Defining recovery trajectories after shoulder arthroplasty: a latent class analysis of patient-reported outcomes.

BACKGROUND: Patients undergoing total shoulder arthroplasty (TSA) can have varying levels of improvement after surgery. As patients typically demonstrate a nonlinear recovery trajectory, advanced analysis investigating the degrees of variation in outcomes is needed. Latent class analysis (LCA) is a mixed and multilevel model that estimates random slope variance to evaluate heterogeneity in outcome patterns among patient subgroups and can be used to outline differing recovery trajectories. The purpose of this study was to determine recovery trajectory patterns after TSA and to identify factors that predict a given trajectory. METHODS: Data from a prospectively collected single institutional database of patients undergoing anatomic and reverse TSA were utilized. Patients were included if they had American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores preoperatively, as well as postoperative scores at 6 weeks, 6 months, 1 year, and 2 years. Patients were excluded if they underwent a revision procedure or hemiarthroplasty or had prior infection. LCA was used to subdivide the patient cohort into subclasses based on postoperative recovery trajectory. This was performed for all patients as well as anatomic TSA and reverse TSA as separate groups. Unpaired Student t tests, analysis of variance, and Fisher exact test were used to compare classes based on factors including age, body mass index, sex, preoperative diagnosis, and type of arthroplasty. RESULTS: A total of 244 TSAs were included in the final analysis, comprising 89 anatomic TSA and 155 reverse TSA. In the combined group, LCA modeling revealed 3 patterns for recovery: Resistant Responders had low baseline scores (ASES < 30) and poor final results (ASES < 50), Steady Progressors had moderate baseline scores (ASES 30-50) with moderate final results (ASES 50-75), and High Performers had moderate baseline scores (ASES > 50) with excellent final results (ASES > 75). For anatomic TSA, we identified Delayed Responders with moderate baseline scores and a delayed response before ultimately achieving moderate final results, Steady Progressors with moderate baseline scores and a steady progression to achieve moderate final results, and High Performers who had moderate baseline scores and excellent final results. For reverse TSA, we identified Late Regressors with low baseline scores and poor final results, Steady Progressors with moderate baseline scores and moderate final results, and High Performers with moderate baseline scores and excellent final results. CONCLUSIONS: Patients recover in a heterogenous manner following TSA. Through LCA, we identified different recovery trajectories for patients undergoing anatomic TSA and reverse TSA.

Do patient outcomes and follow-up completion rates after shoulder arthroplasty differ based on insurance payor?

BACKGROUND: Disparities associated with socioeconomic status (SES) and insurance coverage have been shown to affect outcomes in different medical conditions and surgical procedures. We hypothesized that patients insured by Medicaid will be associated with lower follow-up rates and inferior outcomes relative to those with Medicare or private insurance. METHODS: Patients undergoing shoulder arthroplasty, including anatomic total shoulder arthroplasty, reverse arthroplasty, and hemiarthroplasty, were enrolled preoperatively in an institutional database. Preoperative demographics, payor (Medicaid, Medicare, or private insurance), and baseline American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores were recorded. Postoperatively, patients completed ASES scores at multiple time points. Follow-up completion rate was calculated as the number of follow-up visits completed relative to possible visits. Continuous variables were compared between groups with 1-way analyses of variance, and chi-squared tests were used for categorical variables. Significance was defined as P < .05. RESULTS: There were 491 shoulder replacements performed for 438 patients from 2012-2017. The mean follow-up completed percentage was significantly lower (P < .001) for Medicaid patients (62.6% ± 33.7%) relative to Medicare patients (80.2% ± 26.7%; P < .001) and private insurance patients (77.8% ± 22.1%; P = .001). The ASES Composite score increased significantly for all patients from baseline to final follow-up. At each time point, including before surgery and each postoperative time point, patients with Medicaid insurance had significantly lower ASES Composite scores. The final ASES Composite score was significantly lower in the Medicaid patients (66.1 ± 28.7) relative to private insurance patients (78.3 ± 20.8; P = .023). Medicaid patients had significantly lower preoperative (P < .001) and postoperative (P = .018) ASES Pain subscores. In multivariate regression analysis, Medicaid insurance was associated with both inferior preoperative and postoperative ASES scores relative to patients with Medicare or private insurance. CONCLUSIONS: We observed that all patients, regardless of insurance payor, improved by similar magnitudes after shoulder arthroplasty, though patients with Medicaid insurance had significantly lower preoperative and postoperative ASES scores, primarily because of the ASES Pain subscore. Patients with Medicaid insurance also have lower follow-up rates than other payors.

Treatment of Labral Calcification in the Setting of Femoroacetabular Impingement Syndrome With Arthroscopic Calcification Excision, Labral Repair, and Osteoplasty Improves Outcomes.

PURPOSE: To describe the diagnosis and 2-year outcomes of arthroscopic treatment for labral calcification in the setting of femoroacetabular impingement syndrome (FAIS). METHODS: A retrospective analysis was performed from a prospectively collected database of patients with FAIS undergoing hip arthroscopy. Patients with FAIS with labral calcification were differentiated radiographically from patients with other paralabral radiopaque densities such as os acetabuli, acetabular rim fractures, and labral ossification. Patients with FAIS with labral calcification were treated with arthroscopic calcification excision, labral repair, and osteoplasty and matched by age, sex, and body mass index with a cohort of patients with FAIS without labral calcifications who underwent labral repair and osteoplasty. Pre- and 2 years postoperatively, patients completed patient-reported outcome (PRO) scores including the modified Harris Hip Score, Hip disability and Osteoarthritis Outcome Score (HOOS), 12-item Short-Form survey, and visual analog scale. RESULTS: In total, 40 hips (21 male, 19 female) with FAIS and labral calcification were included (age 36.8 ± 8.1, body mass index, 25.9 ± 4.5). Patients with FAIS with labral calcification demonstrated similar significant PRO score improvements compared with a matched cohort of patients with FAIS without labral calcification at 2 years after surgery (visual analog scale: (-)2.3 ± 0.4, (-)2.7 ± 0.5, modified Harris Hip Score: 16.1 ± 2.6, 17.1 ± 3.2; HOOS symptoms: 21.9 ± 3.7, 18.6 ± 3.6; HOOS pain: 22.1 ± 3.0, 25.0 ± 3.5; HOOS activities of daily living: 20.2 ± 2.8, 23.8 ± 3.3; HOOS sport: 35.6 ± 5.0, 35.6 ± 4.1; HOOS quality of life: 36.9 ± 4.5, 37.5 ± 4.4; 12-item Short-Form survey physical component summary: 15.5 ± 2.3, 20.1 ± 2.1, respectively). Both cohorts achieved minimal clinically important differences at equivalent rates (60%-82.5%) for all PRO scores. CONCLUSIONS: Patients with labral calcification in the setting of FAIS can be effectively treated with arthroscopic calcification excision, labral repair, and osteoplasty. These patients demonstrate significant improvements in patient-reported outcomes and achievement of minimal clinically important differences at 2 years similar to patients undergoing arthroscopic treatment for FAIS without labral calcification. LEVEL OF EVIDENCE: Level III, matched cohort study.

Patellar tendon reconstruction with hamstring autograft for the treatment of chronic irreparable patellar tendon injuries.

BACKGROUND: Patellar tendon injuries not amenable to primary repair present a challenging problem for surgeons and patients alike. No standard surgical technique exists for these injuries and few studies report outcomes after surgical treatment. METHODS: A retrospective analysis was conducted for patients undergoing surgical treatment for irreparable patellar tendon tears. Patients were treated with an indirect tendon reconstruction technique using high-strength suture to set initial patellar height and hamstring autograft for biologic augmentation. Patients who underwent this procedure between 2012 and 2018 and met minimum two-year follow-up with completion of all outcome measurements including KOOS, PROMIS, VAS pain and satisfaction scores were included. RESULTS: Eleven patients met inclusion criteria. Ten of eleven patients (91%) had intact repairs and final patient outcomes were collected at a mean of 54.9 ± 23.1 months after surgery. Only one patient experienced extensor lag at final follow-up (p < 0.001). The preoperative Caton-Dechamps ratio was 1.77 ± 0.58, which decreased to 0.98 ± 0.25 after surgery (p < 0.001). The mean postoperative KOOS ADL score was 61.5. The mean postoperative PROMIS Global Mental and Physical Health scores were 46.9 ± 8.7 and 42.0 ± 9.8. Post-operative mean VAS satisfaction score was 5.6 ± 3.4. CONCLUSIONS: Patellar tendon reconstruction with autologous hamstring tendon graft and suture augmentation allows for acceptable outcomes in the setting of patellar tendon disruption with segmental defects when direct repair is not possible.