Subscapularis management in anatomic total shoulder arthroplasty: A systematic review and network meta-analysis.

Background: This systematic review and network meta-analysis compare clinical outcomes of three different subscapularis management techniques in anatomic total shoulder arthroplasty: lesser tuberosity osteotomy, subscapularis peel, and subscapularis tenotomy. Methods: PubMed, Web of Science, Embase, and Cochrane's trial registry were searched in July 2021. Comparative studies and case series evaluating the outcomes of these three techniques were included. The network meta-analysis was performed only on comparative studies. Results: Twenty-three studies were included. Both lesser tuberosity osteotomy and subscapularis peel had significantly higher Western Ontario Osteoarthritis Scores compared to subscapularis tenotomy, but no difference in American Shoulder and Elbow Society Scores. Subscapularis peel had superior external rotation compared to lesser tuberosity osteotomy. However, no difference was found in external rotation between subscapularis peel and subscapularis tenotomy or between subscapularis tenotomy and lesser tuberosity osteotomy. The overall weighted average for lesser tuberosity osteotomy bony union was 93.6%, whereas the overall weighted average for subscapularis tendon healing was 79.4% and 87% for subscapularis tenotomy and subscapularis peel, respectively. Discussion: This network meta-analysis demonstrated that lesser tuberosity osteotomy and subscapularis peel were associated with the high union and subscapularis healing rates and may be associated with improved shoulder function and quality of life, compared to subscapularis tenotomy. Lesser tuberosity osteotomy and subscapularis peel demonstrate a trend of superior outcomes compared to subscapularis tenotomy during anatomic total shoulder arthroplasty.

Trends in Distal Radius Fixation Reimbursement, Charge, and Utilization in the Medicare Population.

Background Distal radius fractures (DRF) are the second most common fragility fracture experienced by the elderly, and surgical management constitutes an appreciable sum of Medicare expenditure for upper extremity surgery. Using Medicare data from 2012 to 2017, our primary aim was to describe temporal changes in surgical treatment, physician payment, and patient charges for DRF fixation. Methods We examined surgical volumes and retrospective patient charge (services billed by surgeon) and surgeon payment (professional fee) data from 2012 to 2017 for four DRF surgeries: closed reduction percutaneous pinning (CRPP), open reduction internal fixation (ORIF) of extra-articular fractures, ORIF of intra-articular (IA) (2-fragment) fractures, and ORIF of IA (> 3 fragments) fractures. The reimbursement ratio was defined and calculated as the ratio of charges to payment. Rates were adjusted for inflation using the annual consumer-price index. Results For these four surgeries from 2012 to 2017, total patient charges grew by 64% from $117 to 193 million, while surgeon payment grew by 42% from $30 to 42 million. CRPP cases fell by 47%, while ORIF increased by 17, 14, and 45% for extra-articular, IA (2-fragment), and IA (> 3 fragments) surgeries, respectively. After adjusting for inflation, payment to physicians increased by more than or equal to 16% for all procedures except for CRPP, which fell by 2%. Charges during this same period increased from 13 to 38%. Reimbursement ratios declined from -9.2% to -13% for each procedure. Conclusion From 2012 to 2017, while charges have outpaced surgeon payment, payment has outpaced inflation for all forms of distal radius ORIF, aside from CRPP. There has been a continued sharp decline of CRPP. Level of Evidence is III, economic.

Epidemiology of shoulder instability procedures: A comprehensive analysis of complications and costs.

Background: Recurrent shoulder instability is a debilitating condition that can lead to chronic pain, decreased function, and inability to return to activities or sport. This retrospective epidemiology study was performed to report 90-day postoperative complications and costs of Latarjet, anterior bone block reconstruction, arthroscopic, and open Bankart repair for shoulder instability. Methods: Patients 18 years and older who underwent four primary shoulder surgeries from 2010 to 2019 were identified using national claims data. Patient demographics, comorbidities, and 90-day postoperative complications were analyzed using univariate analysis and multivariable logistic regression. Total and itemized 90-day reimbursements were determined for each procedure. Results: The 90-day medical and surgery-specific complication rates were highest for anterior bone block reconstruction, followed by Latarjet. Arthroscopic Bankart repair had the highest 90-day costs and primary procedure costs compared to other procedures. Conclusion: Anterior bone block reconstruction and Latarjet procedures were associated with the highest rates of 90-day medical and surgery-specific complications, while arthroscopic Bankart repair was associated with the highest costs.

Racial Disparities in Short-Stay and Outpatient Total Hip and Knee Arthroplasty: 13-year Trend in Utilization Rates and Perioperative Morbidity Using a National Database.

BACKGROUND: The objective of this study was to assess racial and ethnic disparities in short-stay (< 2-midnight length of stay) and outpatient (same-day discharge) total joint arthroplasties (TJAs). We aimed to determine (1) whether there are differences in postoperative outcomes between short-stay Black, Hispanic, and White patients and (2) the trend in utilization rates of short-stay and outpatient TJA across these racial groups. METHODS: This was a retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Short-stay TJAs done between 2008 and 2020 were identified. Patient demographics, comorbidities, and 30-day postoperative outcomes were assessed. Multivariate regression analysis was used to assess differences between racial groups in minor and major complication rates, as well as readmission and revision surgery rates. RESULTS: Of a total of 191,315 patients, 88% were White, 8.3% were Black, and 3.9% were Hispanic. Minority patients were younger and had greater comorbidity burden when compared with Whites. Black patients had greater rates of transfusions and wound dehiscence when compared with White and Hispanic patients ( P < 0.001, P = 0.019, respectively). Black patients had lower adjusted odds of minor complications (odds ratio [OR], 0.87; confidence interval [CI], 0.78 to 0.98), and minorities had lower revision surgery rates in comparison with Whites (OR, 0.70; CI, 0.53 to 0.92, and OR, 0.84; CI, 0.71 to 0.99, respectively). The utilization rate for short-stay TJA was most pronounced for Whites. CONCLUSION: There continues to persist marked racial disparities in demographic characteristics and comorbidity burden in minority patients undergoing short-stay and outpatient TJA procedures. As outpatient-based TJA becomes more routine, opportunities to address these racial disparities will become increasingly more important to optimize social determinants of health. LEVEL OF EVIDENCE: III, retrospective cohort study.

SLAP repair and bicep tenodesis: a comparison of utilization and revision rates for SLAP tears.

Hypothesis: The management of superior labrum anterior to posterior (SLAP) tears typically consists of either repair or biceps tenodesis (BT). While repair is more frequently recommended in younger patients, patients older than 40 years are often treated with BT. The purpose of this study is to determine whether there has been a change in utilization of these procedures over the past decade with respect to patient age as well as compare reoperation rates between the two procedures. Methods: The Pearldiver database was queried to identify BT and SLAP repairs indicated for SLAP tears performed from 2010 to 2019. The primary outcome was utilization rate, stratified by age. A secondary outcome was 2-year shoulder reoperation rates. Trends were reported in terms of compounded annual growth rate. Outcome analysis was conducted using univariate and multivariable analysis. Results: From 2010 to 2019, SLAP repair was the most common procedure performed for SLAP tears. Regardless of age, BT performed for SLAP tear had a significantly increased utilization rate; whereas, SLAP repair had a significantly decreased utilization rate. SLAP repair was more commonly performed in younger patients compared to BT. Following multivariable analysis, patients who underwent SLAP repair had significantly higher odds (odds ratio (OR): 1.453; 95% confidence interval (CI): 1.26-1.68; P < .001) of requiring an arthroscopic reoperation within 2 years when compared to those who underwent BT with no significant difference with respect to 2-year open reoperation. Conclusion: Although SLAP repair is still more commonly used to treat SLAP tears than BT, especially for younger patients, the utilization of SLAP repair is decreasing while BT is increasing. The increased utilization of BT may be associated with lower rates of shoulder reoperation for problematic SLAP tears.

The 50 most impactful articles on the medial ulnar collateral ligament: An altmetric analysis of online media.

The purpose of this study was to use the Altmetric Attention Score to determine the 50 most impactful medial ulnar collateral ligament articles in online media and compare their characteristics to the most-cited medial ulnar collateral ligament articles in the scientific literature. The Altmetric database was queried to identify all published articles about the medial ulnar collateral ligament, and this list was stratified by the Altmetric Attention Score to identify the 50 highest scoring articles. Several data elements were extracted, including article topic, article type, journal name, and the number of online mentions on Facebook, Twitter, news, and other platforms. Each article's geographic origin was determined based on the institutional affiliation of the first author. Our index search yielded 1283 articles published between 1987 and 2020, from which the 50 articles with the highest Altmetric Attention Scores were included for analysis. Altmetric Attention Scores of the top 50 medial ulnar collateral ligament articles ranged from 20 to 482 (median: 32, interquartile range: 20-62). The most common article type was original research (72%), and the most common topic was epidemiology/risk factors (26%). A majority of studies were Level 3 (36%) or Level 4 evidence (36%). Of the top 50 medial ulnar collateral ligament articles, 94% originated from the United States. A few articles had a high Altmetric Attention Score, suggesting that medial ulnar collateral ligament research does not generate consistently high online attention. The lack of Level 1 studies suggests the need for high-level studies on the medial ulnar collateral ligament. Most studies originated in the United States and were published in the American Orthopaedic Society for Sports Medicine-affiliated journals. The medial ulnar collateral ligament articles included in this study differed substantially from a previous report of the most-cited medial ulnar collateral ligament articles in the literature, suggesting that alternative metrics add a unique dimension to understanding the overall impact of published research on the medial ulnar collateral ligament.

Hypoalbuminemia and the Higher Risk of Perioperative Sentinel Adverse Events in Patients Undergoing Total Shoulder Arthroplasty: A Propensity Score Matched Analysis.

Background: The purpose of this study is to examine the effect of hypoalbuminemia (HA) on sentinel adverse events after total shoulder arthroplasty (TSA). Methods: Patients who underwent primary TSA from 2015-2018 were collected from the National Surgical Quality Improvement Program (NSQIP) database. Patients with HA (serum albumin < 3.5 g/dL) were compared to patients with normal serum albumin. A probit regression model was used to estimate a propensity score. Logistic regression was performed to evaluate the effect of HA on sentinel adverse events after surgery. Results: A total of 4,337 patients were included, 8.2% of patients had HA. Patients with HA had higher rates of sentinel adverse events (14.0% vs 5.5%, P<0.01) compared with patients who had normal serum albumin. Reoperation (4.5% vs 1.5%, P<0.01), readmission (11.2% vs 3.9%, P<0.01), urinary tract infection (0.8% vs 0.03%, p <0.01) and pulmonary embolism (1.1% vs 0.2%, P=0.01) were higher in patients with HA. The odds ratio for a sentinel event for patients with HA was 2.6 (95% CI: 1.54, 4.44, P<0.01) when compared to a propensity score-matched control group. Conclusion: Patients with HA are at increased risk of sentinel adverse events following TSA compared to patients with normal serum albumin levels.

Initial presentation for acute low back pain: is early physical therapy associated with healthcare utilization and spending? A retrospective review of a National Database.

BACKGROUND: Early initiation of physical therapy (PT) has been associated with lower healthcare costs and utilization; however, these studies have been limited to single institutions or healthcare systems. Our goal was to assess healthcare utilization and spending among patients who present for the first time with low back pain (LBP), according to whether they received early physical therapy (PT), using a large, nationwide sample; and geographic variation in rates of early PT and 30-day LBP-related spending. METHODS: Using the Truven MarketScan database, we identified nearly 980,000 US adults ages 18-64 years who initially presented with acute LBP from 2010 through 2014 and did not have nonmusculoskeletal causes of LBP. Approximately 110,000 patients (11%) received early PT (≤2 weeks after presentation). We compared healthcare utilization and spending at 30 days and 1 year after presentation between patients who received early PT and those who did not. Alpha = 0.05. RESULTS: At 30 days, early PT was associated with lower odds of chiropractor visits (odds ratio [OR] = 0.41, 95% confidence interval [CI] = 0.40-0.42), pain specialist visits (OR = 0.49, 95% CI = 0.47-0.51), emergency department visits (OR = 0.51, 95% CI = 0.49-0.54), advanced imaging (OR = 0.57, 95% CI = 0.56-0.58), orthopaedist visits (OR = 0.67, 95% CI = 0.66-0.69), and epidural steroid injections (OR = 0.68, 95% CI = 0.65-0.70). At 1 year, early PT was associated with less healthcare utilization. At 30 days, patients with early PT had lower mean LBP-related spending ($1180 ± $1500) compared with those without early PT ($1250 ± $2560) (P < 0.001). At 1 year, LBP-related spending was significantly less among patients who did not receive early PT ($2510 ± $3826) versus those who did ($2588 ± $3704). Early PT rates (range, 4-25%; P < 0.001) and 30-day LBP-related spending differed by state (range, $421 to -$410; P < 0.001). CONCLUSION: Early PT for acute LBP was associated with less 30-day and 1-year healthcare utilization and less 30-day LBP-related spending. Early PT rates and 30-day spending differed by US state. LEVEL OF EVIDENCE: IV.

Malunion of Pediatric Forearm Shaft Fractures: Management Principles and Techniques.

PURPOSE OF REVIEW: Clinically significant malunion of forearm diaphyseal fractures is an uncommon but potentially disabling condition amongst children and adolescents. We present the preoperative evaluation, including imaging, and discuss surgical indications and contemporary approaches to manage such patients, including an illustrative case. RECENT FINDINGS: While advances in three-dimensional (3D) simulation, modeling, and patient-specific instrumentation have expanded the surgical armamentarium, their impact on long-term outcomes compared to traditional methods remains unknown. Successful outcome following surgical correction of malunion following a both-bone forearm fracture can be achieved with careful patient selection, appropriate indications, and a well-planned surgical execution.

Total Shoulder Arthroplasty: Antibiotic Allergies Increase Risk of Postoperative Complications.

BACKGROUND: Periprosthetic infections after total shoulder arthroplasty (TSA) are associated with devastating complications and prolonged treatment. Patients with identified antibiotic allergy (ABX) may be at increased risk for complications because of suboptimal preincisional prophylaxis. This study aims to quantify the risk of postoperative outcomes and complications for patients undergoing TSA with a history of ABX. METHODS: Retrospective cohort analysis of patient data was conducted using the PearlDiver Patient Records Database. Patients who underwent TSA for osteoarthritis were identified using Current Procedural Terminology and International Classification of Diseases codes and were stratified based on self-reported (1) penicillin, (2) sulfonamide, or (3) other antibiotic allergies. We analyzed patient demographics, comorbidities, 90-day medical complications, and rate of revision at 30 days, 90 days, 1 year, and 2 years. RESULTS: In total, 85,606 patients who underwent TSA for osteoarthritis from 2010 to 2018 were identified, of whom 7,836 (9.15%) had a reported ABX. Univariate analysis found the ABX cohort was younger (67.5 versus 67.7 year; P = 0.042), more often female (67.57% versus 54.79%; P < 0.001), and more likely to have Elixhauser comorbidities than nonallergic control subjects. Multivariate analysis found patients who reported ABX had increased likelihood of periprosthetic joint infection (PJI) within 30 days (odds ratio [OR]: 3.129), 1 year (OR: 2.016), and 2 years of surgery (OR: 2.221). Patients with reported ABX had increased likelihood of postoperative anemia (OR: 1.126), blood transfusion (OR: 1.238), and readmission (OR: 1.585) within 90 days of surgery. Patients with penicillin allergy had a greater incidence of revision due to PJI at 30 days (OR: 4.811), 90 days (OR: 2.91), 1 year (OR: 2.105), and 2 years (OR: 2.72). Rates of reported ABX increased from 2010 to 2018 (8.60% to 10.91%; P = 0.001) in patients undergoing TSA. CONCLUSION: Patients undergoing TSA with a history of ABX had a higher risk of readmission, postoperative anemia, blood transfusions, and PJI. These findings support critical assessment and clarification of reported allergies before TSA and possibly the use of preoperative allergy testing. LEVEL OF EVIDENCE: Level 3 therapeutic study.

What Do We Know About Shoulder Injury Related to Vaccine Administration? An Updated Systematic Review.

BACKGROUND: Shoulder injury related to vaccine administration (SIRVA) is postulated to be an immune-mediated inflammatory response to a vaccine antigen injected into or near the subacromial bursae or synovium, leading to shoulder pain and dysfunction. The number of studies on this topic is rapidly increasing. Recent comparative studies have reported conflicting conclusions, which suggests that a systematic review of the best-available evidence may be helpful. QUESTIONS/PURPOSES: In this systematic review, we asked: What are the (1) clinical characteristics, (2) diagnoses, and (3) management approaches and outcomes reported in association with SIRVA? METHODS: A search was performed on October 4, 2021, of the PubMed and Medline databases for studies related to SIRVA. Inclusion criteria were English-language comparative studies, case series, and case reports that involved shoulder pain occurring after vaccination. Studies of exclusively neurologic conditions after vaccination were excluded. Forty-two studies met the eligibility criteria, including three retrospective comparative studies (72 patients and 105 controls), five database case series (2273 patients), and 34 case reports (49 patients). Study quality was assessed for the database case series and retrospective comparative studies using the Methodological Index for Non-randomized Studies tool. RESULTS: Among patients in the case reports, the median age was 51 years (range 15-90 years), and 73% (36 of 49) were women. BMI was reported for 24% of patients (12 of 49) in case reports, with a median of 23.5 kg/m2 (range 21-37.2 kg/m2). The most common symptoms were shoulder pain and reduced ROM. The most common diagnoses were shoulder bursitis, adhesive capsulitis, and rotator cuff tears. The most frequent management modalities included physical or occupational therapy, NSAIDs, and steroid injections, followed by surgery, which was generally used for patients whose symptoms persisted despite nonsurgical management. Full resolution of symptoms was reported in 2.9% to 56% of patients. CONCLUSION: The association between inflammatory conditions of the shoulder (such as bursitis) and vaccination appears to be exceedingly rare, occurring after approximately 1:130,000 vaccination events according to the best-available comparative study. Currently, there is no confirmatory experimental evidence supporting the theory of an immune-mediated inflammatory response to vaccine antigens. Although the clinical evidence is limited, similar to any bursitis, typical treatments appear effective, and surgery should rarely be performed. Additional research is needed to determine the best injection technique or evaluate alternate injection sites such as the anterolateral thigh that do not involve positioning a needle close to the shoulder.

Are We Working Harder for Less Pay? A Survey of Medicare Reimbursement for Hand and Upper Extremity Surgery.

BACKGROUND: Ongoing concern for declining Medicare payment to surgeons may incentivize surgeons to perform more cases to maintain productivity goals. The authors evaluated trends in physician payment, patient charges, and reimbursement ratios for the most common hand and upper extremity surgical procedures. METHODS: The authors examined Medicare surgeon payment, patient charges, and surgical volume from 2012 to 2017 for 83 common surgical procedures, incorporating the year-to-year Consumer Price Index to adjust for inflation. The reimbursement ratio was calculated by dividing payment by charge. Weighted (by surgery type and volume) averages were calculated. RESULTS: Total Medicare surgeon payment increased 5.6 percent to $272 million for the studied procedures. Patient charges were seven times greater than payment, growing 24 percent to $1.9 billion. Despite growth of total payment, the average overall weighted payment for a single surgery decreased 3.5 percent. The average weighted patient charge increased 8 percent, whereas the reimbursement ratio decreased 13 percent. A hand surgeon would need to perform three more cases per 100 in 2017 to maintain the same reimbursement received in 2012. After categorizing these 83 surgical procedures, distal radius fixation (>3 parts, 21 percent increase; >2-part intra-articular, extra-articular, and percutaneous pinning, 17 percent increase), bony trauma proximal to the distal radius (10 percent increase), and upper extremity flap (5 percent increase) were subject to the greatest increases in payment. Payment for forearm fasciotomy (39 percent decrease), endoscopic carpal tunnel release (30 percent decrease), and mass excisions proximal to the wrist (18 percent decrease) decreased the most. CONCLUSIONS: From 2012 to 2017, despite a disproportionate increase in procedure charges, Medicare surgeon payment has not decreased substantially; however, total reimbursement is multifactorial and involves multiple sources of revenue and cost.

Does Time to Imaging and Surgery for Distal Radius Fractures Vary based on Geographic Socioeconomic Disadvantage?

BACKGROUND: While disparities in aspects of distal radius fracture (DRF) management and orthopedics at large have been studied, disparities in time to DRF evaluation and treatment are unknown. We sought to determine if geographic socioeconomic disadvantage is associated with time to imaging in the emergency department (ED) and time to surgery for DRFs. METHODS: We performed a time-to-event analysis of 105 patients undergoing DRF surgery after ED triage within our hospital system between January 1, 2015, and January 1, 2020. Area Deprivation Index (ADI) national percentile was used as the metric of geographic socioeconomic disadvantage for each patient's ZIP code of residence. We performed Cox regression analysis to determine hazard ratios to undergo DRF imaging and surgery for patients in each ADI group, adjusting for potential confounders, α = 0.05. RESULTS: There was no association between geographic socioeconomic disadvantage and time to DRF imaging, after adjusting for confounders. However, compared to patients from the least disadvantaged areas, patients from the most disadvantaged areas (ADI Quartiles 3 and 4) had an adjusted hazard ratio for surgery of 0.55 [0.32, 0.94] (P = .03), and were thus 45% [6%, 68%] less likely to undergo surgery for DRF at any time following ED triage. CONCLUSIONS: Operative patients from more socioeconomically disadvantaged neighborhoods see disparities in time to surgery for DRF. Equitable access to timely surgical care is needed and may be improved with increased access to orthopedic surgeons, patient education, support in navigating the health system, and improved continuity of fracture care. LEVEL OF EVIDENCE: Level III.

Trends in utilization and patient demographics for shoulder instability procedures from 2010 to 2019.

BACKGROUND: Improved techniques and increased surgeon experience have optimized surgical care in patients with recurrent shoulder instability. Several techniques are used for surgical repair of shoulder instability, yet there are limited data on how utilization has changed over the past decade. The aim of this study was to assess trends in the utilization rate and patient demographic characteristics (age and sex) from 2010 to 2019 for 4 shoulder instability procedures: coracoid transfer/Latarjet procedure (LP), anterior bone block (ABB), open Bankart repair (OBR), and arthroscopic Bankart repair (ABR). METHODS: We identified >87,000 patients using an all-payer claims database. The utilization rate was defined as the number of cases of a procedure divided by the total number of surgical cases for shoulder instability for any given year. Age was divided into 3 groups: <25 years, 25-35 years, and >35 years. Trends were reported in terms of the compounded annual growth rate (CAGR). RESULTS: Although ABR was the most common shoulder instability procedure overall (91% utilization rate), the LP had the greatest increase in utilization from 2010 to 2019 (2.0% to 4.5%; CAGR, +9.8%). In comparison, the utilization of ABB procedures increased by 4.3% annually whereas that of OBR declined by 6.9% annually. The utilization of ABR showed minimal change. Notably, the LP was performed more frequently in younger patients over time. The percentage of patients aged < 25 years who underwent the LP increased from 30% to 41% from 2010 to 2019 (CAGR, +3.4%). There was a trend toward the performance of more LPs in men than in women (+1.2% vs. -3.5%, P < .05), although most cases (68%) were still performed in men. CONCLUSION: ABR continues to account for most shoulder instability procedures. The LP had the greatest increase in the utilization rate from 2010 to 2019 and has now surpassed OBR in the utilization rate. ABB procedures are also being more frequently performed but only represent a minority of stabilization cases. During the course of the study period, a greater percentage of patients undergoing shoulder instability procedures were male individuals and were aged < 25 years.

Impact of Missing Data on Identifying Risk Factors for Postoperative Complications in Hand Surgery.

BACKGROUND: The mismanagement of missing data in large clinical databases may lead to inaccurate findings. The purpose of this study was to demonstrate the effects of missing data on hand surgery research findings using an analysis of postoperative morbidity in patients undergoing hospital-based hand surgery. METHODS: The National Surgical Quality Improvement Program database was queried for patients undergoing common hand and upper extremity surgery between 2011 and 2016. Major and minor postoperative complications were identified. Demographics, comorbidity, and preoperative laboratory values were identified, and the percentage missing of each was tabulated. To demonstrate how missing data can alter analysis results, these variables were evaluated for an association with major complications using multivariable regression on 3 separate cohorts: (1) all patients; (2) all patients after exclusion of any patient entry with >10% of missing data; and (3) after removal of any patient entry with any missing data. RESULTS: Groups 1, 2, and 3 had 48 370, 23 118, and 6280 patients, respectively. There were 14 variables associated with increased odds of major complications in group 1, yet only 10 and 9 variables for groups 2 and 3, respectively. Six variables were associated with increased major complications across all 3 groups, whereas only 1 was associated with decreased odds of major complications across all groups. CONCLUSIONS: Filtering patient cohorts according to the amount of missing patient information affected analyses of predictors for major complications associated with hospital-based hand surgery. These findings highlight the importance of considering and addressing missing data in large database studies.

Factors associated with RVU generation in common sports medicine procedures.

INTRODUCTION: Relative value units (RVUs) are integral to the U.S. physician compensation system used by the Centers for Medicare & Medicaid Services. The use of 'work RVUs' (herein, wRVUs) is intended to reimburse physicians according to the amount of expertise and effort needed to safely and effectively perform a procedure. Our purpose was to determine: 1) the number of wRVUs/hour generated by common sports medicine surgical procedures; and 2) how patient characteristics, surgical approach, and practice setting are associated with the number of wRVUs/hour. This analysis was performed to infer whether wRVUs are assigned appropriately according to the factors on which they are purported to be based. METHODS: We queried the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database for common sports medicine surgical procedures performed in 2018. Data from 19,877 patients (8,258 women) with a mean age of 48 years (range, 18-90) who underwent a surgical sports medicine procedure were analyzed. Work RVUs and operative time were used to calculate work RVUs/hour for each surgical procedure. Univariate and multivariate analyses were used to assess correlations between patient characteristics and wRVUs/hour. RESULTS: Knee chondroplasty generated the most mean (± standard deviation) wRVUs/hour at 22 ± 0.5, whereas 'open tenodesis of biceps tendon, long head' generated the least at 9.6 ± 0.25 wRVUs/hour. Factors associated with a greater mean number of wRVUs/hour were younger patient age, female sex, arthroscopic approach, and outpatient setting. Arthroscopic procedures also generated more wRVUs/hour than the same procedures performed through an open approach. wRVUs were not correlated with case complexity or surgical time. CONCLUSION: wRVUs/hour in surgical sports medicine procedures vary widely depending on the procedure type, patient characteristics, surgical approach, and practice setting.

Impact of 2013 ACGME Minimum Case Requirements on Orthopedic Resident Operative Volume.

In 2013, the Accreditation Council for Graduate Medical Education (ACGME) mandated orthopedic surgery residents to perform at least 1000 surgical cases during residency and specified "case minimums" for 15 core procedure categories. We assessed trends in the volume and variability of graduating orthopedic surgery resident caseload since the implementation of these case minimums. We performed a retrospective linear regression analysis of ACGME-published case log data of US orthopedic residents graduating from 2014 to 2019, with trend analysis, comparison of case volume between residents in 10th and 90th percentiles, and comparison of logged cases vs case minimums for core procedures. Median total procedures performed increased from 1464 (range, 592-2842) in 2014 to 1709 (range, 870-3318) in 2019, representing a 17% increase in case volume (P<.001). Residents performing at the 90th percentile logged twice as many cases as residents performing at the 10th percentile. Of the core procedures, carpal tunnel release and total knee arthroplasty most greatly exceeded ACGME requirements (performed at 4.3 to 4.7 times the minimums, respectively). Graduating resident case volume increased significantly from 2014 to 2019. Variability in operative experience remains high and did not change significantly during the study period. [Orthopedics. 2022;45(1):25-30.].

Prior Nonshoulder Periprosthetic Joint Infection Increases the Risk of Surgical Site Infection, Sepsis, and All-Cause Revision After Primary Total Shoulder Arthroplasty.

INTRODUCTION: Periprosthetic joint infection (PJI) after total joint arthroplasty is a known risk factor for infection in subsequent joint arthroplasty. The purpose of this study was to determine whether prior nonshoulder PJI contributes to the increased risk of infectious complications, greater healthcare utilization, and increased revision surgery after primary total shoulder arthroplasty (TSA). METHODS: Patients who underwent primary TSA for osteoarthritis with prior nonshoulder PJI were identified in a national database (PearlDiver Technologies) using Current Procedural Terminology and International Classification of Diseases codes. These patients were propensity matched based on age, sex, Charlson Comorbidity Index, smoking status, and obesity (body mass index >30 kg/m2) to a control cohort of patients who underwent primary TSA for osteoarthritis without any prior PJI. Primary outcomes include 1- and 2-year revision rates. Secondary outcomes include healthcare-specific outcomes of readmission, emergency department visits, length of stay, and mortality. Bivariate analysis was conducted using chi-square tests to compare all outcomes and complications between both cohorts. RESULTS: Compared with patients without prior PJI, those with prior PJI had a significantly higher risk of 90-day surgical site infection (7.61% versus 0.56%) and sepsis (1.79% versus 0.56%) after TSA (P < 0.05 for both). Patients with prior PJI also had a higher risk of 90-day readmission compared with those without prior PJI (3.36% versus 1.23%, P = 0.008). In terms of surgical complications, patients with prior PJI had significantly higher risk of 2-year revision surgery compared with patients without prior PJI (3.36% versus 1.57%, P = 0.034). CONCLUSION: Prior nonshoulder PJI of any joint increases rates of 90-day surgical site infection, sepsis, and hospital readmission, as well as 2-year all-cause revision after TSA. These results are important for risk-stratifying patients undergoing TSA with prior history of PJI. LEVEL OF EVIDENCE: III.

Advanced Imaging of Ulnar Wrist Pain.

Ulnar-sided wrist pain can be a diagnostic challenge for clinicians and radiologists. The ulnar wrist has complex morphology and is composed of many small bone and soft tissue structures. Within these structures, a wide variety of pathologic conditions can occur. To successfully diagnose and treat these pathologic conditions, clinicians and radiologists must have a strong understanding of the advanced imaging techniques available to them. In this review, the authors present a brief review of the normal ulnar wrist anatomy, discuss the differential diagnosis of ulnar-sided wrist pain, and examine the indications for different advanced imaging modalities.