Patient Perception of Social Media Use by Orthopaedic Surgeons: A Pilot Study.

Background: Social media (SM) use by orthopaedic surgeons is becoming increasingly common; nonetheless, it needs to be clarified how patients perceive the content posted by physicians. Purpose: To characterize SM content posted by orthopaedic surgeons while investigating patient perceptions of this content and how it may influence their health care decisions. Study Design: Cross-sectional study. Methods: Posts on SM outlets by orthopaedic surgeons were reviewed and categorized. A survey to assess patient perception of these categories was administered between December 2021 and February 2022 in the clinics of 3 orthopaedic surgeons. Survey results were analyzed for differences in patient SM use and perception of SM content types. Results: There were 250 completed surveys. SM use was high among all age groups; however, the 18 to 24 years (87.1%) and 25 to 34 years (86.4%) age groups were more likely than older age groups to report daily use (P = .002). Overall, 17% of patients reported using SM to see information about their health care at least once per month, 21% reported reviewing the SM account of a physician at least once per month, 19% reported that they were likely or very likely to view the SM account of their physician, and 23% reported that SM content was likely or very likely to influence which physician they see. Patients held the most consistently positive view of posts that educated patients, discussed sports team coverage, and provided patient testimonials. Patients had consistently neutral views of posts educating colleagues, discussing presentations at national meetings, displaying aspects of surgeons' personal lives, and supporting marginalized groups. Several post categories elicited highly polarized responses-including those discussing research publications and showing surgical techniques or pictures/videos taken during surgery. Respondents had a consistently negative response to posts making political statements. Conclusion: SM is likely a useful tool to help physicians interact with patients. Physicians who wish to interact with patients should consider posting content viewed most positively-including posts educating patients, discussing sports team coverage, and providing patient testimonials. Content that is viewed less favorably should be posted sparingly or with a sensitive tag.

Early analysis shows that endoscopic flexor hallucis longus transfer has a promising cost-effectiveness profile in the treatment of acute Achilles tendon ruptures.

PURPOSE: Current options for treating an Achilles tendon rupture (ATR) include conservative and surgical approaches. Endoscopic flexor hallucis longus (FHL) transfer has been recently proposed to treat acute ruptures, but its cost-effectiveness potential remains to be evaluated. Therefore, the objective of this study was to perform an early cost-effectiveness analysis of endoscopic FHL transfer for acute ATRs, comparing the costs and benefits of current treatments from a societal perspective. METHODS: A conceptual model was created, with a decision tree, to outline the main health events during the treatment of an acute ATR. The model was parameterized using secondary data. A systematic review of the literature was conducted to gather information on the outcomes of current treatments. Data related to outcomes of endoscopic FHL transfers in acute Achilles ruptures was obtained from a single prospective study. Analysis was limited to the two first years. The incremental cost-effectiveness ratio was the main outcome used to determine the preferred strategy. A willingness-to-pay threshold of $100,000 per quality-adjusted life-year was used. Sensitivity analyses were performed to determine whether changes in input parameters would cause significant deviation from the reference case results. Specifically, a probability sensitivity analysis was conducted using Monte Carlo simulations, and a one-way sensitivity analysis was conducted by sequentially varying each model parameter within a given range. RESULTS: For the reference case, incremental cost-effectiveness ratios exceeded the willingness-to-pay threshold for all the surgical approaches. Overall, primary treatment was the main cost driver. Conservative treatment showed the highest direct costs related to the treatment of complications. In the probabilistic sensitivity analysis, at a willingness-to-pay threshold of $100,000, open surgery was cost-effective in 50.9%, minimally invasive surgery in 55.8%, and endoscopic FHL transfer in 72% of the iterations. The model was most sensitive to parameters related to treatment utilities, followed by the costs of primary treatments. CONCLUSION: Surgical treatments have a moderate likelihood of being cost-effective at a willingness-to-pay threshold of $100,000, with endoscopic FHL transfer showing the highest likelihood. Following injury, interventions to improve health-related quality of life may be better suited for improved cost-effectiveness. LEVEL OF EVIDENCE: Level III.

Ambulatory Surgery Centers Significantly Decrease Total Health Care Expenditures in Primary Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) is a commonly performed orthopaedic procedure. The volume and cost of ACLR procedures are increasing annually, but the drivers of these cost increases are not well described. PURPOSE: To analyze the modifiable drivers of total health care utilization (THU), immediate procedure reimbursement, and surgeon reimbursement for patients undergoing ACLR using a large national commercial insurance database from 2013 to 2017. STUDY DESIGN: Descriptive epidemiology study. METHODS: For this study, the cohort consisted of patients identified in the MarketScan Commercial Claims and Encounters database who underwent outpatient arthroscopic ACLR in the United States from 2013 to 2017. Patients with Current Procedural Terminology code 29888 were included. THU was defined as the sum of any payment related to the ACLR procedure from 90 days preoperatively to 180 days postoperatively. A multivariable model was utilized to describe the patient- and procedure-related drivers of THU, immediate procedure reimbursement, and surgeon reimbursement. RESULTS: There were 34,862 patients identified. On multivariable analysis, the main driver of THU and immediate procedure reimbursement was an outpatient hospital as the surgical setting (US$6789 increase in THU). The main driver of surgeon reimbursement was an out-of-network surgeon (US$1337 increase). Health maintenance organization as the insurance plan type decreased THU, immediate procedure reimbursement, and surgeon reimbursement (US$955, US$108, and US$38 decrease, respectively, compared with preferred provider organization; P < .05 for all). CONCLUSION: Performing procedures in more cost-efficient ambulatory surgery centers had the largest effect on decreasing health care expenditures for ACLR. Health maintenance organizations aided in cost-optimization efforts as well, but had a minor effect on surgeon reimbursement. Overall, this study increases transparency into what drives reimbursement and serves as a foundation for how to decrease health care expenditures related to ACLR.

SLAP Repair Versus Biceps Tenodesis in Patients Younger Than 40 Years: A Cost-Effectiveness Analysis.

Background: The surgical management of type II superior labrum anterior and posterior (SLAP) tears in patients younger than 40 years is controversial, but growing evidence suggests comparable outcomes between primary SLAP repair and primary biceps tenodesis, with lower rates of reoperations after primary biceps tenodesis. Given the relatively similar patient-reported outcomes, cost-effectiveness analyses of direct and indirect costs associated with the two procedures propound a valuable comparative technique. Hypothesis: In this value-based comparison of SLAP repair versus biceps tenodesis, we hypothesized that biceps tenodesis would be more cost-effective than SLAP repair in patients younger than 40 years. Study Design: Economic and decision analysis; Level of evidence, 4. Methods: A 1-month Markov cycle was simulated to reflect 10 years of health outcomes. Health states were selected based on outcomes that are especially important in assessing indirect costs for a younger, active patient population: return-to-sport rates, which demonstrate a return to baseline function, and reoperation rates. Transition state probabilities were obtained through an index systematic review and meta-analysis comparing labral repair and biceps tenodesis for the treatment of type II SLAP lesions in patients younger than 40 years. Health state utility and cost values were obtained from accepted values denoted in existing literature. Results: Both primary SLAP repair and primary biceps tenodesis yielded an average expected 8.1 quality-adjusted life years over the 10-year period. The average cost (in 2021 US$) was $16,619 for biceps tenodesis and $19,388 for SLAP repair. Conclusion: In a younger patient population, SLAP repair and biceps tenodesis had comparable quality-adjusted life years and utility in the treatment of type II SLAP tears; however, SLAP repair cost $19,388, while biceps tenodesis cost $16,619, reflecting a 14% cost savings with biceps tenodesis. These findings can be extrapolated to further establish the role for these procedures in treating SLAP tears.

Venous Thromboembolism Chemoprophylaxis in Knee Arthroscopy: A Break-Even Analysis of Cost.

BACKGROUND: Symptomatic venous thromboembolism (VTE) is a serious and costly complication after knee arthroscopy. There continues to be debate regarding the use of VTE prophylaxis after knee arthroscopy, and minimal research has explored its cost-effectiveness. HYPOTHESIS: Both aspirin and enoxaparin would be cost-effective in preventing symptomatic VTE. STUDY DESIGN: Economic and decision analysis; Level of evidence, 3. METHODS: The literature was searched and the TriNetX research database was queried to determine a range of initial rates of VTE. An open-access retail database was used to determine the mean retail price for aspirin (325 mg) and enoxaparin (30 mg and 40 mg). Our institutional records were used to determine the cost of treating VTE. A "break-even" analysis was then performed to determine the absolute risk reduction necessary to make these drugs cost-effective. This value was then used to calculate the number of patients who would need to be treated (NNT) to prevent a single VTE while still breaking even on cost. RESULTS: The cost of treating VTE was $9407 (US Dollars). Aspirin (325 mg), enoxaparin (30 mg), and enoxaparin (40 mg) were found to cost $1.86, $188.72, and $99.99, respectively. The low, TriNetX, and high rates of VTE were 0.34%, 0.86%, and 10.9%, respectively. Aspirin was cost-effective at all 3 rates if the initial rate decreased by 0.02% (NNT = 5058). Both formulations of enoxaparin were cost-effective at the high initial rate if they decreased by 2.01% (NNT = 50) and 1.06% (NNT = 94), respectively. However, at the low and TriNetX rates, the 2 doses of enoxaparin were not cost-effective because their final break-even rate exceeded the initial VTE rate. CONCLUSION: Aspirin and, in some cases, enoxaparin are cost-effective treatments for VTE prophylaxis after knee arthroscopy.

Trends in Health Care Expenditures and Patient Out-of-Pocket Expenses in Primary Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) is one of the most commonly performed orthopaedic procedures in the United States, and the number of procedures is increasing annually, as is the cost. Patients are expected to shoulder a larger out-of-pocket expenditure. PURPOSE: To answer the following questions: (1) How is reimbursement changing for ACLR, and how is this affecting patients' out-of-pocket expenditures? (2) How are reimbursements from payers and patients' out-of-pocket expenses for ACLR distributed, and how is this changing? (3) Does performing ACLR in an ambulatory surgery center (ASC) result in lower costs for payers and patients? STUDY DESIGN: Economic and decision analysis study; Level of evidence, 4. METHODS: A total of 37,763 patients who underwent outpatient primary arthroscopic ACLR in the United States between 2013 and 2017 were identified using the IBM MarketScan Commercial Claims and Encounters Database. Patients with concomitant procedures and revision ACLR were excluded. Recorded outcomes were total patient payments and reimbursed claim totals in US dollars. RESULTS: Day-of-surgery reimbursement decreased 4.3% from $11,536 in 2013 to $11,044 in 2017, while patient out-of-pocket expenses increased 36% from $1085 in 2013 to $1480 in 2017. Day-of-surgery charges were the highest expense for patients, followed by physical therapy and magnetic resonance imaging (MRI) costs. Total reimbursement for MRI decreased 22.5%, while patient out-of-pocket expenses for MRI increased 166%. ACLR performed in an outpatient hospital resulted in 61% greater day-of-surgery expenditure for payers compared with ACLR performed in an ASC; however, the median total patient out-of-pocket savings for ACLRs performed in an ASC versus outpatient hospital was only $11. CONCLUSION: Out-of-pocket expenses for patients are increasing as they are forced to cover a larger percentage of their health care costs despite overall payer reimbursement decreasing. High-deductible health plans reimbursed the least out of all insurance types while having the highest patient out-of-pocket expenditure.

Midterm Outcomes of Posterior Medial Meniscus Root Tear Repair: A Systematic Review.

BACKGROUND: Whereas there has been growing interest in surgical repair of posterior medial meniscus root tears (PMMRTs), our understanding of the medium- and long-term results of this procedure is still evolving. PURPOSE: To report midterm clinical outcomes from PMMRT repairs. STUDY DESIGN: Systematic review. METHODS: A literature review for this systematic analysis was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We identified studies that reported the results of arthroscopic repair of PMMRTs. Functional and imaging outcomes were reviewed and summarized. RESULTS: In total, 28 studies with a total of 994 patients (83% female) with an overall mean age of 57.1 were included in this review. Clinical outcomes (Lysholm, International Knee Documentation Committee, Hospital for Special Surgery, and Tegner scores) were improved at final follow-up in all studies. Of patients, 49% had radiographic progression of at least 1 grade in the Kellgren-Lawrence scale at a mean follow-up of 4.0 years in 11 studies. Cartilage degeneration had progressed at least 1 grade on magnetic resonance imaging scans in 23% of patients at a mean follow-up of 31.6 months in 4 studies. CONCLUSION: PMMRT repairs provide a functional benefit with consistent improvements in clinical outcome scores. There is some evidence that PMMRT repair slows the progression of osteoarthritis but does not prevent it at midterm follow-up.

Increased Total Cost and Lack of Diagnostic Utility for Emergency Department Visits After ACL Injury.

BACKGROUND: Patients are commonly evaluated at the emergency department (ED) with acute anterior cruciate ligament (ACL) tears, but providers without orthopaedics training may struggle to correctly diagnose these injuries. HYPOTHESIS: It was hypothesized that few patients would be diagnosed with an ACL tear while in the ED and that these patients would be of lower socioeconomic status and more likely to have public insurance. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The 2017 State Ambulatory Surgery and Services Database (SASD) and State Emergency Department Database (SEDD) from the state of Florida were utilized in this study. Cases with Current Procedural Terminology code 29888 (arthroscopically aided ACL reconstruction [ACLR]) were selected from the SASD, and data from the SEDD were matched to patients who had an ED visit for a knee injury within 120 days before ACLR. Chi-square analysis was used to test for differences in patient and surgical variables between the ED visit and nonvisit patient groups. A generalized linear model was created to model the effect of ED visit on total cost for an ACL injury. RESULTS: While controlling for differences in patient characteristics and concomitant procedure usage, a visit to the ED added $4587 in total cost (P < .001). The ED visit cohort contained a greater proportion of patients with Medicaid (20.2% vs 9.1%), patients who were Black (18.4% vs 10.3%), and patients in the lowest income quartile (34.4% vs 25.0%) (P < .001 for all). In the ED visit cohort, 14.4% of patients received an allograft versus 10.1% in the non-ED visit cohort (P = .001) despite having a similar mean age. An ACL sprain was diagnosed in only 29 of the 645 (4.5%) patients who visited the ED. CONCLUSION: Utilizing the ED for care after an ACL injury was expensive, averaging a $4587 increase in total cost associated with ACLR. However, patients rarely left with a definitive diagnosis, with only 4.5% of patients who underwent ACLR being correctly diagnosed with an ACL tear in the ED. This additional cost was levied disproportionately on patients of low socioeconomic status and patients with Medicaid.

Cost Drivers Associated With Anterior Shoulder Stabilization Surgery.

BACKGROUND: Arthroscopic Bankart repair, open Bankart repair, and the Latarjet procedure are common treatments for anterior shoulder instability; however, little is known of costs by patient- and surgeon-specific factors. This study aimed to identify areas where cost reduction may be achieved. HYPOTHESIS: Increased total charges will be associated with low-volume surgeons and surgical facilities, hospital-owned facilities, open surgical techniques, and patients with at least 1 comorbidity. STUDY DESIGN: Economic and decision analysis; Level of evidence, 3. METHODS: The 2014 State Ambulatory Surgery and Services Databases from 6 states were utilized. There were 3 Current Procedural Terminology codes (23455, 23462, 29806) used to identify open Bankart repair, the Latarjet procedure, and arthroscopic Bankart repair, respectively. Patient demographic and surgical variables were evaluated on a univariate basis, and all significant factors were then included in the multiple linear regression to determine which factors had the largest effect on cost. Total charges billed for the encounter were used as a proxy for cost of surgery. RESULTS: For open Bankart repair, arthroscopic Bankart repair, and the Latarjet procedure, longer operative times increased costs, and high-volume surgical facilities had decreased charges. For the arthroscopic Bankart group, additional factors that increased charges included postoperative hospital admission (US$11,516; P < .001), patient residence in a ZIP code with a below-median income (US$2909; P < .001), presence of a comorbidity (US$1982; P < .001), male sex (US$1545; P = .003), Hispanic race (US$2493; P = .005), and use of regional anesthesia (US$1898; P = .025). Additional cost drivers for the Latarjet procedure included postoperative hospital admission (US$7028; P = .022) and older age (US$187/y; P = .039). CONCLUSION: Postoperative admission to the hospital was the largest cost driver for arthroscopic Bankart repair and the Latarjet procedure. Low-volume facilities were the largest cost driver for open Bankart repair. High-volume surgery centers had lower costs when compared with low-volume surgery centers. Regional anesthesia increased costs in the arthroscopic Bankart group. These findings may help to show where cost savings can be achieved, particularly considering increasing trends toward bundled health care payments.

Safer and Cheaper: An Enhanced Milestone-Based Return to Play Program After Anterior Cruciate Ligament Reconstruction in Young Athletes Is Cost-Effective Compared With Standard Time-Based Return to Play Criteria.

BACKGROUND: Safe return to play (RTP) after anterior cruciate ligament (ACL) reconstruction is critical to patient satisfaction. Enhanced rehabilitation after ACL reconstruction with appropriate objective criteria for RTP may reduce the risk of subsequent injury. The cost-effectiveness of an enhanced RTP (eRTP) strategy relative to standard post-ACL reconstruction rehabilitation has not been investigated. PURPOSE: To determine if an eRTP strategy after ACL reconstruction is cost-effective compared with standard rehabilitation. STUDY DESIGN: Economic and decision analysis. METHODS: A decision-analysis model was utilized to compare standard rehabilitation with an eRTP strategy, which includes additional neuromuscular retraining, advanced testing, and follow-up physician visits. Cost-effectiveness was evaluated from a payer perspective. Costs of surgical procedures and rehabilitation protocols, risks of graft rupture and contralateral ACL injury, risk reductions as a result of the eRTP strategy, and relevant health utilities were derived from the literature. An incremental cost-effectiveness ratio of <$100,000/quality-adjusted life-year was used to determine cost-effectiveness. Sensitivity analyses were performed on pertinent model parameters to assess their effect on base case conclusions. In the base case analysis, the eRTP strategy cost was conservatively estimated to be $969 more than the standard rehabilitation protocol. Completion of the eRTP strategy was considered to confer a 25% risk reduction for graft rupture in comparison with standard rehabilitation. RESULTS: The eRTP strategy was more cost-effective than standard rehabilitation alone. Based on 1-way threshold analyses, the eRTP strategy was cost-effective as long as its additional cost over standard rehabilitation was <$2092 or the eRTP strategy decreased the incidence of contralateral ACL rupture by >13.8%. CONCLUSION: The eRTP strategy in this study adds additional neuromuscular retraining and additional physician follow-up-as well as advanced testing goals upon which RTP is contingent-to traditional physical therapy. Our data suggest that these additions are cost-effective, even assuming only modest associated decreases in ACL graft failure. This study also determined that the only variable that had the potential to change the cost-effectiveness conclusion based on predetermined ranges was the additional cost of rehabilitation based on 1-way sensitivity analysis. CLINICAL RELEVANCE: This study provides evidence of cost-effectiveness for payers, supporting the use of enhanced RTP programs. The sensitivity analyses herein may be used to determine if any given RTP program going forward is cost-effective, regardless of the exact components of the program.

Cost-efficacy of Knee Cartilage Defect Treatments in the United States.

BACKGROUND: Multiple knee cartilage defect treatments are available in the United States, although the cost-efficacy of these therapies in various clinical scenarios is not well understood. PURPOSE/HYPOTHESIS: The purpose was to determine cost-efficacy of cartilage therapies in the United States with available mid- or long-term outcomes data. The authors hypothesized that cartilage treatment strategies currently approved for commercial use in the United States will be cost-effective, as defined by a cost <$50,000 per quality-adjusted life-year over 10 years. STUDY DESIGN: Systematic review. METHODS: A systematic search was performed for prospective cartilage treatment outcome studies of therapies commercially available in the United States with minimum 5-year follow-up and report of pre- and posttreatment International Knee Documentation Committee subjective scores. Cost-efficacy over 10 years was determined with Markov modeling and consideration of early reoperation or revision surgery for treatment failure. RESULTS: Twenty-two studies were included, with available outcomes data on microfracture, osteochondral autograft, osteochondral allograft (OCA), autologous chondrocyte implantation (ACI), and matrix-induced ACI. Mean improvement in International Knee Documentation Committee subjective scores at final follow-up ranged from 17.7 for microfracture of defects >3 cm2 to 36.0 for OCA of bipolar lesions. Failure rates ranged from <5% for osteochondral autograft for defects requiring 1 or 2 plugs to 46% for OCA of bipolar defects. All treatments were cost-effective over 10 years in the baseline model if costs were increased 50% or if failure rates were increased an additional 15%. However, if efficacy was decreased by a minimum clinically important amount, then ACI (periosteal cover) of femoral condylar lesions ($51,379 per quality-adjusted life-year), OCA of bipolar lesions ($66,255) or the patella ($66,975), and microfracture of defects >3 cm2 ($127,782) became cost-ineffective over 10 years. CONCLUSION: Currently employed treatments for knee cartilage defects in the United States are cost-effective in most clinically acceptable applications. Microfracture is not a cost-effective initial treatment of defects >3 cm2. OCA transplantation of the patella or bipolar lesions is potentially cost-ineffective and should be used judiciously.

Recurrent Shoulder Instability: Do Morbidity and Treatment Differ Based on Insurance?

BACKGROUND: Patients with public insurance often face barriers to obtaining prompt orthopaedic care. For patients with recurrent traumatic anterior shoulder instability, delayed care may be associated with increasing bone loss and subsequently more extensive surgical procedures. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate whether differences exist in patients undergoing treatment for shoulder instability between those with Medicaid versus non-Medicaid insurance. We hypothesized that at the time of surgery, Medicaid patients would have experienced greater delays in care, would have a more extensive history of instability, would have more bone loss, and would require more extensive surgical procedures than other patients. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients were identified who underwent surgical stabilization for traumatic anterior shoulder instability between January 1, 2011, and December 1, 2015, at a single sports medicine practice. Clinic, billing, and operative records were reviewed for each patient to determine age, sex, insurance type, total number of instability episodes, time from first instability episode to surgery, intraoperative findings, and procedure performed. Glenoid bone loss was quantified by use of preoperative imaging studies. RESULTS: During this time period, 206 patients (55 Medicaid, 131 private insurance, 11 Tricare, 9 workers' compensation) underwent surgical stabilization for traumatic anterior shoulder instability. Average wait time from initial injury to surgery was 1640 days (95% CI, 1155-2125 days) for Medicaid patients compared with 1237 days (95% CI, 834-1639 days) for others (P = .005). Medicaid patients were more likely to have sustained 5 or more instability events at the time of surgery (OR, 3.3; 95% CI, 1.64-6.69; P = .001), had a higher risk of having 15% or more glenoid bone loss on preoperative imaging (OR, 3.5; 95% CI, 1.3-10.0; P = .01), and had a higher risk of requiring Latarjet or other open stabilization procedures as opposed to an arthroscopic repair (OR, 3.0; 95% CI, 1.5-6.2; P = .002) when compared with other patients. CONCLUSION: Among patients undergoing surgery for traumatic anterior shoulder instability, patients with Medicaid had significantly more delayed care. Correspondingly, they reported a more extensive history of instability, were more likely to have severe bone loss, and required more invasive stabilization procedures.

Meniscus Root Repair vs Meniscectomy or Nonoperative Management to Prevent Knee Osteoarthritis After Medial Meniscus Root Tears: Clinical and Economic Effectiveness.

BACKGROUND: Medial meniscus root tears are a common knee injury and can lead to accelerated osteoarthritis, which might ultimately result in a total knee replacement. PURPOSE: To compare meniscus repair, meniscectomy, and nonoperative treatment approaches among middle-aged patients in terms of osteoarthritis development, total knee replacement rates (clinical effectiveness), and cost-effectiveness. STUDY DESIGN: Meta-analysis and cost-effectiveness analysis. METHODS: A systematic literature search was conducted. Progression to osteoarthritis was pooled and meta-analyzed. A Markov model projected strategy-specific costs and disutilities in a cohort of 55-year-old patients presenting with a meniscus root tear without osteoarthritis at baseline. Failure rates of repair and meniscectomy procedures and disutilities associated with osteoarthritis, total knee replacement, and revision total knee replacement were accounted for. Utilities, costs, and event rates were based on literature and public databases. Analyses considered a time frame between 5 years and lifetime and explored the effects of parameter uncertainty. RESULTS: Over 10 years, meniscus repair, meniscectomy, and nonoperative treatment led to 53.0%, 99.3%, and 95.1% rates of osteoarthritis and 33.5%, 51.5%, and 45.5% rates of total knee replacement, respectively. Meta-analysis confirmed lower osteoarthritis and total knee replacement rates for meniscus repair versus meniscectomy and nonoperative treatment. Discounted 10-year costs were $22,590 for meniscus repair, as opposed to $31,528 and $25,006 for meniscectomy and nonoperative treatment, respectively; projected quality-adjusted life years were 6.892, 6.533, and 6.693, respectively, yielding meniscus repair to be an economically dominant strategy. Repair was either cost-effective or dominant when compared with meniscectomy and nonoperative treatment across a broad range of assumptions starting from 5 years after surgery. CONCLUSION: Repair of medial meniscus root tears, as compared with total meniscectomy and nonsurgical treatment, leads to less osteoarthritis and is a cost-saving intervention. While small confirmatory randomized clinical head-to-head trials are warranted, the presented evidence seems to point relatively clearly toward adopting meniscus repair as the preferred initial intervention for medial meniscus root tears.

Performance of PROMIS Global-10 Compared With Legacy Instruments for Rotator Cuff Disease.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 was recently developed to assess physical and mental health and provide an estimated EuroQol-5 Dimension (EQ-5D) score. This instrument needs to be validated for specific patient cohorts such as those with rotator cuff pathology. HYPOTHESIS: There is moderate to high correlation between the PROMIS Global-10 and legacy patient-reported outcome measures; PROMIS Global-10 will not show ceiling effects; and estimated EQ-5D scores will show good correlation and low variance with actual EQ-5D scores. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A total of 323 patients with rotator cuff disease were prospectively enrolled before treatment. Each patient completed the PROMIS Global-10, EQ-5D, American Shoulder and Elbow Surgeons (ASES) shoulder assessment form, and Single Assessment Numeric Evaluation (SANE), and those with known rotator cuff tears completed the Western Ontario Rotator Cuff Index (WORC). Spearman correlations were calculated. Bland-Altman agreement tests were conducted between estimated EQ-5D scores from the PROMIS and actual EQ-5D scores. Ceiling and floor effects were assessed, defined as ≥15% respondents with highest or lowest possible score. RESULTS: Correlation between the PROMIS Global-10 and EQ-5D was excellent (0.70, P < .0001). Correlation of the PROMIS physical scores was excellent-good with the ASES (0.62, P < .0001), good with the WORC (0.47, P < .0001), and good with the SANE (0.41, P < .0005). Correlation between the PROMIS mental scores was poor with the ASES (0.34, P < .0001), the WORC (0.32, P = .0016), and the SANE (0.24, P < .0001). No floor or ceiling effects were found. Agreement analysis showed substantial variance in individual scores, despite the overall similarity in mean scores between the estimated and actual EQ-5D scores, indicating poor agreement. Bland-Altman 95% limits of agreement for estimated EQ-5D scores ranged from 34% below to 31% above actual EQ-5D scores. CONCLUSION: Physical function scores of the PROMIS Global-10 show high correlation with legacy patient-reported outcome instruments, suggesting that it is a reliable tool for outcome assessment in a population with rotator cuff pathology. The large variability in 95% limit of agreement suggested that the estimated EQ-5D scores from the PROMIS Global-10 cannot replace traditional EQ-5D scores.

Prevalence and Epidemiology of Injuries Among Elite Cyclists in the Tour de France.

BACKGROUND: Cycling injuries are increasing, particularly among elite athletes during major events such as the Tour de France. Many athletes miss considerable time from sport and require surgical intervention. Little is known about the epidemiology of injuries to guide practice participation strategies, return-to-competition expectations, and injury prevention protocols. PURPOSE: To evaluate the injury epidemiology, operative incidence, and return-to-competition timeline among all elite cyclists participating in the 21-stage Tour de France race over a span of 8 years. STUDY DESIGN: Descriptive epidemiological study. METHODS: All injuries sustained during 1584 unique rides by cyclists participating in the Tour de France from 2010 to 2017 were evaluated. In the absence of an established Tour de France injury database, demographic, injury, surgical, and return-to-competition details from all athletes who withdrew because of a traumatic injury were retrospectively compiled using publicly available data, which were cross-referenced for validity. The inclusion criterion consisted of any cyclist who withdrew from the Tour de France because of an injury; cyclists who withdrew for noninjury reasons were excluded. Independent variables included injury demographics, missed days, and whether the injury required surgery. Injury prevalence, relative frequency distributions, and sample proportions were dependent metrics for this investigation. RESULTS: Among the 1584 cycling entries evaluated over the 8-year study period, there were 259 cyclists (16%) who withdrew (17 cyclists/year). A total of 138 withdrawals were caused by acute trauma, 49% of which were fractures (n = 67), which represented the most common reason for withdrawal. A total of 29 (43%) cyclists with fractures underwent surgery. The most commonly fractured bones were the clavicle (n = 21), followed by the wrist (n = 6), hand (n = 5), femur (n = 5), humerus (n = 5), and ribs (n = 5). Cyclists who underwent operative fracture fixation had a longer time between the injury and their next race compared with those who did not undergo surgery (77 vs 44 days, respectively; P = .065). CONCLUSION: The most common injury leading to withdrawal from the Tour de France over the study period was acute fracture, comprising 49% of all injuries. Almost half of the cyclists with fractures underwent surgery. The clavicle was the most commonly fractured bone. For cyclists who underwent operative treatment of their fractures, return to competition was more than 1 month longer than for those who did not. A prospective database is warranted to catalog injuries among these elite cyclists.

Short-term Outcomes Following Concussion in the NFL: A Study of Player Longevity, Performance, and Financial Loss.

BACKGROUND: A short-term protocol for evaluation of National Football League (NFL) athletes incurring concussion has yet to be fully defined and framed in the context of the short-term potential team and career longevity, financial risk, and performance. PURPOSE: To compare the short-term career outcomes for NFL players with concussions by analyzing the effect of concussions on (1) franchise release rate, (2) career length, (3) salary, and (4) performance. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: NFL player transaction records and publicly available injury reports from August 2005 to January 2016 were analyzed. All players sustaining documented concussions were evaluated for a change to inactive or DNP ("did not participate") status. A case-control design compared franchise release rates and remaining NFL career span. Career length was analyzed via survival analysis. Salary and performance differences were analyzed with publicly available contract data and a performance-scoring algorithm based on position/player level. RESULTS: Of the 5894 eligible NFL players over the 11-year period, 307 sustained publicly reported concussions resulting in the DNP injury protocol. Analysis of the probability of remaining in the league demonstrated a statistically significantly shorter career length for the concussion group at 3 and 5 years after concussion. The year-over-year change in contract value for the concussion group resulted in a mean overall salary reduction of $300,000 ± $1,300,000 per year (interquartile range, -$723,000 to $450,000 per year). The performance score reduction for all offensive scoring players sustaining concussions was statistically significant. CONCLUSION: This retrospective study demonstrated that NFL players who sustain a concussion face a higher overall franchise release rate and shorter career span. Players who sustained concussions may incur significant salary reductions and perform worse after concussion. Short-term reductions in longevity, performance, and salary after concussion exist and deserve additional consideration.

Factors Influencing Patient Selection of an Orthopaedic Sports Medicine Physician.

BACKGROUND: The rise in consumer-centric health insurance plans has increased the importance of the patient in choosing a provider. There is a paucity of studies that examine how patients select an orthopaedic sports medicine physician. PURPOSE: To evaluate factors that patients consider when choosing an orthopaedic sports medicine physician. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 1077 patients who sought treatment by 3 sports medicine physicians were administered an anonymous questionnaire. The questionnaire included 19 questions asking respondents to rate the importance of specific factors regarding the selection of orthopaedic sports medicine physicians on a scale of 1 (not important at all) to 10 (very important). The remaining 6 questions were multiple-choice and regarded the following criteria: preferred physician age, appointment availability, clinic waiting room times, travel distance, and medical student/resident involvement. RESULTS: Of the 1077 consecutive patients administered the survey, 382 (35%) responded. Of these, 59% (n = 224) were male, and 41% (n = 158) were female. In ranking the 19 criteria in terms of importance, patients rated board certification (9.12 ± 1.88), being well known for a specific area of expertise (8.27 ± 2.39), and in-network provider status (8.13 ± 2.94) as the 3 most important factors in selecting an orthopaedic sports medicine physician. Radio, television, and Internet advertisements were rated the least important. Regarding physician age, 63% of patients would consider seeking a physician who is ≤65 years old. Approximately 78% of patients would consider seeking a different physician if no appointments were available within 4 weeks. CONCLUSION: The study results suggest that board certification, being well known for a specific area of expertise, and health insurance in-network providers may be the most important factors influencing patient selection of an orthopaedic sports medicine physician. Advertisements were least important to patients. Patient preferences varied regarding ideal physician age, clinic appointment availability, medical student/resident involvement, and travel distance in choosing an orthopaedic sports medicine physician. In the context of health care delivery and as reimbursement becomes increasingly consumer centered, understanding the process of provider selection is important.

Understanding Preferences for Treatment After Hypothetical First-Time Anterior Shoulder Dislocation: Surveying an Online Panel Utilizing a Novel Shared Decision-Making Tool.

BACKGROUND: Although surgical management of a first-time anterior shoulder dislocation (FTASD) can reduce the risk of recurrent dislocation, other treatment characteristics, costs, and outcomes are important to patients considering treatment options. While patient preferences, such as those elicited by conjoint analysis, have been shown to be important in medical decision-making, the magnitudes or effects of patient preferences in treating an FTASD are unknown. PURPOSE: To test a novel shared decision-making tool after sustained FTASD. Specifically measured were the following: (1) importance of aspects of operative versus nonoperative treatment, (2) respondents' agreement with results generated by the tool, (3) willingness to share these results with physicians, and (4) association of results with choice of treatment after FTASD. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A tool was designed and tested using members of Amazon Mechanical Turk, an online panel. The tool included an adaptive conjoint analysis exercise, a method to understand individuals' perceived importance of the following attributes of treatment: (1) chance of recurrent dislocation, (2) cost, (3) short-term limits on shoulder motion, (4) limits on participation in high-risk activities, and (5) duration of physical therapy. Respondents then chose between operative and nonoperative treatment for hypothetical shoulder dislocation. RESULTS: Overall, 374 of 501 (75%) respondents met the inclusion criteria, of which most were young, active males; one-third reported prior dislocation. From the conjoint analysis, the importance of recurrent dislocation and cost of treatment were the most important attributes. A substantial majority agreed with the tool's ability to generate representative preferences and indicated that they would share these preferences with their physician. Importance of recurrence proved significantly predictive of respondents' treatment choices, independent of sex or age; however, activity level was important to previous dislocators. A total of 125 (55%) males and 33 (23%) females chose surgery after FTASD, as did 37% of previous dislocators compared with 45% of nondislocators. CONCLUSION: When given thorough information about the risks and benefits, respondents had strong preferences for operative treatment after an FTASD. Respondents agreed with the survey results and wanted to share the information with providers. Recurrence was the most important attribute and played a role in decisions about treatment.

The Effect of Socioeconomic Status on the Choice of Treatment for Patients With Cruciate Ligament Injuries in the Knee: A Population-Based Cohort Study.

BACKGROUND: The socioeconomic status (SES) of patients has been widely recognized as playing an important role in many health-related conditions, including orthopaedic conditions, in which a higher SES has been associated with a higher utilization of more advanced medical treatments such as drugs, diagnostics, and surgery. However, the association between SES and cruciate ligament surgery has not been thoroughly investigated. PURPOSE: To evaluate the association between SES and choice of treatment in patients with a cruciate ligament injury. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All Swedish patients with a diagnosed cruciate ligament injury between 1987 and 2010 were identified from the Swedish National Patient Register (N = 98,349). The Longitudinal Integration Database for Health Insurance and Labor Market Studies (LISA) provided information on household income and highest achieved educational level, which were used as socioeconomic indices. The exposure was the SES of patients as determined by the household income and educational level, and the main outcome measure was treatment choice (surgical reconstruction vs nonoperative treatment). Poisson regression models estimated the association. RESULTS: A total of 52,566 patients were included in the study; of these, 20,660 (39%) were treated operatively. Patients in the highest quartile of household income had a significantly higher likelihood of undergoing surgery than those in the lowest quartile (relative risk [RR], 1.16; 95% CI, 1.11-1.20). Patients classified as highly educated had a significantly increased likelihood of being treated operatively compared with those with a low education (RR, 1.29; 95% CI, 1.19-1.39). CONCLUSION: This study provides a population-based validation that having a higher SES as determined by the household income and/or level of education increases the likelihood of undergoing operative treatment after a cruciate ligament injury. CLINICAL RELEVANCE: All Swedish citizens are entitled by law to the same quality of health care; therefore, unmotivated differences in treatment between different socioeconomic groups are to be seen as a challenge. It is important to evaluate the specific mechanisms by which the patient's SES influences the decision of whether to treat a cruciate ligament injury operatively.

Patterns of healthcare resource utilization prior to anterior cervical decompression and fusion in patients with radiculopathy.

OBJECTIVE: To assess patterns of healthcare resource utilization prior to anterior cervical decompression and fusion (ACDF) in patients diagnosed with radiculopathy with a retrospective cohort study design. BACKGROUND: ACDF is associated with improvement in quality of life among patients with cervical radiculopathy. However, little is known regarding utilization of healthcare services and total cost of care before ACDF surgery in the United States. METHODS: We analyzed a group of patients who received ACDF for radiculopathy during 2009-2011 using a healthcare database of over 20 million patients of all ages. Patients with fewer than two years of data prior to ACDF procedure were excluded. Inclusion criteria included patients with a diagnosis of disc displacement/degeneration and radiculopathy. All charges related to healthcare administration within two years prior to surgery were recorded and analyzed. RESULTS: Sixteen hundred seventy six patients met the inclusion criteria. Seventy-three percent of patients were in the 40-59 year age range; 55% were women and 45% were men. In the two years preceding the surgery, 34% of patients received prescription NSAIDs, and 98% received prescription narcotics for total charges of $101,188 ($174.46/patient) and $222,860 ($134.82/patient) respectively. Total pain-related interventions over two years (oral pharmacotherapy and injections) were charged at $4,368,900 at an average of $2,606/treatment. Total outpatient charges including physician office visits, other outpatient visits and emergency room visits amounted to $25,450,012. Mean total outpatient charges over the two years preceding ACDF was $15,556 per patient for 26,397 episodes of care. Injectable corticosteroids were provided for 84.7% of patients and charges related to this treatment totaled $1,137 per patient. CONCLUSIONS: In the two years prior to ACDF, healthcare resource utilization is extremely high. Given that these patients ultimately undergo surgical intervention, opportunities to reduce charges of conservative care exist.