Journal of the American Academy of Orthopaedic Surgeons最新文献

Introduction: Total shoulder arthroplasty (TSA) is an increasingly common orthopaedic procedure. Expansion of TSA to outpatient surgical settings has the potential to reduce costs, although there is limited research on the cost and efficiency of this shift in surgical site of care. The purpose of this study is to compare costs and efficiency of TSA between an ambulatory surgical center (ASC) and a hospital.

Methods: Retrospective cost and time data were obtained from 175 surgeries performed from 2019 to 2020 using a single institution's existing cost accounting system (hospital = 97, ASC = 78). In addition, 34 patients were prospectively enrolled undergoing primary anatomic (n = 10) or reverse (n = 24) TSA. Hand-timed data were collected at each location (ASC = 23, hospital = 11) throughout the entire episode of perioperative care. Data were analyzed to investigate the effects of surgery location on labor cost, efficiency, and provider time.

Results: The cost per TSA in the ASC was markedly lower than that in the hospital (ASC = $27,250.59, hospital = $30,266.80; P < 0.001). Examining individual discrete activities, TSA performed at the ASC was markedly longer in multiple preoperative, intraoperative, and postanesthesia care unit categories, with the greatest difference being case duration (ASC = 2.2 hours, hospital = 1.7 hours; P = 0.002). The decreased cost in the ASC, despite longer case duration, can be explained by differences in cost margins between locations with ASC cases having markedly lower costs for almost all categories.

Conclusion: It is markedly more expensive for patients to undergo TSA in a hospital setting than in an ASC. Furthermore, preoperative and postanesthesia care unit times markedly contribute to differences in efficiency associated with different surgical platforms, representing target areas to focus on improving efficiency of care delivery. These findings should be considered by orthopaedic surgeons when considering TSA in patients who are suitable to undergo TSA at an outpatient ASC.

Level of evidence: Level II, Prospective cohort study.

Introduction: Cast saw injury is a notable source of medicolegal risk. Previous work with plaster casts demonstrated that cast saw injury was minimized by waiting 12 minutes before removal. In this study, we evaluate the safety parameters of fiberglass casting materials.

Methods: Eight-ply plaster and fiberglass casts were applied to a pediatric forearm model at variable dip-water temperatures, and the mean time to reach their exothermic peak was determined. Fiberglass casts were then maintained at the manufacturer's recommended dip-water temperature and removed at intervals of 2 (before exothermic peak), 6 (approximately fiberglass's exothermic peak), or 12 (after exothermic peak) minutes. All casts were removed by a pediatric orthopaedic surgeon blinded to the cast set time. Cast/blade temperature, saw force, blade-to-skin contact, bivalve time, cast spreading force, and cut completeness were assessed individually and as short (<6-minutes) or long (≥6-minutes) set times.

Results: Fiberglass casts exothermically peaked markedly earlier (5.2 [IQR = 5-5.4] minutes) than plaster (14.8 [IQR = 13.7-15.3] minutes), P < 0.0001, at maximum temperatures, which did not markedly differ. Downward force applied during fiberglass cast removal was markedly lower in the short versus long set time groups [average forces of 8.3 (IQR = 6.4-10.4) versus 12.9 (IQR = 11.1-14.5) Newtons, P < 0.0001, as were maximum forces: 23.2 (IQR = 18.9-26.6) versus 43.8 (IQR = 38.6-48.5) Newtons, P < 0.0001]. Bivalve time and maximum cast spreading force were decreased in short set times with 40.5 (IQR = 39.2-44.7) versus 44.4 (IQR = 40.6-47.3) seconds (P = 0.06) and 15.5 (IQR = 14-18.5) versus 21.5 (IQR = 18-26.5) N (P = 0.07), respectively. Maximum saw blade temperature was markedly lower in the short (99.6°C [IQR = 98.2-105.6°C]) versus long (130.6°C [IQR = 121.9-141°C]) set times (P = 0.04). No notable differences in blade-to-skin touches or touch duration were detected.

Discussion: Unlike plaster, fiberglass casts cut before exothermically peaking were associated with less downward force, faster bivalve times, and decreased spread force without increased blade temperature or skin contacts. This suggests that fiberglass casts can be bivalved markedly earlier without increased risk of injury.

Introduction: Previous research has determined that objective and subjective internal rotation (IR) may be discordant. The purpose of this study was to identify predictors of patient-reported ability to perform IR-dependent activities of daily living (IRADLs) and favorable patient satisfaction after reverse shoulder arthroplasty (RSA) despite the loss of objective IR.

Methods: A single, institutional, shoulder arthroplasty database was queried for patients undergoing primary RSA with a minimum 2-year follow-up. Patients who were wheelchair bound or had a preoperative diagnosis of infection, fracture, or tumor were excluded. We first identified patients in the overall cohort that lost objective IR from pre- to postoperative assessment, defined as a one-point reduction in the eight-point Flurin scale. In this cohort, we identified patient characteristics that were predictive of patient-reported ability to perform IRADLs and overall patient satisfaction and thresholds in postoperative objective IR.

Results: Out of 599 RSAs initially identified, 107 RSAs lost objective IR (45% female, mean age 70 years). On average, patients lost 1.7 IR score points pre- to postoperatively. Greater preoperative IR and lesser loss of objective IR pre- to postoperatively were associated with greater patient-reported ability to perform all 4 IRADLs (odds ratio 1.54 to 2.5), whereas female sex was associated with worse patient-reported ability to perform 3 IRADLs (odds ratio 0.26 to 0.36). We identified that patients with postoperative IR below the sacrum were unlikely to be able to perform IRADLs and those with postoperative IR at or above L4-L5 were likely to be satisfied.

Conclusion: Despite losing objectively assessed IR after RSA, many patients are still able to perform IRADLs and report favorable satisfaction as long as objective IR reaches L4/5. Female sex and postoperative IR below the sacrum were associated with the inability to perform IRADLs, whereas postoperative IR to or above L4-L5 was associated with subjective ratings of satisfaction.

Introduction: Medicaid coverage is associated with longer appointment wait times, decreased access to care, and poorer health outcomes compared with private insurance across medical subspecialties. The purpose of this study was to evaluate new patient appointment wait times for subspecialty Orthopaedic care based on insurance type and to identify factors influencing these wait times.

Methods: Orthopaedic physicians were identified using the American Academy of Orthopaedic Surgeons patient-facing database in the fields of Adult Reconstruction, Foot and Ankle, Hand, Sports Medicine, Spine, Pediatric, and General Orthopaedic surgery. Mystery callers, posing as patients with either Medicaid or Blue Cross/Blue Shield (BCBS) insurance, contacted physicians to request the next available new patient appointment. The business days until the first available new patient appointment were recorded and analyzed using a linear mixed Poisson model.

Results: A total of 1,002 phone calls were made to 501 unique physicians in 47 states. Among the 349 physicians meeting inclusion criteria, 37% (n = 130) did not accept Medicaid. Medicaid patients experienced a 10% longer wait for a new patient appointment compared with patients with BCBS (incidence rate ratio: 1.10; CI: 1.05 to 1.15; P < 0.01) with mean wait times of 24.9 business days (SD ± 24) and 19.6 business days (SD ± 23), respectively. Increased waiting times were also associated with academic institutions (P < 0.01), prolonged call times (P < 0.01), and specific geographic regions (P < 0.05). Our model achieved an R-squared value of 0.94, demonstrating strong explanatory power.

Conclusion: Patients with Medicaid experience longer wait times and decreased access to care when scheduling an appointment with an Orthopaedic surgeon compared with patients with private insurance. This may be due to reimbursement structures in Medicaid that do not cover the full cost of treatment. Aside from advocating for higher reimbursement rates, telehealth initiatives may help bridge this gap to ensure accessibility to orthopaedic surgery for all patients.

Management of Carpal Tunnel Syndrome Evidence-Based Clinical Practice Guideline is based on a systematic review of published studies with regard to the diagnosis and treatment of carpal tunnel syndrome in adult patients (≥18 years of age). The scope of this guideline addresses the diagnosis and treatment of carpal tunnel syndrome and contains nine recommendations to assist orthopaedic surgeons and all qualified clinicians managing patients presenting with signs and symptoms which may be attributable to carpal tunnel syndrome based on the best current available evidence. It is also intended to serve as an information resource for professional healthcare practitioners, health services researchers, and developers of practice guidelines and recommendations. In addition to providing pragmatic practice recommendations, this guideline also highlights gaps in the literature and informs areas for future research and quality measure development.

Background: Patients with Medicaid insurance are at an increased risk of postoperative complications following total knee arthroplasty and total hip arthroplasty (TJA); however, their outcomes following revision TJA for periprosthetic joint infection (PJI) requires further study.

Methods: A retrospective query was conducted for adult patients undergoing implant explantation and antibiotic spacer placement for TJA PJI from the Premier Healthcare Database between December 1, 2016, and December 31, 2021. Patients were then grouped by Medicaid or non-Medicaid insurance status and were age matched through exact caliper matching. Multivariable regression models addressed potential confounding. Adjusted risks of 90-day postoperative complications were reported.

Results: Of the 40,346 patients identified, 2,711 Medicaid patients were matched to 10,844 non-Medicaid patients on age (56.1 vs. 56.1 years, P = 1.000). Patients with Medicaid experienced higher risk of sepsis (adjusted odds ratio [aOR] = 1.20, P = 0.010), readmission (aOR = 1.12, P = 0.022), being discharged to a skilled nursing facility (aOR = 1.13, P = 0.031), and had longer length of stay (9.48 vs. 6.67 days, P < 0.001), compared with patients with non-Medicaid. Medicaid patients had a higher rate of inpatient mortality (0.81% vs. 0.48%, P = 0.038); however, the risk was similar after accounting for differences in comorbidities.

Conclusion: Following revision TJA for PJI, patients with Medicaid were at an increased risk for postoperative complication, including sepsis and readmission. They experienced a higher rate of inpatient mortality that may be driven by differences in comorbidities. Insurers and policy makers should consider this information to develop risk stratification-based payment strategies that take into account the healthcare burden of this high-risk patient population.

Level of evidence: IV.

Introduction: Osteoporosis screening and subsequent treatment has been shown to be efficacious in decreasing the rates of fragility fractures and periprosthetic fractures (PPF). However, current screening and treatment rates are low. This study aims to determine (1) the prevalence of total shoulder arthroplasty (TSA) patients who meet criteria for osteoporosis screening, (2) the prevalence of those screened, and (3) the 5-year cumulative incidence of fragility fracture (FF) and periprosthetic fractures (PPF).

Methods: The PearlDiver database was used to identify all patients older than 50 years who underwent TSA. Guidelines from the American Association of Clinical Endocrinologists were used to stratify patients into "high risk" and "low risk" of osteoporosis cohorts using International Classification of Disease codes for various risk factors. The prevalence of osteoporosis screening using dual-energy x-ray absorptiometry (DXA) scan was analyzed, and the 5-year cumulative incidence of FF and PPF was calculated between the "low-risk" and "high-risk" groups using Kaplan-Meier analysis.

Results: In total, 66,140 (65.5%) who underwent TSA were considered "high risk" for osteoporosis. Of the "high-risk" patients, 11.7% patients received routine osteoporosis screening preoperatively. Within 5 years, "high-risk" TSA patients had markedly higher cumulative incidence for PPF (HR: 1.4; 95% CI: 1.0-1.9; P = 0.037) and FF (HR: 2.42; 95% CI: 2.1-2.8; P < 0.001) when compared with those at "low risk".

Discussion: There is a high prevalence of osteoporosis among patients undergoing TSA but a low rate of routine osteoporosis screening in this cohort. Patients with osteoporosis who are categorized as "high risk" have an increased rate of fragility fractures and PPF. Therefore, there is an opportunity to increase appropriate osteoporosis screening and management in this cohort, which may affect future risk of FF and periprosthetic fracture.

Level of evidence: III.

Objective: The purpose of this study was to evaluate the clinical outcomes in patients who underwent bilateral total shoulder arthroplasty (TSA) at a single institution. Secondarily, we evaluated the influence of the time interval between successive TSAs on clinical outcomes of the second TSA.

Methods: A single-institution shoulder arthroplasty database was reviewed for patients undergoing bilateral primary anatomic TSA (aTSA) or reverse TSA (rTSA) between 2000 and 2022. Clinical outcomes, including outcome scores, range of motion, and shoulder strength, were assessed in patients with minimum 2-year follow-up. Postoperative complications and achievement of the minimal clinical important difference, substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) were evaluated. Statistical comparisons were made between first and second TSAs, between TSA variations, and based on time between TSAs (<1, 1 to 5, >5 years).

Results: We identified 180 bilateral TSA patients (68 aTSA/aTSA, 29 aTSA/rTSA, three rTSA/aTSA, 80 rTSA/rTSA). When evaluating side-to-side differences, the second rTSA in the aTSA/rTSA group had more favorable postoperative Shoulder Pain and Disability Index (P = 0.032) and forward elevation strength (P = 0.028) compared with the first aTSA. No other side-to-side comparisons were statistically significant or exceeded the minimal clinical important difference, SCB, or PASS. Patients undergoing second aTSA after first aTSA or undergoing first rTSA had superior SCB and PASS for active external rotation (P = 0.009 and P = 0.005, respectively). Complications were similar between strata, but revision rates were lowest after first rTSA in rTSA/rTSA patients. The time interval between successive TSAs did not influence the clinical outcome.

Conclusion: All bilateral TSA combinations demonstrated excellent outcomes with most patients achieving clinically relevant benchmarks, with no influence of timing between arthroplasties.

Level of evidence: III, retrospective comparative cohort study.

Background: Primary hip and knee total joint arthroplasties (TJAs) are among the most frequently performed orthopaedic surgeries in the United States, with demand projected to increase to two million cases per year by 2040. Despite the growing demand, previous studies have shown a declining value of Medicare surgeon reimbursements. Given recent inflationary trends, an updated analysis of the changing value of primary TJA reimbursement is necessary. This study examines surgeon reimbursement trends for primary TJA among Medicare patients from 2017 to 2022.

Methods: We analyzed Medicare Part B claims data from the Centers for Medicare and Medicaid Services Medicare Physician & Other Practitioners database. Using Healthcare Common Procedure Coding System codes for primary TJA, we queried the database for procedures performed between 2017 and 2022. Yearly service counts and allowed Medicare reimbursements were examined. Reimbursement values were adjusted for inflation using the Consumer Price Index with all values converted to 2022 U.S. dollars.

Results: The study included 2,421,710 Medicare claims for primary TJA from 2017 to 2022. During this period, the volume of primary TJA increased by 2.9%. However, average reimbursement decreased by 4.2%, from $1,343 in 2017 to $1,286 in 2022. When adjusted for inflation, the decrease in reimbursement was more pronounced, falling by 19.6% from $1,600 to $1,286. Trends in reimbursement varied by procedure type and geographic region.

Conclusion: Between 2017 and 2022, while the volume of primary TJA increased, Medicare surgeon reimbursement for these procedures decreased, with a markedly greater reduction when adjusted for inflation. These trends highlight the need for policy reforms to ensure sustainable reimbursement for surgeons performing primary TJA.

Background: A large proportion of total knee arthroplasty (TKA) patients are on antidepressant medications at the time of surgery. Postoperative outcomes of this patient demographic have not been characterized. This study compared the risk of 90-day adverse events and 5-year survival to revision surgery between patients on antidepressants and those not on antidepressants at the time of surgery.

Methods: TKA patients were identified from the PearlDiver M151Ortho data set. Of these patients, those taking antidepressants (selective serotonin reuptake inhibitors or serotonin norepinephrine reuptake inhibitors) and those not taking antidepressants were identified and matched 1:1 based on patient age, sex, and Elixhauser Comorbidity Index scores. The incidence of 90-day adverse events was determined for the two groups and compared by multivariate analyses. Five-year survival to revision surgery was compared between TKA patients on antidepressants and those not on antidepressants.

Results: In total, 21.8% of TKA patients were taking antidepressants; 209,320 matched TKA patients on antidepressants and 837,066 not on antidepressants were extracted from the data set. Controlling for patient age, sex, and Elixhauser Comorbidity Index, those on antidepressants at the time of surgery had markedly higher odds of experiencing any (odds ratio [OR] 1.50), severe (OR 1.23), and minor (OR 1.61) adverse events in the 90 days following TKA (P < 0.0001 for all). Five-year survival to revision surgery of TKA patients on antidepressants was 96.4% (95% CI, 96.3% to 96.5%), compared with 96.9% (95% CI 96.8% to 96.9%) for patients not on antidepressants.

Conclusions: TKA patients on antidepressants at the time of surgery were found to have markedly greater odds of experiencing 90-day postoperative adverse events but not clinically notable differences in five-year revision surgeries. TKA patients taking antidepressants could constitute a patient population at risk for inferior perioperative outcomes following surgery and thus may require additional counseling and mitigation strategies.

Study design: Retrospective database study.

Level of evidence: Level III.