Cost of Arthroscopic Rotator Cuff Repairs Is Primarily Driven by Procedure-Level Factors: A Single-Institution Analysis of an Ambulatory Surgery Center.

PURPOSE: To identify intraoperative drivers of cost associated with arthroscopic rotator cuff repairs (RCRs) through analysis of an institutional database. METHODS: This was a single-institution retrospective review of arthroscopic RCRs performed at an ambulatory surgical center between November 2016 and July 2019. Patient-level factors analyzed included age, sex, insurance type (private, Medicare, Medicaid, self-pay, and other government), American Society of Anesthesiologists grade (I, II, III, and missing), and Charlson comorbidity index (0, 1, 2, and ≥3). Procedure-level factors included use of biologics (decellularized dermal allograft or bioinductive healing implant), anesthesia type (regional block, monitored anesthesia care, or general), number of anchors and sutures, additional procedures (biceps tenodesis, distal clavicle resection, subacromial decompression), and operative time. Multivariate linear regression analysis was used to identify factors significantly associated with higher or lower charges. RESULTS: A total of 712 arthroscopic RCRs were included. The risk-adjusted operative charges were $19,728 (95% confidence interval $16,543 to $22,913). The above factors predicted nearly 65% of the variability in operative charges. The only patient-level factor significantly associated with lower charges was female sex (- $1,339; P = .002). Procedure-level factors significantly associated with higher charges were use of biologics (+ $17,791; P < .001), concurrent open biceps tenodesis (+ $4,027; P < .001), distal clavicle resection (+ $2,266; P = .039), use of regional block (+ $1,256; P = .004), number of anchors (+ $2,245/anchor; P < .001), and increasing operative time ($26/min). Other factors had no significant association. CONCLUSIONS: Procedural factors are the most significant drivers of operative cost in arthroscopic RCRs, such as quantity and type of implants; additional procedures such as biceps tenodesis and distal clavicle resection; and perioperative conditions such as type of anesthesia and total operating room time. Overall, patient-level factors were not shown to correlate well with operative costs, other than lower charges with female sex. LEVEL OF EVIDENCE: IV, economic study.

Patient Outcomes After Horizontal Cleavage Tear Repair: A Systematic Review.

PURPOSE: To analyze the clinical outcomes and survivorship of meniscal horizontal cleavage tear (HCT) repairs with hopes of guiding future treatment decisions. METHODS: Standard systematic review methodology was used. A comprehensive search of PubMed was conducted on June 1, 2019. The inclusion criteria were articles that were published in English, involved human subjects, and reported on at least 1 outcome after repair of HCTs. The exclusion criteria included technique guides and reviews, studies without full text available, and studies with HCT outcomes not separated from other repair groups. Effect heterogeneity was determined using the I2 measure. Forest plots were created in addition to a random-effects model to show the results. RESULTS: The systematic review yielded 19 studies evaluating 289 knees in a total of 273 patients. At most recent follow-up, there was a high probability of return to sport (93.1% [67 of 72]). Overall, 74% of patients (67 of 90) were symptom free at last follow-up, and 80% expressed satisfaction with their overall result (80 of 100). The most frequently reported subjective outcome was the Lysholm score, which improved from a preoperative study range of 48 to 79 (I2 = 20.7%, P = .283) to a postoperative study range of 56 to 99 (I2 = 49%, P = .081). The next most commonly reported was the International Knee Documentation Committee subjective score, which improved from a preoperative study range of 16 to 49 (I2 = 47.7%, P = .125) to a postoperative study range of 72 to 95 (I2 = 0%, P = .660). An overall 11.7% reported risk of reoperation was found, with most cases involving revision meniscectomy. Rates of complications beyond fixation failure were overall very low, with infrequent reports of septic arthritis and transitory dysesthesia. CONCLUSIONS: The short- to intermediate-term results of repair of HCTs are comparable to prior studies. Survivorship is comparable to repairs of other types of meniscal tears with high rates of return to sport and low complication rates. LEVEL OF EVIDENCE: Level IV, systematic review of Level I-IV studies.

Rapidity of Correction of Hyponatremia Due to Syndrome of Inappropriate Secretion of Antidiuretic Hormone Following Tolvaptan.

BACKGROUND: Tolvaptan effectively corrects hyponatremia due to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH), but undesired overcorrection can occur. We hypothesized that pretherapy parameters can predict the rapidity of response to tolvaptan in SIADH. STUDY DESIGN: Multicenter historical cohort study. SETTING & PARTICIPANTS: Adults with SIADH or congestive heart failure (CHF) treated with tolvaptan for a serum sodium concentration ≤ 130 mEq/L at 5 US hospitals. PREDICTORS: Demographic and laboratory parameters. OUTCOMES: Rate of change in serum sodium concentration. MEASUREMENTS: Spearman correlations, analysis of variance, and multivariable linear mixed-effects models. RESULTS: 28 patients with SIADH and 39 patients with CHF treated with tolvaptan (mean baseline serum sodium, 120.6 and 122.4 mEq/L, respectively) were studied. Correction of serum sodium concentration > 12 mEq/L/d occurred in 25% of patients with SIADH compared to 3% of those with CHF (P<0.001). Among patients with SIADH, the increase in serum sodium over 24 hours was correlated with baseline serum sodium concentration (r=-0.78; P<0.001), serum urea nitrogen concentration (SUN; r=-0.76; P<0.001), and estimated glomerular filtration rate (r=0.58; P=0.01). Baseline serum sodium and SUN concentrations were identified as independent predictors of change in serum sodium concentration in multivariable analyses. When patients were grouped into 4 categories according to baseline serum sodium and SUN median values, those with both low baseline serum sodium (≤121 mEq/L) and low baseline SUN concentrations (≤10mg/dL) exhibited a significantly greater rate of increase in serum sodium concentration (mean 24-hour increase of 15.4 mEq/L) than the other 3 categories (P<0.05). Among patients with CHF, only baseline SUN concentration was identified as an independent predictor of change in serum sodium concentration over time. LIMITATIONS: Lack of uniformity in serial serum sodium concentration determinations and documentation of water intake. CONCLUSIONS: Baseline serum sodium and SUN values are predictive of the rapidity of hyponatremia correction following tolvaptan use in SIADH. We advise caution when dosing tolvaptan in patients with both low serum sodium and SUN concentrations.