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.

Arthroscopically Assisted Percutaneous Screw Fixation of Tibial Plateau Fractures.

Tibial plateau fractures account for approximately 1% to 2% of fractures in adults1. These fractures exhibit a bimodal distribution as high-energy fractures in young patients and low-energy fragility fractures in elderly patients. The goal of operative treatment is restoration of joint stability, limb alignment, and articular surface congruity while minimizing complications such as stiffness, infection, and posttraumatic osteoarthritis. Open reduction and internal fixation with direct visualization of the articular reduction or indirect evaluation with fluoroscopy has traditionally been the standard treatment for displaced tibial plateau fractures. However, there has been concern regarding inadequate visualization of the articular surface with open tibial plateau fracture fixation, contributing to a fivefold increase in conversion to total knee arthroplasty2. In addition, the risk of wound complications and infection has been reported to be as high as 12%3,4. Knee arthroscopy with percutaneous, cannulated screw fixation provides a less invasive procedure with excellent visualization of the articular surface and allows for accurate reduction and fracture fixation compared with traditional open reduction and internal fixation techniques1. Recent studies of arthroscopically assisted percutaneous screw fixation of tibial plateau fractures have reported excellent early clinical and radiographic outcomes and low complication rates3,5,6. Description: This technique involves the use of both arthroscopy and fluoroscopy to facilitate reduction and fixation of the tibial plateau fracture. Through a minimally invasive technique, the depressed articular joint surface is targeted with use of preoperative computed tomography (CT) scans and intraoperative biplanar fluoroscopy. Reduction is then directly visualized with arthroscopy and fixation is performed with use of fluoroscopy. Lastly, restoration of the articular surface is confirmed with use of arthroscopy after definitive fixation. Modifications can be made as needed. Alternatives: The traditional method for fixation of displaced tibial plateau fractures is open reduction and internal fixation. Articular reduction can be visualized directly with an open submeniscal arthrotomy and an ipsilateral femoral distractor or indirectly with fluoroscopy. Rationale: Visualization of the articular surface is essential to achieve anatomic reduction of the joint line. Inspection of the posterior plateau is difficult with an open surgical approach. Arthroscopically assisted percutaneous screw fixation of a tibial plateau fracture may allow for improved restoration of articular surfaces through enhanced visualization. Less soft-tissue dissection is associated with lower morbidity and may result in less damage to the blood supply, lower rates of infection and wound complications, faster healing, and better mobility for patients. In our experience, this technique has been successful in patients with severe osteoporosis and comminution of depressed fragments. If total knee arthroplasty is required, we have also observed less damage to the blood supply and fewer surgical scars with use of this surgical technique. Expected Outcomes: Arthroscopically assisted percutaneous screw fixation of a tibial plateau fracture facilitates anatomical reduction through a less invasive approach. Patients undergoing this method of tibial plateau fracture fixation are able to engage earlier in rehabilitation2. Studies have shown early postoperative range of motion, excellent patient-reported outcomes, and minimal complications7,8. Important Tips: Arthroscopically assisted fixation can be applied to a variety of tibial plateau fractures; however, the minimally invasive approach is best suited for patients with isolated lateral tibial plateau fractures (Schatzker I to III) and a cortical envelope that can be easily restored. The cortical envelope refers to the outer rim of the tibial plateau. Fracture pattern and ligamentotaxis determine the cortical envelope, which can be evaluated on preoperative CT scans. In our experience, even depressed segments with a high degree of comminution may be treated with use of this technique with satisfactory results.Articular depression should be targeted with use of a preoperative CT scan and intraoperative fluoroscopy and arthroscopy.The surgeon should be careful not to "push up" in 1 small area; rather, a "joker" elevator or bone tamp should be utilized, moving anterior to posterior, which can be frequently assessed with arthroscopy.The intra-articular pressure of the arthroscopy irrigation fluid should be low (≤45 mm Hg or gravity flow), and the operative extremity should be monitored for compartment syndrome throughout the procedure. Acronyms and Abbreviations: ACL = anterior cruciate ligamentK-wires = Kirschner wiresORIF = open reduction and internal fixationAP = anteroposteriorCR = computed radiography.

Locked plating of geriatric olecranon fractures leads to low fixation failure and acceptable complication rates.

HYPOTHESIS: The purpose of this study was to report the rate of major complications in patients with geriatric olecranon fractures managed operatively with a locking plate. Secondary objectives included minor complications, as well as pain and range of motion at the final follow-up. We hypothesized that these patients have a low rate of complications as well as low pain and satisfactory elbow range of motion at the final follow-up. MATERIALS AND METHODS: A retrospective review of isolated geriatric olecranon fractures presenting from 2006 to 2019 was performed at a single level I trauma center. Inclusion criteria were ≥75 years of age, operative management with a locking plate, and clinic follow-up at least until evidence of radiographic union or a major complication. Exclusion criteria included nonoperative management, insufficient follow-up, and absence of locking plate in surgical technique. Variables examined included demographic information, Charleston comorbidity index, American Society of Anesthesiologists score, living independence, gait assistance, mechanism of injury, open vs. closed fracture, Mayo radiographic classification, Arbeitsgemeinschaft für Osteosynthesefragen classification, time to surgery, implant type, presence of triceps offloading suture, length of postoperative immobilization, date of radiographic union, range of motion at the final follow-up, pain visual analog scale score at the final follow-up, major and minor complications, and return to the operative room. A major complication was defined as a return to the operative room for deep infection or loss of fixation (displacement of fracture >5 mm). A minor complication was defined as any other complication. RESULTS: A total of 65 patients ≥75 years of age with olecranon fractures were identified. Of these, 36 patients met inclusion criteria with an average follow-up of 23 weeks (range 5-207). The mean length of immobilization was 13 days (range 0-29 days). Thirty-two of 36 (88.8%) patients achieved radiographic evidence of union at an average of 8.9 weeks (range 5.3-24.1 weeks). There were 4 remaining patients who underwent secondary intervention before primary union representing an 11.1% major complication rate including 2 deep infections (5.6%) and 3 failures of fixation (8.3%). There were 7 minor complications in 5 of 36 (13.9%) patients. At the final follow-up, the average visual analog scale score was 2.6 (range 0-6), the average elbow arc of motion was 120° (range 70-147°), and mean pronation/supination was 85°/84° (range 45-90°/45-90°). CONCLUSION: Geriatric olecranon fractures are a challenging orthopedic problem with remaining controversy regarding ideal treatment. Despite advancement in geriatric fracture care, there is scant literature on the outcomes of locked plating technology in geriatric olecranon fractures. This study supports use of operative anatomic fixation with precontoured locked plates and early mobilization with an acceptable failure rate.

Osteochondritis Dissecans: Current Understanding of Epidemiology, Etiology, Management, and Outcomes.

➤: Osteochondritis dissecans occurs most frequently in the active pediatric and young adult populations, commonly affecting the knee, elbow, or ankle, and may lead to premature osteoarthritis. ➤: While generally considered an idiopathic phenomenon, various etiopathogenetic theories are being investigated, including local ischemia, aberrant endochondral ossification of the secondary subarticular physis, repetitive microtrauma, and genetic predisposition. ➤: Diagnosis is based on the history, physical examination, radiography, and advanced imaging, with elbow ultrasonography and novel magnetic resonance imaging protocols potentially enabling early detection and in-depth staging. ➤: Treatment largely depends on skeletal maturity and lesion stability, defined by the presence or absence of articular cartilage fracture and subchondral bone separation, as determined by imaging and arthroscopy, and is typically nonoperative for stable lesions in skeletally immature patients and operative for those who have had failure of conservative management or have unstable lesions. ➤: Clinical practice guidelines have been limited by a paucity of high-level evidence, but a multicenter effort is ongoing to develop accurate and reliable classification systems and multimodal decision-making algorithms with prognostic value.

Advanced Templating for Total Shoulder Arthroplasty.

¼: Longitudinal clinical and radiographic success of total shoulder arthroplasty (TSA) is critically dependent on optimal glenoid component position. ¼: Historically, preoperative templating utilized radiographs with commercially produced overlay implant templates and a basic understanding of glenoid morphology. ¼: The advent of 3-dimensional imaging and templating has achieved more accurate and precise pathologic glenoid interrogation and glenoid implant positioning than historical 2-dimensional imaging. ¼: Advanced templating allows for the understanding of unique patient morphology, the recognition and anticipation of potential operative challenges, and the prediction of implant limitations, and it provides a method for preoperatively addressing abnormal glenoid morphology. ¼: Synergistic software, implants, and instrumentation have emerged with the aim of improving the accuracy of glenoid component implantation. Additional studies are warranted to determine the ultimate efficacy and cost-effectiveness of these technologies, as well as the potential for improvements in TSA outcomes.

Arthroscopic Transosseous Repair of a Medial Meniscal Posterior-Root Tear.

Meniscal root tears are soft-tissue and/or osseous injuries characterized by an avulsion of, or tear within 1 cm of, the native meniscal insertion1. These injuries account for 10% to 21% of all meniscal tears, affecting nearly 100,000 patients annually2. Medial meniscal posterior-root tears (MMPRTs) expose the tibiofemoral joint to supraphysiologic contact pressure, decreased contact area, and altered knee kinematics similar to a total meniscectomy3. This injury predisposes the patient to exceedingly high rates of osteoarthritis and total knee arthroplasty secondary to an inability to resist hoop stress4. The arthroscopic transosseous repair of an MMPRT is described in the present article. Description: (1) Preoperative evaluation, including patient history, examination, and imaging (i.e., radiographs and magnetic resonance imaging). (2) Preparation and positioning. The patient is placed in the supine position, and anteromedial and anterolateral portals are created. (3) Placement of sutures. Two simple cinch sutures are placed into the posterior horn, within approximately 5 mm of each other. (4) Footprint decortication. Remove articular cartilage from the native root insertion site. (5) Drilling of the transosseous tibial tunnel. Introduce a tibial tunnel guide over the decorticated base, set guide to 45° to 50°, place a 2-cm vertical incision over an anteromedial tibial guide footprint, advance a 2.4-mm guide pin through the guide, and overream to 5 mm. (6) Passing of the sutures with use of a looped suture passer introduced retrograde through the tibial tunnel to retrieve sutures. (7) Anchor placement and fixation. Apply maximum suture traction, drill a second aperture 0.5 to 1.0 cm distal to the original aperture on the anteromedial aspect of the tibia, pass the suture ends through the anchor, and fix the anchor into the aperture. (8) Repair evaluation and closure. Note the position and stability of the meniscal root relative to the native footprint. Standard closure in layers is performed. Alternatives: If the patient experiences no relief from nonoperative treatment, an MMPRT can be treated operatively via partial meniscectomy or repaired via direct suture-anchor repair or indirect transosseous (transtibial) repair. Direct repair utilizes a suture anchor inserted at the root site5. Variations of the present technique include different suture configurations or numbers of tunnels. Although several suture configurations have been described, the simple cinch stitch (utilized in the present procedure) has been shown to be better at resisting displacement than the locking loop stitch6. Moreover, it has been suggested that simple stitches are less technically difficult and more able to resist displacement because they require less tissue penetration than other stitches7. Lastly, procedures that utilize a single versus a second transtibial tunnel have been shown to be equivalent in cadaveric studies8. Rationale: The desired results of MMPRT repair include anatomic reduction, preservation of meniscal tissue and knee biomechanics, and preservation of hoop stress, which improve activity, function, and symptoms and mitigate degenerative changes and the risk of progression to total knee arthroplasty. Expected Outcomes: At a minimum of 2 years after transosseous repair, the Lysholm, Western Ontario and McMaster Universities Osteoarthritis Index, 12-Item Short Form, and Tegner activity scale were significantly improved8,9. Previous studies have shown significant improvement in the Hospital for Special Surgery and Lysholm scores without radiographic osteoarthritis progression at the same minimum follow-up10. Lastly, in the longest-term follow-up study to date, transosseous repair survivorship was reported to be 99% at 5 years and 92% at 8 years, with failure defined as conversion to total knee arthroplasty11. Important Tips: Pearls○ Decorticate the native meniscal root down to bleeding bone.○ Consider fenestration or percutaneous release of the medial collateral ligament in order to further open a tight medial compartment.○ A self-retrieving suture passer allows the use of standard arthroscopy portals.○ A multiuse variable-angle tibial tunnel drill guide allows point-to-point placement over the native meniscal root insertion.○ A guide with a tip may be easier and more accurate to control.○ Consider different guides when drilling the tibial tunnel, according to the anatomy of the patient.○ A low-profile guide may provide better clearance along the condyles.○ Utilize a cannula when shuttling sutures through the tibial tunnel in order to prevent a soft-tissue bridge.○ With anchor fixation, consider drilling over a guide pin and tapping when the bone is hard.○ Study preoperative imaging to evaluate the amount of arthritis present. Evaluate all compartments on magnetic resonance imaging for additional pathology.Pitfalls○ Obliquity of the tibial tunnel can cause the guide pin and reamer to enter too anteriorly.○ Patient failure to adhere to postoperative rehabilitation and restrictions can lead to unfavorable outcomes.○ The use of lower-strength sutures may increase the risk of fixation failure.

Cost Savings of Carpal Tunnel Release Performed In-Clinic Compared to an Ambulatory Surgery Center: Time-Driven Activity-Based-Costing.

Purpose: The purpose of our study was to investigate carpal tunnel release (CTR) performed in the clinic versus the ambulatory surgery center (ASC) to evaluate for potential cost savings. Methods: Patients who underwent either CTR in clinic under a local anesthetic or CTR in the ASC with sedation and local anesthetic were prospectively enrolled in a registry between 2014 and 2016. All patients completed a Visual Analog Scale (VAS) pain scale for procedural and postprocedure pain. Time-Driven Activity-Based Costing (TDABC) was utilized to quantify cost of both CTR in clinic and CTR in the ASC. Statistical analysis involved parametric comparative tests between patient cohorts for both the TDABC-cost and patient pain. Results: A total of 59 participants completed the postprocedure CTR survey during the study period, 23 (38.9%) in the ASC group and 36 (61.1%) in the clinic group. Overall time for the procedure from patient arrival to discharge was significantly longer for the ASC cases, averaging 215.7 minutes (range: 201-230) compared to 78.6 minutes (range: 59-98) in the clinic group (P < .01). Both procedural and postoperative VAS pain scores were comparable between clinic and ASC cohorts, procedural pain: 1.8 vs 1.9 (P = .91) and postoperative pain: 4.8 vs 4.9 (P = .88). TDABC analysis estimated ASC CTR procedures to cost an average of $557.07 ($522.06-$592.08) and clinic procedures to cost an average of $151.92 ($142.59-$161.25) (P < .05). Conclusions: CTR in the clinic setting results in significant cost savings compared to CTR in the ASC with no difference in pain scores during the procedure or postoperative period. Level of Evidence: Therapeutic Level II.

Complementary and Alternative Medicine for Postoperative Pain: A Systematic Review.

BACKGROUND: The treatment of postoperative pain is an ongoing challenge for orthopaedic surgeons. Poorly controlled pain is associated with poorer patient outcomes, and the prescription of opioids may lead to prolonged, nonmedical use. Complementary and alternative medicine is widely adopted by the general public, and its use in chronic musculoskeletal pain conditions has been studied; however, its efficacy in a postoperative context has not yet been established. METHODS: We conducted a systematic literature review of 10 databases to identify all relevant publications. We extracted variables related to pain measurement and postoperative opioid prescriptions. RESULTS: We identified 8 relevant publications from an initial pool of 2,517 items. Of these, 5 were randomized studies and 3 were nonrandomized studies. All 8 studies addressed postoperative pain, with 5 showing significant decreases (p < 0.05) in postoperative pain. Also, 5 studies addressed postoperative opioid use, with 2 showing significant differences (p < 0.05) in opioid consumption. Substantial heterogeneity among the studies precluded meta-analysis. No articles were found to be free of potential bias. CONCLUSIONS: Currently, there is insufficient evidence to determine the efficacy of complementary and alternative medicines for postoperative pain management or as an alternative to opioid use following orthopaedic surgery. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Factors Associated with a Second Opioid Prescription Fill in Total Knee Arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) creates a relatively large degree of nociception, making it a good setting to study variation in pain intensity and pain alleviation. The purpose of this study is to investigate factors associated with a second prescription of opioid medications within 30 days of primary TKA. METHODS: Using an insurance database, we studied 1372 people over a 6-year period with no mental health comorbidities including substance misuse and no comorbid pain illness at the time of TKA. Factors associated with a second prescription of opioid medication within 30 days of TKA were sought among patient demographics and the overall prescription morphine milligram equivalents. Patient and prescription-related risk factors were evaluated utilizing logistic relative risk regression. We reserved a year of data, 222 people, to evaluate the performance of the derived model. RESULTS: More than half the patients filled a second prescription for opioids within 30 days of TKA. Factors associated with a second prescription of opioid medication within 30 days of TKA included age (P < .01), current smoker (P = .01), and the total morphine milligram equivalents of the initial prescription (P < .01). Applied to the 222 people we reserved for validation, the model was 81% sensitive and 14% specific for a second prescription within 30 days, with a positive predictive value of 74%, and a negative predictive value of 20%. CONCLUSION: People that are given more opioids tend to request more opioids, but our model had limited diagnostic performance characteristics indicating that we are not accounting for the key factors associated with a second opioid prescription. Future studies might address undiagnosed patient social and mental health opportunities, factors known to associate with pain intensity and satisfaction with pain alleviation. LEVEL OF EVIDENCE: Diagnostic Level III.

Reliability of EOS compared to conventional radiographs for evaluation of lower extremity deformity in adult patients.

OBJECTIVE: The purpose of this study was to compare reliability of lower extremity imaging measurements using EOS and conventional X-ray (CR) of adult patients with mechanical axis malalignment. MATERIALS AND METHODS: Ten patients (20 lower limbs) of mean age of 31.6 years (range 21-39) with post-traumatic deformities who presented for evaluation of osteotomies and/or ligament and cartilage reconstructions were prospectively enrolled. Two independent observers performed full-length anterior-posterior (AP) measurements 2 weeks apart on both CXR and two-dimensional (2D) EOS images. Measurements included weight-bearing axis (WBA), varus/valgus angle (V/V), femoral length (FL), tibial length (TL), femoral mechanical axis (FMA), tibial mechanical axis (TMA), and total limb length (TLL). Reliability was determined with random effects modeling of intraclass correlation coefficients (ICC) set to consistency. Three statistical operations were performed to compare interrater validity in CXR and EOS: students' two-sample t test, paired two-sample t test, and Pearson's correlative r-statistical agreement. RESULTS: There was a statistically significant difference for V/V, FL, and TLL (all p < 0.01) between CXR and EOS. A relatively large proportion of the population consistently had larger V/V measures for EOS compared to CXR. In contrast, the FL and TLL measures were consistently larger for CXR compared to EOS. The differences between CXR and EOS measurements were statistically significant, though the small differences in values were not clinically meaningful. Agreement of all measures remained high (r = 0.84-0.99). CONCLUSION: Using 2D EOS for lower extremity measurements is reproducible, reliable, and comparable to the gold standard, standing long leg radiographs.

Osteochondral Allograft Cartilage Transplantation for a Full-Thickness Femoral Condyle Chondral Lesion.

Cartilage lesions of the knee pose a difficult challenge for orthopaedic surgeons. Osteochondral allograft transplantation is an option in the setting of large chondral or osseous defects, or after failure of other treatment options1-3. The use of allograft offers the benefit of utilizing both viable hyaline cartilage and bone4. Fresh allografts are usually transplanted into the femoral condyle, although they can also be used in the patella, tibial plateau, or femoral trochlea1. Research has shown that patients who undergo this procedure for the treatment of focal and diffuse chondral defects have favorable outcomes and satisfaction scores1. The procedure is performed as follows. (1) Preoperative evaluation: patients are evaluated for a cartilage procedure after obtaining history, examination, and imaging (radiographs and magnetic resonance imaging). (2) Approach: a longitudinal parapatellar tendon arthrotomy is performed. (3) Debridement: the lesion is identified, and unstable cartilage is debrided back to stable cartilage. (4) Measure defect: the recipient site depth is measured in 4 positions, as on the face of a clock (12, 3, 6, and 9 o'clock). (5) Template allograft: a sizer is used to template the allograft hemicondyle. (6) Secure and harvest allograft: the allograft is secured in the Osteochondral Allograft Transplantation Surgery (OATS) Workstation (Arthrex) and harvested from cadaver bone. (7) Measure depth: the recipient depth measurements are marked on the allograft. (8) Cut graft: the graft is held with allograft-holding forceps while graft is cut with a saw. (9) Check measurements: allograft measurements are checked to ensure that they match recipient measurements. (10) Round edges: the osseous ends are rounded to assist with insertion of graft. (11) Irrigate: the allograft is irrigated after final cuts. (12) Graft insertion: the graft is inserted after lining up the 12-o'clock position recipient and donor reference marks and is held in place with a press fit. (13) Closure: standard closure in layers is performed.