Measure what matters: Single Assessment Numeric Evaluation (SANE) score as the critical measure for shoulder outcomes.

BACKGROUND: Implementation of a system anchored in patient outcomes is challenged to gain widespread adoption required to demonstrate the value of care provided for shoulder conditions. This is in large part because of the administrative burden created by current tools and clinical implementation barriers that limit practical use and therefore leave most clinicians, administrators, payers, and patients without a measure of what matters most: Are patients improving? Thus, we must ask ourselves, How do we accurately and efficiently measure and report quality of care in a simple, reliable, and easily communicated manner? We propose that the Single Assessment Numeric Evaluation (SANE) score is the best solution to measure patient improvement and can be used universally for all shoulder conditions. The measure is simple, valid, reliable, and sensitive to change and has the lowest implementation barrier compared with all other outcome measures. METHODS: We synthesized the available literature (11 studies) that demonstrates strong psychometrics comparable to legacy measures across >4000 patients with a wide range of shoulder conditions. RESULTS: SANE scores range from 40% to 60% at baseline for most patients before treatment and range from 75% to 85% at 1 year after therapy depending on the condition, similar to legacy scores such as the American Shoulder and Elbow Surgeons score. Additionally, the SANE score shows similar baseline and post-care measures across conditions that can be used to guide clinical care. This finding shows that the observed baseline and improvement scores can provide valuable patient assessment and can be used in aggregate for quality improvement and other value-based purposes. CONCLUSION: We strongly recommend the SANE score as the primary patient outcome measure for patients with all shoulder conditions, given the value of measuring every patient's progress and growing pressure to quantify patient outcomes.

Radiographic and clinical outcomes after definitive spine fusion for skeletally immature patients with idiopathic scoliosis.

PURPOSE: To assess the intermediate-term radiographic and clinical outcomes of skeletally immature idiopathic scoliosis (IS) patients that underwent definitive fusion (DF). METHODS: A retrospective review of patients with IS who were Risser 0 with open tri-radiate cartilages at the time of DF with minimum 5-year follow-up. Outcomes included Scoliosis Research Society (SRS)-30 scores, major Cobb angle, pulmonary function tests (PFTs), and unplanned returns to the operating room (UPROR). Adding-on was defined as progression of the major Cobb angle > 5° or tilt of the lowest instrumented vertebra > 5°. RESULTS: Thirty-two patients (78% female, mean age 12.2 ± 1.3 years old, mean preoperative major Cobb 64.8° ± 15.9) were included. Of these patients, 20 (62.5%) experienced adding-on and 6 (18.8%) required a revision surgery to correct their progressive spinal deformity. Adding-on was associated with lower 5-year postoperative SRS scores for appearance (3.7 ± 0.7 vs 4.4 ± 0.3, p = 0.0126), mental health (4.2 ± 0.6 vs 4.6 ± 0.3, p = 0.0464), satisfaction with treatment (4.0 ± 0.8 vs 4.7 ± 0.4, p = 0.0140), and total score (4.0 ± 0.4 vs 4.4 ± 0.2, p = 0.0035). The results of the PFTs did not differ between groups. Patients experienced an average of 0.53 UPROR/patient. CONCLUSION: DF in skeletally immature patients results in a high rate of adding-on, which adversely affects Health-Related Quality of Life. However, reoperation rates, both planned and unplanned, remain lower when compared to patients undergoing growth-friendly treatment.

ICD-10 diagnosis codes in electronic health records do not adequately capture fracture complexity for proximal humerus fractures.

BACKGROUND: The ability to do comparative effectiveness research (CER) for proximal humerus fractures (PHF) using data in electronic health record (EHR) systems and administrative claims databases was enhanced by the 10th revision of the International Classification of Diseases (ICD-10), which expanded the diagnosis codes for PHF to describe fracture complexity including displacement and the number of fracture parts. However, these expanded codes only enhance secondary use of data for research if the codes selected and recorded correctly reflect the fracture complexity. The objective of this project was to assess the accuracy of ICD-10 diagnosis codes documented during routine clinical practice for secondary use of EHR data. METHODS: A sample of patients with PHFs treated by orthopedic providers across a large, regional health care system between January 1, 2016, and December 31, 2018, were retrospectively identified from the EHR. Four fellowship-trained orthopedic surgeons reviewed patient radiographs and recorded the Neer Classification characteristics of displacement, number of parts, and fracture location(s). The fracture characteristics were then reviewed by a trained coder, and the most clinically appropriate ICD-10 diagnosis code based on the number of fracture parts was assigned. We assessed congruence between ICD-10 codes documented in the EHR and radiograph-validated codes, and assessed sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for EHR-documented ICD-10 codes. RESULTS: There were 761 patients with unilateral, closed PHF who met study inclusion criteria. On average, patients were 67 years of age and 77% were female. Based on radiograph review, 37% were 1-part fractures, 42% were 2-part, 11% were 3-part, and 10% were 4-part fractures. Of the EHR diagnosis codes recorded during clinical practice, 59% were "unspecified" fracture diagnosis codes that did not identify the number of fracture parts. Examination of fracture codes revealed PPV was highest for 1-part (PPV = 0.66, 95% confidence interval [CI] 0.60-0.72) and 4-part fractures (PPV = 0.67, 95% CI 0.13-1.00). CONCLUSIONS: Current diagnosis coding practices do not adequately capture the fracture complexity needed to conduct subgroup analysis for PHF. Conclusions drawn from population studies or large databases using ICD-10 codes for PHF classification should be interpreted within this limitation. Future studies are warranted to improve diagnostic coding to support large observational studies using EHR and administrative claims data.

30-Day Postoperative Complications After Surgical Treatment of Proximal Humerus Fractures: Reverse Total Shoulder Arthroplasty Versus Hemiarthroplasty.

INTRODUCTION: The purpose of this study was to evaluate risk factors associated with complications after reverse total shoulder arthroplasty (TSA) and hemiarthroplasty for the treatment of proximal humerus fractures. METHODS: A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database was conducted. Current Procedural Terminology codes were used to identify patients treated for proximal humerus fracture with reverse TSA or hemiarthroplasty between 2005 and 2018. RESULTS: One thousand five hundred sixty-three shoulder arthroplasties were conducted: 436 hemiarthroplasties and 1,127 reverse TSA. The overall complication rate was 15.4% (15.7% reverse TSA; 14.7% hemiarthroplasty) (P = 0.636). Most frequent complications included transfusion 11.1%, unplanned readmission 3.8%, and revision surgery 2.1%. A 1.1% incidence of thromboembolic events was noted. Complications occurred most frequently in patients older than 65 years; male; and patients with anemia, American Society of Anesthesiologists classification III-IV, inpatient procedure, bleeding disorders, duration of surgery >106 minutes, and length of stay >2.5 days. Patients with body mass index >36 kg/m2 had a decreased risk of 30-day postoperative complications. DISCUSSION: There was a 15.4% complication rate in the early postoperative period. In addition, no notable difference was found in complication rates between groups (hemiarthroplasty: 14.7%; reverse TSA 15.7%). Future studies are needed to determine whether there is a difference between these groups in the long-term outcome and survivorship of these implants.

Arm injury in youth baseball players: a 10-year cohort study.

BACKGROUND: Arm injuries are commonly encountered in baseball as young athletes play into adulthood. The purpose of this study was to examine the incidence of arm injury and risk for surgery in adolescent baseball players followed over a 10-year period from scholastic, age-group, and travel baseball leagues through their highest level of competition. METHODS: A prospective study was conducted enrolling middle and high school baseball players in 2010-2012, then followed for 10 years or until retirement from competitive baseball. Players were included if fully participating in team activities at the time of preseason study enrollment. Players with prior arm (shoulder or elbow) surgery or those diagnosed with time loss arm injury within the past year were excluded. Only shoulder and elbow overuse problems resulting in time-loss from sport and medical attention from a sports medicine physician or orthopedic surgeon were documented as injuries in this study. Musculoskeletal overuse injuries were classified based on the orchard injury classification system. Incidence proportion and risk ratio (RR) and 95% confidence intervals (CIs) for initial injury and injuries requiring surgery were calculated. RESULTS: A total of 261 pitchers (age: 14.2 ± 2.6 years; follow-up: 4.2 ± 2.7 years) were enrolled. Twenty percent of the cohort was followed for ≥7 years. The overall injury incidence was 25.6/100 athletes (95% CI 21-31) with a cumulative surgical incidence of 5.4/100 athletes (95% CI 3.2-8.8). The risk of experiencing shoulder injury (n = 25) and elbow injury (n = 38) were similar (n = 38) (RR 0.7, 95% CI 0.4-1.1). The athletes also presented with a similar frequency of requiring surgery regardless of the injured body part. However, the risk of surgery in those playing beyond the high school level was 4.3 times greater (95% CI 1.2-15.0) than those only playing high school. CONCLUSION: This is the first study to follow a large cohort of youth baseball players as they progress, showing a relatively high arm injury incidence. Shoulder and elbow injury incidence was similar but surgical risk increased playing beyond high school, specifically for the elbow. The high injury frequency and burden of care required by young baseball players as reported in this study is concerning, and strategies to reduce injury should be investigated.

Mental health status, not resilience, influences functional recovery after arthroscopic rotator cuff repairs.

BACKGROUND: Recent literature has shown the importance of patient psychosocial status in overcoming stressful events, such as surgery. Resilience, the ability to "bounce back" from adversity, has been recently correlated to outcomes following arthroscopic rotator cuff repair (RCR). Overall mental well-being has also been shown to be important because patients with clinical depression and anxiety may have worse outcomes. Substantial clinical benefit (SCB) is the threshold of outcome improvement that a patient perceives as considerable. The purpose of this study was to assess the influence of preoperative resilience, mental health status, and rotator cuff tear size on patient outcome recovery measured by the American Shoulder and Elbow Surgeons (ASES) score. METHODS: Patients undergoing arthroscopic RCR performed from 2016 through 2019 at a single tertiary institution by fellowship-trained sports surgeons with a high-volume shoulder practice were included. The Brief Resilience Scale (BRS) score and Veterans RAND 12-Item Health Survey (VR-12) Mental Component Score (MCS) were collected preoperatively. ASES scores were obtained preoperatively, as well as 6 and 12 months postoperatively. Patients were divided into 2 groups based on the SCB threshold of 87 for the ASES score based on validated, established literature. Rotator cuff tear size was classified as small (≤3 cm) or large (>3 cm). VR-12 MCS, BRS, and ASES scores were compared at baseline, 6 months, and 1 year using separate mixed-model analyses of variance between the tear size and SCB groups. For ASES score comparison, the VR-12 MCS was used as a covariate to account for differences in baseline mental status. RESULTS: RCR was performed in 119 patients, with an average age of 61 years (standard deviation, 10 years). There were 71 male and 48 female patients. At 6 months, 43% of patients met the SCB threshold. The VR-12 MCS was significantly different between RCR patients who met the SCB threshold for the ASES score and those who did not at 6 and 12 months for large rotator cuff tears (P = .001) but not small tears (P = .07). The BRS score was not different between the tear size and SCB groups at any time point (P = .12). CONCLUSION: Our results show that patients who met the SCB threshold at 6 months postoperatively after arthroscopic RCR demonstrated higher preoperative VR-12 MCS values; however, higher preoperative BRS scores were not seen in those meeting the SCB threshold. In fact, when baseline VR-12 MCS values were accounted for in patients with large rotator cuff tears, the differences in ASES scores normalized. This finding suggests that baseline mental health status, as measured by the VR-12 MCS, significantly influenced patients' functional recovery following RCR. Future research should focus on preoperative psychosocial well-being to optimize postoperative outcomes.

Combined Transphyseal and Lateral Extra-articular Pediatric Anterior Cruciate Ligament Reconstruction: A Novel Technique to Reduce ACL Reinjury While Allowing for Growth.

BACKGROUND: Treatment of anterior cruciate ligament (ACL) injuries in the adolescent population continues to be complicated by an unacceptably high rate of secondary ACL injury. PURPOSE: To describe the failure rate and outcomes after a hybrid pediatric ACL reconstruction (ACLR) employing transphyseal hamstring (TPH) autograft combined with an extra-articular technique using an iliotibial band (ITB) autograft. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Consecutive patients undergoing combined TPH-ITB ACLR between January 2012 and April 2017 with a minimum 2-year follow-up were reviewed. With the goal of decreasing ACL graft injury in this high-risk group, this technique employed anteromedial portal drilling for TPH with an extraosseous femoral ITB technique and intra-articular TPH-ITB grafts fixed within the tibial bone tunnel. Demographics, bone age, standing alignment radiograph for growth and mechanical axis grade, return to sport, graft failure, and patient-reported outcome measures were analyzed. RESULTS: A total of 61 knees in 60 adolescents underwent the combined TPH-ITB ACLR, with 57 knees (93.4%) meeting inclusion criteria with a mean follow-up of 38.5 months (range, 24-78 months). Only 3 of 57 knees (5.3%) sustained ACL reinjury. The mean age was 13.0 years (range, 11-16 years) with 36 male patients (mean bone age, 14.2 years) and 21 female patients (mean bone age, 13.3 years), and 91% of patients (52 of 57) returned to sport. Participants demonstrated a high functional level at final follow-up, with a mean score of 91.2 (range, 46.7-100) on the Pediatric International Knee Documentation Committee (Pedi-IKDC) Subjective Knee Evaluation Form and mean score of 22.4 (range, 4-30) on the Pediatric Functional Activity Brief Scale (Pedi-FABS). To critically assess growth, a cohort with ≥18 months of growth remaining at surgery was evaluated at maturity. No difference was seen in mean operative and nonoperative leg growth (49.7 mm and 49.8 mm). Although no family reported cosmetic or functional alignment or length concerns, 1 of 18 (5.5%) had a final limb length discrepancy >10 mm (12 mm) and a perioperative alignment difference (0-Grade II valgus). CONCLUSION: Combined TPH-ITB ACLR in adolescents resulted in high activity levels (Pedi-FABS, 22.4; median, 25) and a low (5.3%) graft failure rate at a mean 38.5 months.