Identifying surgeon and institutional drivers of cost in total shoulder arthroplasty: a multicenter study.

BACKGROUND: Despite rapid increases in the demand for total shoulder arthroplasty, data describing cost trends are scarce. We aim to (1) describe variation in the cost of shoulder arthroplasty performed by different surgeons at multiple hospitals and (2) determine the driving factors of such variation. METHODS: A standardized, highly accurate cost accounting method, time-driven activity-based costing, was used to determine the cost of 1571 shoulder arthroplasties performed by 12 surgeons at 4 high-volume institutions between 2016 and 2018. Costs were broken down into supply costs (including implant price and consumables) and personnel costs, including physician fees. Cost parameters were compared with total cost for surgical episodes and case volume. RESULTS: Across 4 institutions and 12 surgeons, surgeon volume and hospital volume did not correlate with episode-of-care cost. Average cost per case of each institution varied by factors of 1.6 (P = .47) and 1.7 (P = .06) for anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RSA), respectively. Implant (56% and 62%, respectively) and personnel costs from check-in through the operating room (21% and 17%, respectively) represented the highest percentages of cost and highly correlated with the cost of the episode of care for TSA and RSA. CONCLUSIONS: Variation in episode-of-care total costs for both TSA and RSA had no association with hospital or surgeon case volume at 4 high-volume institutions but was driven primarily by variation in implant and personnel costs through the operating room. This analysis does not address medium- or long-term costs.

Effects of acquired glenoid bone defects on surgical technique and clinical outcomes in reverse shoulder arthroplasty.

BACKGROUND: Reverse total shoulder arthroplasty is the accepted method of treatment for selected shoulder disorders. The purpose of this study was to compare primary reverse shoulder arthroplasty surgical techniques as well as clinical and radiographic outcomes in patients with acquired glenoid bone defects and in those with normal glenoid morphology. METHODS: Preoperative three-dimensional computed tomography scans were performed on 216 shoulders in 211 patients undergoing primary reverse shoulder arthroplasty between 2004 and 2007. The glenoids were classified as normal or abnormal on the basis of preoperative radiographs and three-dimensional reconstructions of the scapula. One hundred and forty-three shoulders had been followed for two years. There were eighty-seven normal and fifty-six abnormal glenoids. The surgical techniques that were compared included bone-grafting and glenosphere selection. The clinical outcomes for the two groups were compared with respect to the American Shoulder and Elbow Surgeons score. RESULTS: Surgical technique differed between the groups. All fifty-six glenoids with acquired bone defects had center screw placement along an alternative (scapular spine) centerline. A bone graft was used in twenty-two shoulders with acquired glenoid bone defects compared with none of those with normal glenoid morphology (p = 0.016). Shoulders with glenoid defects were treated with larger glenospheres (36 or 40 mm) more often than those with normal glenoids (p < 0.001). No significant difference was detected between the groups with regard to the preoperative or postoperative American Shoulder and Elbow Surgeons scores. Radiographs did not demonstrate failure or resorption of a glenoid bone graft when present. All outcomes improved significantly postoperatively. There were five complications, and one patient was unsatisfied with the result. CONCLUSIONS: Glenoid bone defects, when managed with an alteration of surgical technique, including bone-grafting when indicated, are not a contraindication to reverse total shoulder arthroplasty.

Results of surgical treatment for unstable distal clavicular fractures.

HYPOTHESIS: Delayed surgical treatment of unstable distal clavicle fractures is associated with a higher complication rate. MATERIALS AND METHODS: Between 1998 and 2008, a retrospective study of 38 patients (average age, 42.9 year) with Neer type II clavicular fractures was performed. Fractures were treated with a hook-plate (22 patients) or with superior locked plate with suture augmentation (16 patients). Patients were divided into acute (27 patients) or delayed (11 patients) treatment groups based on the timing of surgical intervention before or after 4 weeks. All had clinical and radiographic follow-up for 1 year or until fracture union. RESULTS: Union was achieved in 36 of 38 patients (94.7%). The acute treatment group had an average American Shoulder and Elbow Surgeons score of 77.9 compared with 65.0 in the delayed group. Six complications occurred (15.8%) including 2 infections (5.3%), 1 hardware failure (2.6%), and 3 peri-implant fractures (7.9%). The complication rate was 36.4% in the delayed group vs 7.4% in the acutely treated group (P = .047). DISCUSSION: A high rate of union was observed in all cases regardless of timing or method of fixation. Despite a high rate of union, the results of treatment in the delayed group were more problematic. Patients treated with a hook-plate in a delayed fashion had more complications than those treated in an acute fashion (P = .039). Peri-implant fractures occurred only in patients treated with hook-plates. CONCLUSION: Surgical timing played a critical role in the outcome and complication rate in treatment of unstable distal third clavicle fractures.