concentrations in the presence of clonidine, dexamethasone, and buprenorphine. The goal was prolonged analgesia with minimal motor blockade. DESIGN: Prospective, double-blind, randomized controlled trial. SETTING: University-affiliated orthopedic hospital. METHODS: Patients (20/group) received acetaminophen, ketorolac, pregabalin, opioids, and "Control"; interscalene block, 0.375% ropivacaine, intravenous additives (buprenorphine, clonidine, dexamethasone); "High Dose"; 0.375% ropivacaine, perineural additives; "Medium Dose"; 0.2% ropivacaine, perineural additives; and "Low Dose"; 0.1% ropivacaine, perineural additives. RESULTS: Pain with movement at 24 hours was 4.9 ± 2.5 (mean ± standard deviation [SD]) (Control), 4.5 ± 3.0 (High Dose), 3.4 ± 1.8 (Medium Dose), 4.2 ± 2.4 (Low Dose). The difference between Medium Dose and Control was -1.5 (95% CI: -2.9, -0.1) (P = 0.040). Median time until need for opioids was 16.1 hours (Control) vs 23.7 hours (High Dose); hazard ratio 0.37 [95% CI: 0.17, 0.79]. High Dose had less pain with movement the morning after surgery, vs Control; 2.9 ± 2.5 vs 4.9 ± 2.7; P = 0.027. Pain with movement in the Post-Anesthesia Care Unit was higher in Low Dose, vs Control; 0.9 ± 1.4 vs 0 ± 0, P = 0.009. Low Dose had superior hand strength in the Post-Anesthesia Care Unit (mean ± SD of pre-operative strength: 44.0 ± 20.3%) compared to Control (27.5 ± 24.5%) (P = 0.031). CONCLUSIONS: For maximum pain reduction, combining perineural additives with ropivacaine 0.375% or 0.2% is suggested. To minimize motor blockade, perineural additives can be combined with ropivacaine, 0.1%.

Scapular Notching.

Developed in 1985, the Grammont-style reverse total shoulder arthroplasty offered a biomechanical advantage for the deltoid muscle as well as predictably reduced pain and improved shoulder function in rotator cuff-deficient shoulders. Despite favorable outcomes, reverse total shoulder arthroplasty is associated with a unique set of complications, one of which is scapular notching. Scapular notching is believed to be a result of mechanical impingement of the humeral component on the lateral scapular pillar. Although it appears that scapular notching progresses with time, its effect on implant survivorship and clinical outcomes is unknown. Factors associated with scapular notching are categorized into several groups, including patient-specific risk factors, surgical approach and technique, and prosthetic design. Surgical strategies to reduce the rate of scapular notching include inferior positioning of the glenosphere, inferior tilting of the glenosphere, and increasing the size of the glenosphere. A lateralized center of rotation and a decreased humeral shaft-neck angle also decrease the incidence of scapular notching. As the indications for reverse total shoulder arthroplasty expand, it is important for orthopaedic surgeons to understand the etiology and incidence, predictive factors, and clinical relevance of scapular notching as well as strategies to avoid it.

Staged bilateral total shoulder arthroplasty: improved outcomes with less than 6 months between surgeries.

BACKGROUND: Research on optimal timing of bilateral anatomic total shoulder arthroplasty (TSA) is lacking. The purpose of this study was to investigate functional outcomes in patients undergoing bilateral anatomic TSA to understand the ideal timing for the second arthroplasty. METHODS: Patients who underwent bilateral TSA for osteoarthritis between 2000 and 2012 with a minimum follow-up of 12 months since their most recent surgery were evaluated. Postoperative patient-reported outcomes (University of California-Los Angeles [UCLA] shoulder rating scale, Constant score, and Simple Shoulder Test [SST]), biometrics (strength and range of motion), and a subjective questionnaire were compared for 4 "interval groups" based on timing between surgeries: <6 months, 6 to 12 months, 12 to 24 months, and >24 months. RESULTS: Eighty-two shoulders (41 patients, 70 ± 9 years old) were analyzed. Mean postoperative UCLA, Constant, and SST scores were 29, 72, and 9 points, respectively; 83% of patients reported satisfaction with both shoulders. Patients with <6 months between surgeries demonstrated significantly better UCLA scores than 6- to 12-month interval patients (P = .04), greater Constant scores compared with all other groups (P < .001), and greater SST scores compared with 6- to 12-month and 12- to 24-month interval patients (P = .002), with no differences in length of follow-up between groups. CONCLUSION: In the absence of extrinsic factors, such as convenience, changes in social support structure, or changes in health status, patients may be advised that having the second surgery within 6 months of the first might optimize their postoperative functional outcomes and satisfaction compared with waiting a longer interval between surgeries.

Malnutrition: a marker for increased complications, mortality, and length of stay after total shoulder arthroplasty.

BACKGROUND: Malnutrition is an established risk factor for postoperative complications. The purpose of this investigation was to determine the overall prevalence of malnutrition in total shoulder arthroplasty (TSA) patients, the differences in prevalence across obesity subgroups, and the overall complication risk of malnourished patients compared with normal patients. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for TSA cases from 2005 to 2013 for this retrospective cohort study. Malnutrition was defined as preoperative albumin concentration of <3.5 g/dL. Rates of postoperative complications were compared between normal and malnourished patients. RESULTS: We identified 4,655 TSA cases, with preoperative albumin measurements available for 1681 patients (36.1%). Propensity score adjustment successfully reduced selection bias, with adjusted P values of >.05 for demographics, body mass index, and modified Charlson Comorbidity Index. Of the cohort with albumin measurements, 7.6% of patients were malnourished according to our criteria. Bivariate analysis showed malnourished patients had higher rates of pulmonary complications, anemia requiring transfusion, extended length of stay (LOS), and death (all P < .05). Propensity-adjusted multivariable logistic regression demonstrated that malnutrition was significantly associated (all P < .05) with postoperative transfusion (odds ratio, 2.49), extended LOS (odds ratio, 1.69), and death (odds ratio, 18.09). CONCLUSION: The overall prevalence of malnutrition was 7.6%. Malnourished patients were at a significantly increased risk for blood transfusion, longer hospital LOS, and death within 30 days of surgery. Multivariable analysis showed TSA patients with preoperative albumin levels of <3.5 g/dL are at much higher risk for morbidity and death after surgery than patients with albumin levels within normal reference ranges.

Arthroplasty for the surgical management of complex proximal humerus fractures in the elderly: a cost-utility analysis.

BACKGROUND: Shoulder hemiarthroplasty (HA) has been the standard treatment for complex proximal humerus fractures in the elderly requiring surgery but not amenable to fixation. Reverse total shoulder arthroplasty (RTSA) has also emerged as a costly albeit highly effective alternative. The purpose of this study was to compare the cost-effectiveness of nonoperative fracture care, HA, and RTSA for complex proximal humerus fractures from the perspective of both U.S. payors and hospitals. METHODS: A Markov model was constructed for the treatment alternatives. Costs were expressed in 2013 U.S. dollars and effectiveness in quality-adjusted life-years (QALYs). The principal outcome measure was incremental cost-effectiveness ratio (ICER). Sensitivity analyses were performed to evaluate model assumptions. RESULTS: In the base case, from the payor perspective, RTSA was associated with an ICER of $8100/QALY; HA was eliminated from payor analysis as a cost-ineffective strategy. From the hospital perspective, however, HA was not cost-ineffective and the ICER for HA was $36,700/QALY, with RTSA providing incremental effectiveness at $57,400/QALY. RTSA was the optimal strategy in 61% and 54% of payor and hospital probabilistic sensitivity analyses, respectively. The preferred strategy was dependent on associated QALY gains, primary RTSA cost, and failure rates for RTSA. CONCLUSIONS: RTSA can be a cost-effective intervention in the surgical treatment of complex proximal humerus fractures. HA can also be a cost-effective intervention, depending on the cost perspective (cost-ineffective for payor but cost-effective for the hospital). This analysis highlights the opportunities for increased cost-sharing strategies to alleviate the cost burden on hospitals.

Causes of poor postoperative improvement after reverse total shoulder arthroplasty.

BACKGROUND: Although reverse total shoulder arthroplasty (RTSA) has been successful in improving pain and function in most patients, some patients fail to improve clinically. The present study used a large registry of RTSA patients to evaluate associations between patient-related factors and poor postoperative improvement after RTSA. MATERIALS AND METHODS: A prospectively collected shoulder arthroplasty registry was queried for consecutive patients who underwent RTSA from 2007 to 2013. Patients with baseline and minimum 2-year postoperative American Shoulder and Elbow Surgeons (ASES) scores were included. Poor postoperative improvement was defined as a change in the ASES of less than 12 points. Multivariate logistic regression analysis was used to identify independent risk factors. RESULTS: A total of 150 patients met inclusion and exclusion criteria. Logistic regression revealed that male sex (adjusted odds ratio [OR], 7.9; P = .004), presence of an intact rotator cuff at the time of surgery (adjusted OR, 4.8; P = .025), depression (adjusted OR, 11.2; P = .005), a higher baseline ASES score (P < .001), and higher total number of medical comorbidities (P = .035) were associated with poor postoperative improvement after RTSA. CONCLUSIONS: Surrogates for better preoperative function after RTSA, such as a higher baseline ASES score and intact rotator cuff at the time of surgery, correlated with poor postoperative improvement. In addition, male sex, depression, and total number of medical comorbidities also correlated with poor postoperative improvement. Interestingly, factors such as patient age and indication for surgery were not found to correlate with poor improvement after RTSA.

No differences in early results of a hybrid glenoid compared with a pegged implant.

BACKGROUND: Glenoid component loosening after total shoulder arthroplasty is one of the most common causes of failure. A hybrid glenoid that uses peripherally cemented pegs and a central press-fit post may improve implant longevity. QUESTIONS/PURPOSES: We asked, compared with polyethylene pegged glenoid implants, do hybrid glenoid implants with a titanium post provide (1) better ingrowth with fewer radiolucencies, (2) better outcome and pain scores, and (3) lower risk of complications and revisions? METHODS: Between 2009 and 2010, 126 patients underwent primary total shoulder arthroplasty for osteoarthritis. Patients were included in this retrospective study if they consented for inclusion in a shoulder arthroplasty registry, had complete baseline and 2-year data, and had complete radiographs. Eighty-three (67%) were available at an average followup of 3.2 years (range, 24-45 months). Forty received a conventional all-polyethylene pegged glenoid and 43 received a hybrid component. During the period in question, four of the participating surgeons used only one implant, and four used only the other; there was one high-volume surgeon in each of the study groups. Radiographs were taken at the 2-year followup and analyzed for radiolucent lines. CT scans were obtained randomly for 10 patients with hybrid glenoid implants to assess bone ongrowth. American Shoulder and Elbow Surgeons score, VAS score, complications and revisions were recorded. RESULTS: At final followup, radiolucent lines between the two study groups were not different (hybrid, 1.0 ± 0.4; pegged, 1.6 ± 0.3; mean difference, 0.6; 95% CI, 0.85-1.72; p = 0.323). Final VAS pain scores were not different (hybrid, 1.2 ± 0.2; pegged, 1.5 ± 0.3; p = 0.056). Change in American Shoulder and Elbow Surgeons scores were not different (hybrid, 33.7 ± 7.3; pegged, 35.5 ± 8.2; p = 0.283). There were no differences in complication risk (hybrid, one of 43 [2.3%]; pegged, three of 40 [7.5%]; relative risk, 2.3; 95% CI, 0.82-3.12; p = 0.061). CONCLUSIONS: With the numbers available and at early followup, there were no differences between the hybrid and pegged glenoids in terms of fixation, functional outcome, pain scores, and complications. CT scans confirmed bone ongrowth on the porous titanium post in a small subcohort of patients. Further studies are needed to determine how this new implant will perform with time. Until then, its use should be initiated with caution. LEVEL OF EVIDENCE: Level III, therapeutic study.