Trends of Ulnar Collateral Ligament Reconstruction in the United States from 2003 to 2014: Analysis of 3,133 Patients.

PURPOSE: The purpose of this study is to investigate the trends concerning ulnar collateral ligament (UCL) reconstruction (UCLR) for athletic injuries within the United States over the years 2003 to 2014. METHODS: A retrospective review of the Truven Health Marketscan® Commercial Database was conducted for patients undergoing UCLR. Data was reviewed for patients treated between 2003 and 2014, and the cohort of patients undergoing UCLR was queried using Common Procedural Terminology code 24346. Patients ages 11 to 40 years were included and divided into 6 different age groups, with the rate of UCLR calculated for each group. RESULTS: The overall rate of UCLR increased from 4.4 per million in 2003 to 11.9 per million in 2014 (p < .01). Throughout the same time period, the rate per million increased from 3.3 to 22.1 in 11- to 15-year-olds (p < .01), from 105.4 to 293.2 in 16- to 20-year-olds (p < .01), from 23.1 to 67.0 in 21- to 25-year-olds (p < .01), and from 2.1 to 5.7 in 31- to 35-year-olds (p < .01). There was no significant increase in the rate of UCLR in the age groups of 26 to 30 and 36 to 40 years. CONCLUSION: UCLR was mostly performed in patients aged 11 to 25 years (96.6%), and specifically most common in those patients aged 16 to 20 years (67.4%). The rate of UCLR procedures increased over time for younger age groups significantly more than for their older counterparts. CLINICAL RELEVANCE: UCLR rates are increasing in young patients despite efforts addressing injury risk reduction strategies and education for coaches, players, and parents regarding risk factors for UCL injury.

Effect of Global Fracture Care Billing on Distal Radius Fractures.

Nonoperative distal radius fracture treatment without manipulation can be coded and billed in a global fee or itemized structure. Little is known regarding the association between these coding/billing structures and subsequent clinical care. The MarketScan Research Database (IBM, Armonk, New York) was retrospectively queried for patients with a distal radius fracture diagnosis code from 2003 to 2014. Patients with a Current Procedural Terminology code for surgical treatment or closed treatment with manipulation were excluded. The remaining nonoperatively treated patients were separated based on billing structure. Results were analyzed for provider initiating global fracture care, as well as the likelihood and frequency of follow-up visits related to the injury for each group. A total of 381,561 patients were identified based on inclusion criteria. Global fracture care billing was initiated for 177,153 (46%) patients, whereas itemized billing was performed for 204,408 (54%) patients. Orthopedic surgeons were the most likely provider (69%) to initiate global fracture care after diagnosis of distal radius fracture. Emergency physicians were the second most common specialty (6%). Patients for whom global fracture care was initiated were more likely to not receive any follow-up office visits compared with patients for whom itemized billing was performed (39.2% vs 25.4%). Additionally, patients with global billing had significantly fewer office visits during the 90-day global period (1.3 vs 2.3). This study demonstrates that patients billed via global fracture care have less frequent follow-up and fewer office visits during the 90-day global period than patients billed in itemized fashion. [Orthopedics. 2020;43(5);e471-e475.].

Rates of Subsequent Shoulder Surgery Within Three Years for Patients Undergoing SLAP Repair Versus Biceps Tenodesis.

PURPOSE: To investigate the demographics of patients for whom SLAP repair or biceps tenodesis was performed, as well as to compare rates of additional shoulder surgery for these 2 procedures within 3 years postoperatively. METHODS: Using the MarketScan Commercial Database, we examined all patients with SLAP tear who underwent arthroscopic SLAP repair or open or arthroscopic biceps tenodesis within the encompassed time period (2003-2014). Rates of repeat shoulder surgery within 3 years were evaluated, as were comparative demographics. RESULTS: In total, 25,142 patients initially underwent SLAP repair, of whom 11.5% had subsequent shoulder surgery within 3 years. A total of 840 patients initially underwent biceps tenodesis as treatment for a SLAP tear, of whom 13.0% underwent additional shoulder surgery within 3 years. Rates of subsequent shoulder surgery between the 2 procedural groups did not statistically differ (P = .19). Patients who underwent SLAP repair were younger than those who underwent tenodesis (mean age 38.3 vs 49.3 years, P < .01). For patients requiring additional surgery, the SLAP repair group had a greater representation of those ≥35 years old, whereas the tenodesis group had a greater representation of those <35 years old (P < .01). Male patients experienced an increase in rate of subsequent shoulder surgery when initially undergoing tenodesis versus SLAP repair (13.3% vs 11.1%, P < .01). CONCLUSIONS: The rates of additional shoulder surgery for patients undergoing SLAP repair and biceps tenodesis were similar within 3 years of the index procedure. Patients who underwent SLAP repair were younger than those who underwent tenodesis. Of those requiring additional surgery, patients initially treated with SLAP repair were older (≥35 years) and those treated with tenodesis were younger (<35 years). Male patients experienced an increase in rate of subsequent shoulder surgery when initially treated with tenodesis versus SLAP repair. LEVEL OF EVIDENCE: III, retrospective comparative study.

Lumbar discectomy is associated with higher rates of lumbar fusion.

BACKGROUND CONTEXT: Lumbar disc herniation affects more than 3 million people in the United States every year, and the rate of operation continually increases, particularly in patients 60 years or older (Taylor et al., 1994; Jordan et al., 2011). Surgical discectomy is a common treatment for lumbar disc herniation (Taylor et al., 1994; Atlas et al., 1996). One concern for this method is the risk of undergoing additional surgeries (Jordan et al., 2011; Österman et al., 2003; Lebow et al., 2011). There are very limited population-level studies that examine the rate of lumbar fusion after lumbar discectomy. Additionally, there is no study that examines the risk of undergoing lumbar fusion in patients who have undergone lumbar discectomies compared with the risk of lumbar fusion in the general population with no previous lumbar discectomy. PURPOSE: The present study aimed to calculate a more definitive rate of lumbar fusion after a lumbar discectomy procedure using a population-size study of more than 200,000 patients in the Truven Healthcare Analytics Marketscan Research Database who underwent discectomies. Additionally, the study aimed to compare the rate of lumbar fusion in patients who have undergone a lumbar discectomy to the rate of lumbar fusion in patients with no prior lumbar discectomy procedure. STUDY DESIGN/SETTING: This is a retrospective cohort study. PATIENT SAMPLE: The patients from both parts of the present study were extracted from the Truven Healthcare Analytics Marketscan Research Database. Ten-year fusion after discectomy rates: 223,291 patients who underwent discectomies from the years 2003 to 2015. Fusion rate comparison: 489,975 patients with a previous lumbar ICD-9 (International Classification of Diseases, Ninth Revision) diagnosis code who have also been enrolled in the database for at least 10 years. OUTCOME MEASURES: Ten-year fusion after discectomy rates: The proportion of patients who received a lumbar fusion up to 10 years after a lumbar discectomy. Fusion rate comparison: The proportion of patients who received a lumbar fusion after a lumbar discectomy compared with the proportion of patients who received a lumbar fusion with no previous lumbar discectomy. METHODS: Ten-year fusion after discectomy rates: The patients who had undergone discectomies were filtered in the Marketscan database via Current Procedural Terminology (CPT) codes specific for lumbar discectomy (63030, 63035). Patients who had a lumbar fusion before or concurrently with these indexed lumbar discectomy dates were removed from the index group. The group was then followed up every year up to 10 years after the initial indexed lumbar discectomy dates for reoperation involving a lumbar spinal fusion according to the lumbar fusion CPT codes (22533, 22558, 22612, 22630, 22632, 22633, 22634, 22534, 22585, 22614). Fusion rate comparison: Study population only included patients who had a previous lumbar ICD-9 diagnosis in the Marketscan database (7242, 72210, 72251, 72252, 72273, 72293, 7213, 72142, 72283, 72293, 7243, 72402, 72403, 7244, 7245, 7249). The patients were then separated into two arms: one with patients who had undergone lumbar discectomy after initial lumbar diagnosis and another with patients who had not undergone a lumbar discectomy procedure. Pearson chi-square test was used to assess significance when comparing the proportion of patients who receive lumbar fusion after lumbar discectomy with the proportion of patients who receive lumbar fusion without a prior lumbar discectomy in the general ICD-9 lumbar diagnosis population. RESULTS: For the 10-year trend of lumbar fusion rates after lumbar discectomy, the rate of fusion ranged from 1.69% (1-year time frame after discectomy) to 8.50% (10-year time frame after discectomy). When comparing the two cohorts in the second part of the present study, the fusion rates were 12.50% for the discectomy group and 4.19% for the non-discectomy group. The Pearson chi-square test reported a statistically significant difference between the fusion rates of the two groups (p<.0001, α=.05). We found that people who had a lumbar discectomy procedure were 2.97 (95% confidence interval [2.86, 3.10]) times more likely to undergo a lumbar fusion than those who with a lumbar diagnosis but had not undergone a lumbar discectomy in the past. CONCLUSIONS: Our study is the largest population study that explores the rate of lumbar fusion after an initial lumbar discectomy. To our knowledge, it is the first study that concludes that an initial lumbar discectomy is statistically associated with an increased likelihood of a patient undergoing a lumbar fusion in the future. We observed that patients who had previously undergone a lumbar discectomy were roughly three times more likely to undergo a lumbar fusion procedure than a patient with a lumbar diagnosis, but had not undergone a lumbar discectomy. Although not calculated, it stands to reason the difference would be even greater when comparing the discectomy population with a population without lumbar diagnoses. This finding can be an important supplement for the physician-patient discussion regarding expectations and potential for reoperation.

Treatment Trends, Complications, and Effects of Comorbidities on Distal Radius Fractures.

Background: Distal radius fractures (DRFs) are the most common upper extremity fractures in adults. This study seeks to elucidate the impact age, fracture type, and patient comorbidities have on the current treatment of DRFs and risk of complications. We hypothesized that comorbidities rather than age would relate to the risk of complications in the treatment of DRFs. Methods: A retrospective review of data was performed for patients treated between 2007 and 2014 using Truven Health MarketScan Research Databases. Patients who sustained a DRF were separated into "closed" versus "open" treatment groups, and the association between patient demographics, treatment type, and comorbidities with complication rates was analyzed, along with the trend of treatment modalities throughout the study time interval. Results: In total, 155 353 DRFs were identified; closed treatment predominated in all age groups with the highest percentage of open treatment occurring in the 50- to 59-year age group. Between 2007 and 2014, there was an increase in the rate of open reduction and internal fixation (ORIF) in all age groups <90 with the largest increase (11%) occurring in the 70- to 79-year age group. Higher complication rates were observed in the open treatment group in all ages <90 years with a trend toward decreasing complication rates as age increased. Comorbidities were more strongly associated with the risk of developing complications than age. Conclusions: Closed treatment of DRFs remains the predominant treatment method among all age groups, but DRFs are increasingly being treated with ORIF. Emphasis on the patients' comorbidities rather than chronological age should be considered in the treatment decision-making process of elderly patients with DRFs.

Thromboprophylaxis in Spinal Surgery.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: Determine the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) in spinal surgery patients receiving no thromboprophylaxis, mechanoprophylaxis, and chemoprophylaxis. SUMMARY OF BACKGROUND DATA: The incidence of thromboembolic complications after spinal surgery is not well established. Although a variety of effective mechanical and chemical thromboprophylaxis interventions exist, their role in spinal surgery remains unclear. Spine surgeons are faced with the difficult decision of balancing the risk of death from a thromboembolic complication against the risk of permanent neurological damage from an epidural hematoma (EDH). METHODS: The Medline database was queried using combinations of the terms related to the aforementioned subject matter. Articles meeting our predetermined inclusion criteria were reviewed and relevant data extracted. Meta-analyses were created using a random-effects model for incidence of DVT and PE by type of thromboprophylaxis, method of screening, and study type. RESULTS: Twenty-eight articles were included in the final analyses. The higher mean incidence of DVT and PE in the mechanoprophylaxis group (DVT: 1%, PE: 0.81%) compared to the chemoprophylaxis group (DVT: 0.85%, PE: 0.58%) was not observed to be statistically significant. Six percent of PEs was fatal; the rate of EDHs was 0.3%. The incidence of DVT was higher in prospective studies (1.4%) compared to retrospective studies (0.61%); the incidence of DVT was not affected by whether the study screened only symptomatic patients. CONCLUSION: Although the incidence of DVT and PE was relatively low regardless of prophylaxis type, the true incidence is difficult to determine given the heterogeneous nature of the small number of studies available in the literature. Our findings suggest there may be a role for chemoprophylaxis given the relatively high rate of fatal PE. Future studies are needed to determine which patient population would benefit most from chemoprophylaxis. LEVEL OF EVIDENCE: 2.

Trend of Spine Surgeries in the Outpatient Hospital Setting Versus Ambulatory Surgical Center.

STUDY DESIGN: Retrospective database review. OBJECTIVE: The aim of the present study was to examine how often spine surgery is being performed in an outpatient hospital setting versus a more "true" ambulatory setting, specifically ambulatory surgery centers (ASCs) in which admission and discharge are required on the same calendar day. SUMMARY OF BACKGROUND DATA: Recent studies have assessed the safety, satisfactory clinical outcomes, and increasing utilization of both cervical and lumbar spinal surgeries performed in the outpatient setting. No studies have delineated between true ambulatory settings and outpatient hospitals when assessing the rates of these procedures. METHODS: A retrospective review of the Truven Health Marketscan Research Databases was conducted for patients undergoing spine operations between 2003 and 2014. The frequency of each Common Procedural Terminology code was identified per year, and then categorized into each of "inpatient hospital," "outpatient hospital," or "ASC" in states that clearly define ASCs as facilities in which patients are discharged on the same calendar day of the operation, and do not stay overnight. RESULTS: During the period between 2003 and 2014, the procedures that had the most dramatic increase as an outpatient hospital procedure included lumbar decompression laminotomy first level (18.7%-68.5%) and posterior cervical decompression laminectomy without facetectomy discectomy first level (0%-46.7%). ASC procedures had more modest increases during this time period with the most significant increases in lumbar decompression laminotomy first level (0.7%-10.6%) and posterior cervical decompression laminotomy first level (0%-23.4%). CONCLUSION: "True" ambulatory surgeries are not increasing at the same rate as outpatient procedures with 23-hour observation capacity. Although prior studies have demonstrated the safety of outpatient spine surgery, one possible reason for this trend may be that surgeons feel that this safety may not be comparable to that of other outpatient procedures. LEVEL OF EVIDENCE: 3.