Regional differences in reimbursement, volume, and patient characteristics exist for rotator cuff repairs: a temporal analysis from 2013 to 2021.

BACKGROUND: Prior studies have demonstrated declining reimbursement and changing procedural utilization across multiple orthopedic subspecialties, yet a comprehensive examination of this has not been performed for rotator cuff repair (RCR), particularly at a geographic level. The purpose of this study was to evaluate changes in reimbursement, utilization, and patient populations for open and arthroscopic RCRs from 2013 to 2021 at a national and regional level. METHODS: The Medicare Physician and Other Practitioners database from years 2013 to 2021 were queried to extract all episodes of open chronic RCR, open acute RCR, and arthroscopic RCR. Utilization was measured as procedural volume per 10,000 Medicare beneficiaries. Inflation-adjusted reimbursement, utilization, surgeon information, and patient characteristics were extracted for each procedure for each year. Data was stratified geographically based on US Census regions and rural-urban commuting codes. Kruskal-Wallis tests and linear regressions were performed to compare geographical areas. RESULTS: Between 2013 and 2021, arthroscopic RCR utilization increased by 9.4% (11.0/10,000-12.0/10,000), while open chronic RCR utilization decreased by 58.8% (2.0/10,000-0.8/10,000). During that time, average inflation-adjusted reimbursement declined by 10.0% and 11.3% for arthroscopic and open chronic RCR, respectively. The increase in utilization and decrease in reimbursement was greatest in the Midwest. In 2021, arthroscopic RCR utilization was 12.0/10,000, while average reimbursement was $846.87, nationally. Utilization was highest in the South (14.5/10,000) and lowest in the Northeast (8.1/10,000) (P < .001). Alternatively, reimbursement was highest in the Northeast ($904.60) and lowest in the South ($830.80) (P < .001). The proportion of patients who were male, Medicaid eligible, or non-White was highest in the West (P < .001). Patients in the West also had the fewest comorbidities. Increased patient comorbidities, when controlling patient demographics, were associated with lower reimbursement nationally and within the Northeast (P < .001). CONCLUSION: Geographical discrepancies in RCR utilization and reimbursement exist. The South consistently demonstrates the highest utilization of RCR, while also having the lowest reimbursement. Alternatively, the Northeast has the lowest utilization but the highest reimbursement. Increased patient population comorbidities were associated with reduced RCR reimbursement for surgeons in the Northeast, but not in other regions.

A coronoid-centric classification system of proximal trans-ulnar fracture-dislocations has almost perfect intraobserver and interobserver agreement.

BACKGROUND: Fracture-dislocations of the elbow, particularly those that involve a fracture through the proximal ulna, are complex and can be difficult to manage. Moreover, current classification systems often cannot discriminate between Monteggia-variant injury patterns and trans-olecranon fracture-dislocations, particularly when the fracture involves the coronoid. The Mayo classification of proximal trans-ulnar fracture-dislocations categorizes these fractures into 3 types according to what the coronoid is still attached to: trans-olecranon fracture-dislocations (the coronoid is still attached to the ulnar metaphysis); Monteggia-variant fracture-dislocations (the coronoid is still attached to the olecranon); and ulnar basal coronoid fracture-dislocations (the coronoid is not attached to either the olecranon or the ulnar metaphysis). The purpose of this study was to evaluate the intraobserver and interobserver agreement of the Mayo classification system when assessing elbow fracture-dislocations involving the proximal ulna based on radiographs and computed tomography scans. METHODS: Three fellowship-trained shoulder and elbow surgeons and 2 fellowship-trained orthopedic trauma surgeons blindly and independently evaluated the radiographs and computed tomography scans of 90 consecutive proximal trans-ulnar fracture-dislocations treated at a level I trauma center. The inclusion criteria included subluxation or dislocation of the elbow and/or radioulnar joint with a complete fracture through the proximal ulna. Each surgeon classified all fractures according to the Mayo classification, which is based on what the coronoid remains attached to (ulnar metaphysis, olecranon, or neither). Intraobserver reliability was determined by scrambling the order of the fractures and having each observer classify all the fractures again after a washout period ≥ 6 weeks. Interobserver reliability was obtained to assess the overall agreement between observers. κ Values were calculated for both intraobserver reliability and interobserver reliability. RESULTS: The average intraobserver agreement was 0.87 (almost perfect agreement; range, 0.76-0.91). Interobserver agreement was 0.80 (substantial agreement; range, 0.70-0.90) for the first reading session and 0.89 (almost perfect agreement; range, 0.85-0.93) for the second reading session. The overall average interobserver agreement was 0.85 (almost perfect agreement; range, 0.79-0.91). CONCLUSION: Classifying proximal trans-ulnar fracture-dislocations based on what the coronoid remains attached to (olecranon, ulnar metaphysis, or neither) was associated with almost perfect intraobserver and interobserver agreement, regardless of trauma vs. shoulder and elbow fellowship training. Further research is needed to determine whether the use of this classification system leads to the application of principles specific to the management of these injuries and translates into better outcomes.

Tranexamic Acid Administered at Time of Hospital Admission Does Not Decrease Transfusion Rates or Blood Loss for Extracapsular Hip Fractures: A Double-Blinded Randomized Clinical Trial.

OBJECTIVES: To evaluate tranexamic acid (TXA) when administered immediately on hospital presentation in patients with extracapsular peritrochanteric hip fractures to determine its effect on (1) transfusion rates, (2) estimated blood loss, and (3) complications. DESIGN: Prospective, double-blinded, randomized clinical trial. SETTING: Single-center, Level 1 trauma center. PATIENT SELECTION CRITERIA: All patients with isolated OTA/AO 31-A fracture patterns from 2018 to 2022 were eligible for inclusion. Study drug was administered in the emergency department at the time of presentation-1-g bolus over 10 minutes followed by a 1-g infusion over 8 hours. OUTCOME MEASURES AND COMPARISONS: The primary outcome was the rate of red blood cell transfusion hospital days 1-4. Secondary outcomes included estimated blood loss and complications including venous thromboembolic events, stroke, myocardial infarction, all-cause 90-day readmissions, and all-cause mortality. RESULTS: One hundred twenty-eight patients were included-64 patients were randomized to intravenous TXA and 64 patients to intravenous normal saline (ie, placebo). There was no difference in the rate of red blood cell transfusion between treatment arms between hospital days 1-4 (27% in the TXA arm vs. 31% in the placebo arm, P = 0.65). Patients randomized to placebo who required transfusion received a mean of 2.30 units compared with 1.94 units in the TXA cohort (P = 0.55). There was no difference in the estimated blood loss between hospital days 1-4. There was no difference in the incidence of postoperative complications including venous thromboembolic events, stroke, myocardial infarction, 90-day readmission, or death. CONCLUSIONS: The results of this study do not support the use of preoperative TXA for reducing blood loss for geriatric patients with extracapsular hip fractures. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Avascular Necrosis and Posttraumatic Arthritis After Proximal Humerus Fracture Internal Fixation: Evaluation and Management.

PURPOSE OF REVIEW: Avascular necrosis (AVN) and posttraumatic arthritis (PTA) are common complications following both conservative treatment and open reduction and internal fixation (ORIF) of proximal humerus fractures (PHFs). Despite the frequent utilization of ORIF, information regarding these leading causes of failure is limited. This review includes a discussion of incidence, risk factors, and evaluation of AVN and PTA following PHF. The mechanisms of treatment options and associated outcomes are also reviewed. RECENT FINDINGS: Recent best available evidence demonstrates significant rates of AVN and PTA following ORIF of PHF. This is particularly true of complex fracture patterns. A thorough workup is required in the setting of failure caused by AVN and PTA. This includes a careful patient history, clinical exam, plain film radiographs, and CT scans. EMG and/or aspiration may also be indicated. Special consideration is given to the examination of the deltoid muscle, neurovascular status, rotator cuff function, and the possibility of infection. Biological supplementation, anatomic total shoulder replacement (aTSA), and fusion are rarely employed in the treatment of AVN and/or PTA. Due to satisfactory patient outcomes, reverse total shoulder replacement (rTSA) has increased in popularity for the elderly population, while hemiarthroplasty (HA) may be appropriate for some young, active patients. With careful patient selection and meticulous surgical technique, AVN and PTA can be mitigated. Careful indications for ORIF may decrease the frequency of these complications. For most patients, rTSA is the optimal treatment option. Given the frequent utilization of ORIF and the higher than acceptable complication and failure rates, AVN and PTA warrant our attention.

Winquist View of the Femoral Neck: Ideal Visualization of Femoral Neck Fixation.

Background: Despite the increased frequency of cephalomedullary fixation for unstable intertrochanteric hip fractures, failure with screw cut-out and varus collapse remains a significant failure mode. Proper positioning of implants into the femoral neck and head directly influences the stability of fracture fixation. Visualization of the femoral neck and head can be challenging and failure to do so may lead to poor results; Obstacles include patient positioning, body habitus, and implant application tools. We present the "Winquist View," an oblique fluoroscopic projection that shows the femoral neck in profile, aligns the implant and cephalic component, and assists in implant placement. Methods: With the patient in the lateral position, the legs are scissored when possible. Following standard reduction techniques, the Winquist view is used to check reduction prior to surgical draping. Intraoperatively, we rely on a perfect image to place implants in the ideal portion of the femoral neck, with a trajectory that achieves the center-center or center-low position of the femoral neck. This is achieved by incorporating the anterior-posterior, lateral, and Winquist view. Results: We present 3 patients who underwent fixation with a cephalomedullary nail for intertrochanteric hip fractures. The Winquist view facilitated excellent visualization and positioning in all cases. All postoperative courses were uneventful, without failures or complications. Conclusion: While standard intraoperative imaging may be adequate in many cases, the Winquist view facilitates optimal implant positioning and fracture reduction. With lateral imaging, implant insertion guides may obscure visualization of the femoral neck during which Winquist view is the most helpful. Level of Evidence: V.

The Use of the Piriformis Fossa Radiographic Landmark to Predict "In-Out-In" Placement of the Posterosuperior Femoral Neck Screw.

OBJECTIVES: To investigate the correlation between a screw's radiographic relationship to the piriformis fossa with position on CT in the clinical setting. METHODS: Intraoperative fluoroscopic images of patients treated with cannulated screw fixation of a femoral neck fracture, who also had a postoperative CT scan, were retrospectively evaluated by 4 fellowship-trained orthopaedic trauma surgeons. The posterosuperior screw on the AP fluoroscopic view was determined to be above the piriformis fossa (APF) or below the piriformis fossa (BPF). Using CT scan to determine IOI placement, the ability to predict IOI position based on fluoroscopic imaging was evaluated by calculating accuracy, sensitivity, specificity, and interobserver reliability. RESULTS: 73 patients met inclusion criteria. The incidence of IOI screw placement was 59% on CT evaluation. The use of the PF landmark accurately predicted CT findings in 89% of patients. A screw placed APF was 90% sensitive and 88% specific in predicting cortical breach, with near-perfect interobserver agreement (κ = 0.81). CONCLUSION: The use of the PF radiographic landmark is highly sensitive and specific in predicting the placement of an IOI posterosuperior femoral neck screw. LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Patella Fracture Fixation With Novel Wagon Wheel Construct Versus Tension-Band Construct: A Technical Trick.

SUMMARY: Internal fixation of patella fractures remains technically challenging. Cannulated screws with an anterior tension band have been associated with high rates of implant prominence, and fracture comminution can make appropriate application of a tension band impractical. We present the results of a novel technique using a transtendinous/transligamentous mini-fragment plate positioned peripherally around the patella with radially directed screws: termed the wagon-wheel (WW) construct. Compared with a cohort of fractures treated with cannulated screws with an anterior tension band, there was no difference in final range of motion and rate of nonunion. The WW construct had a significantly decreased incidence of symptomatic implants (5% vs. 32%, P = 0.02), rate of reoperation (9% vs. 38%, P = 0.018), dependency on gait aids (10% vs. 38%, P = 0.031), and a faster time to union (HR: 2.2; 95% CI, 1.28-3.95, P = 0.005). In summary, the WW was designed with the goal of obtaining peripheral plate fixation to maximize fragment-specific fixation while minimizing implant prominence. Patients treated with the WW demonstrated reduced rates of implant prominence and reoperation.

Stemless anatomic total shoulder arthroplasty: surgical technique and review of the literature.

Stemless anatomic total shoulder arthroplasty (aTSA) is a promising option for the treatment of degenerative disease in patients. This novel technique avoids the stem-related complications associated with the traditional stemmed aTSA. Stemless aTSA offers additional benefits such as decreased operative time, preservation of bone stock, improved radiographic outcomes, and easier revision. Moreover, loading of the metaphyseal region rather than the diaphysial region with traditional stemmed implants can decrease stress shielding. When compared to stemmed-implants, stemless aTSA has demonstrated similar outcomes and complication rates. The purpose of this article is to analyze published outcomes and complications following the utilization of stemless aTSA. Additionally, key aspects of the surgical technique that may promote optimal results in stemless aTSA implantation are presented.