Ambulatory Surgery Centers Reduce Patient Out-of-Pocket Expenditures for Isolated Arthroscopic Rotator Cuff Repair, but Patient Out-of-Pocket Expenditures Are Increasing at a Faster Rate Than Total Healthcare Utilization Reimbursement From Payers.

PURPOSE: To categorize and trend annual out-of-pocket expenditures for arthroscopic rotator cuff repair (RCR) patients relative to total healthcare utilization (THU) reimbursement and compare drivers of patient out-of-pocket expenditures (POPE) in a granular fashion via analyses by insurance type and surgical setting. METHODS: Patients who underwent outpatient arthroscopic RCR in the United States from 2013 to 2018 were identified from the IBM MarketScan Database. Primary outcome variables were total POPE and THU reimbursement, which were calculated for all claims in the 9-month perioperative period. Trends in outcome variables over time and differences across insurance types were analyzed. Multivariable analysis was performed to investigate drivers of POPE. RESULTS: A total of 52,330 arthroscopic RCR patients were identified. Between 2013 and 2018, median POPE increased by 47.5% ($917 to $1,353), and median THU increased by 9.3% ($11,964 to $13,076). Patients with high deductible insurance plans paid $1,910 toward their THU, 52.5% more than patients with preferred provider plans ($1,253, P = .001) and 280.5% more than patients with managed care plans ($502, P = .001). All components of POPE increased over the study period, with the largest observed increase being POPE for the immediate procedure (P = .001). On multivariable analysis, out-of-network facility, out-of-network surgeon, and high-deductible insurance most significantly increased POPE. CONCLUSIONS: POPE for arthroscopic RCR increased at a higher rate than THU over the study period, demonstrating that patients are paying an increasing proportion of RCR costs. A large percentage of this increase comes from increasing POPE for the immediate procedure. Out-of-network facility status increased POPE 3 times more than out-of-network surgeon status, and future cost-optimization strategies should focus on facility-specific reimbursements in particular. Last, ambulatory surgery centers (ASCs) significantly reduced POPE, so performing arthroscopic RCRs at ASCs is beneficial to cost-minimization efforts. CLINICAL RELEVANCE: This study highlights that although payers have increased reimbursement for RCR, patient out-of-pocket expenditures have increased at a much higher rate. Furthermore, this study elucidates trends in and drivers of patient out-of-pocket payments for RCR, providing evidence for development of cost-optimization strategies and counseling of patients undergoing RCR.

Association between timing of initiating supervised physical rehabilitation after rotator cuff repair and incidence of repeat repair and capsulitis: a population-based analysis.

BACKGROUND: There is limited consensus on the optimal time to initiate supervised physical rehabilitation after a rotator cuff repair (RCR). We examined whether timing of initiating supervised physical rehabilitation was associated with repeat RCR or development of adhesive capsulitis within 12 months postoperatively in an observational cohort of commercially insured adults. METHODS: This retrospective cohort study used the IBM MarketScan Commercial Claims and Encounters Database. We included adults aged 18-64 who underwent a unilateral outpatient RCR between 2017 and 2020 and initiated supervised physical rehabilitation 1-90 days postoperatively. Multivariable logistic regression models examined the adjusted association between time of initiating supervised physical rehabilitation (1-13, 14-27, 28-41, and 42-90 days postoperatively) and each of the primary outcomes: repeat RCR and capsulitis. In a sensitivity analysis, time to rehabilitation was alternatively categorized using a data-driven approach of quartiles (1-7, 8-16, 17-30, and 31-90 days postoperatively). We report adjusted odds ratios (OR). RESULTS: Among 33,841 patients (86.7% arthroscopic index RCR), the median time between index RCR and rehabilitation initiation was 16 days (interquartile range 7-30), with 39.9% initiating rehabilitation at 1-13 days. Additionally, 2.2% underwent repeat RCR within 12 months, and 12-month capsulitis was identified in 1.9% of patients. There were no significant associations between timing of initiating rehabilitation and 12-month repeat RCR (OR 0.85-0.93, P = .18-.49) or 12-month capsulitis (OR 0.83-0.94, P = .22-.63). Lack of associations between timing and outcomes was supported in sensitivity analyses. CONCLUSIONS: Timing of initiating rehabilitation was not significantly associated with adverse outcomes after RCR. The finding of no increased odds of repeat RCR or capsulitis with the earliest timing may support earlier initiation of rehabilitation to accelerate return to daily activities. Findings should be replicated in another dataset of similarly-aged patients.

Assessment of Risk Factors and Rate of Conversion to Total Hip Arthroplasty Within 2 Years After Hip Arthroscopy Utilizing a Large Database of Commercially Insured Patients in the United States.

Background: The conversion rate of hip arthroscopy (HA) to total hip arthroplasty (THA) has been reported to be as high as 10%. Despite identifying factors that increase the risk of conversion, current studies do not stratify patients by type of arthroscopic procedure. Purpose/Hypothesis: To analyze the rate and predictors of conversion to THA within 2 years after HA. It was hypothesized that osteoarthritis (OA) and increased patient age would negatively affect the survivorship of HA. Study Design: Cohort study; Evidence level, 3. Methods: The IBM MarketScan database was utilized to identify patients who underwent HA and converted to THA within 2 years at inpatient and outpatient facilities between 2013 and 2017. Patients were split into 3 procedure cohorts as follows: (1) femoroacetabular osteoplasty (FAO), which included treatment for femoroacetabular impingement; (2) isolated debridement; and (3) isolated labral repair. Cohort characteristics were compared using standardized differences. Conversion rates between the 3 cohorts were compared using chi-square tests. The relationship between age and conversion was assessed using linear regression. Predictors of conversion were analyzed using multivariable logistic regression. The median time to conversion was estimated using Kaplan-Meier tests. Results: A total of 5048 patients were identified, and the rates of conversion to THA were 12.86% for isolated debridement, 8.67% for isolated labral repair, and 6.76% for FAO (standardized difference, 0.138). The isolated labral repair cohort had the shortest median time to conversion (isolated labral repair, 10.88 months; isolated debridement, 10.98 months; and FAO, 11.9 months [P = .034). For patients >50 years, isolated debridement had the highest rate of conversion at 18.8%. The conversion rate increased linearly with age. Factors that increased the odds of conversion to THA were OA, having an isolated debridement procedure, and older patient age (P < .05). Conclusion: Older patients and those with preexisting OA of the hip were at a significantly increased risk of failing HA and requiring a total hip replacement within 2 years of the index procedure. Younger patients were at low risk of requiring a conversion procedure no matter which arthroscopic procedure was performed.

Variation in Utilization of Physical Therapist and Occupational Therapist Services After Rotator Cuff Repair: A Population-Based Study.

OBJECTIVE: The objective of this study was to describe the utilization of physical therapist and occupational therapist services after rotator cuff repair (RCR) and examine variation in rehabilitation characteristics by profession. METHODS: This retrospective cohort study used the IBM MarketScan Commercial Claims and Encounters database. Eligible patients were 18 to 64 years old and had undergone outpatient RCR between 2017 and 2020. Physical therapist and occupational therapist services were identified using evaluation and treatment codes with profession-specific modifiers ("GP" or "GO"). Factors predicting utilization of formal rehabilitation and physical therapist versus occupational therapist services were examined; and univariable and multivariable analyses of days to initiate therapy, number of visits, and episode length by profession were completed. RESULTS: Among 53,497 patients with an RCR, 81.2% initiated formal rehabilitation (93.8% physical therapist, 5.2% occupational therapist, 1.0% both services). Patients in the Northeast and West (vs the South) were less likely to receive rehabilitation (odds ratio [OR] = 0.67 to 0.70) and less likely to receive occupational therapist services (OR = 0.39). Patients living in the Midwest (versus the South) were less likely to receive rehabilitation (OR = 0.79) but more likely to receive occupational therapist services (OR = 1.51). Similarly, those living in a rural (versus urban) area were less likely to utilize rehabilitation (OR = 0.89) but more likely to receive occupational therapist services (OR = 2.21). Additionally, receiving occupational therapist instead of physical therapist services was associated with decreased therapist visits (-16.89%), days to initiate therapy (-13.43%), and episode length (-13.78%). CONCLUSION: Most patients in our commercially insured cohort utilized rehabilitation services, with a small percentage receiving occupational therapist services. We identified profession-specific variation in utilization characteristics that warrants further examination to understand predictors and associated outcomes. IMPACT: Variation in rehabilitation utilization after RCR, including profession-specific and regional differences, may indicate opportunities to improve standardization and quality of care.

Increased rate of out-of-network surgeon selection for hip arthroscopy compared to more common orthopedic sports procedures.

Background: Demand for hip arthroscopy (HA) has increased, but shortfalls in HA training may create disparities in care access. This analysis aimed to (1) compare out-of-network (OON) surgeon utilization for HA with that of more common orthopedics sports procedures, including rotator cuff repair (RCR), partial meniscectomy (PM), and anterior cruciate ligament reconstruction (ACLR), (2) compare the HA OON surgeon rate with another less commonly performed procedure, meniscus allograft transplant (MAT), and (3) analyze trends and predictors of OON surgeon utilization. Methods: The 2013-2017 IBM MarketScan database identified patients under 65 who underwent HA, RCR, PM, ACLR, or MAT. Demographic differences were determined using standardized differences. Cochran-Armitage tests analyzed trends in OON surgeon utilization. Multivariable logistic regression identified predictors of OON surgeon utilization. Statistical significance was set to p < 0.05 and significant standardized differences were >0.1. Results: 410,487 patients were identified, of which 12,636 patients underwent HA, 87,607 RCR, 233,241 PM, 76,700 ACLR, and 303 MAT. OON surgeon utilization increased for HA, rising from 7.98 % in 2013 to 9.37 % in 2017 (p = 0.026). Compared to RCR, PM, and ACLR, HA was associated with higher likelihood of OON surgeon utilization. Usage of ambulatory surgery centers (ASCs) was predictive of higher OON surgeon rates along with procedure year, insurance plan type, and geographic region. HA performed in an ASC was 13 % less likely to have an OON surgeon (p = 0.047). Conclusion: OON surgeon utilization generally declined but increased for HA. HA was a predictor of OON surgeon status, possibly because HA is a technically complicated procedure with fewer trained in-network providers. Other predictors of OON surgeon status included ASC usage, PPO/EPO plan type, and Northeast geographic region. There is a need to improve access to experienced HA providers-perhaps with prioritization of HA training in residency and fellowship programs-in order to address rising OON surgeon utilization.

Hip Arthroscopy Trends: Increasing Patient Out-of-Pocket Costs, Lower Surgeon Reimbursement, and Cost Reduction With Utilization of Ambulatory Surgery Centers.

PURPOSE: To (1) report on trends in immediate procedure reimbursement, patient out-of-pocket expenditures, and surgeon reimbursement in hip arthroscopy (2) compare trends in ambulatory surgery centers (ASC) versus outpatient hospitals (OH) utilization; (3) quantify the cost differences (if any) associated with ASC versus OH settings; and 4) determine the factors that predict ASC utilization for hip arthroscopy. METHODS: The cohort for this descriptive epidemiology study was any patient over 18 years identified in the IBM MarketScan Commercial Claims Encounter database who underwent an outpatient hip arthroscopy, identified by Current Procedural Terminology codes, in the United States from 2013 to 2017. Immediate procedure reimbursement, patient out-of-pocket expenditure, and surgeon reimbursement were calculated, and a multivariable model was used to determine the influence of specific factors on these outcome variables. Statistically significant P values were less than .05, and significant standardized differences were more than 0.1. RESULTS: The cohort included 20,335 patients. An increasing trend in ASC utilization was observed (P = .001), and ASC utilization for hip arthroscopy was 32.4% in 2017. Patient out-of-pocket expenditures for femoroacetabular impingement surgery increased 24.3% over the study period (P = .003), which was higher than the rate for immediate procedure reimbursement (4.2%; P = .007). ASCs were associated with $3,310 (28.8%; P = .001) reduction in immediate procedure reimbursement and $47 (6.2%; P = .001) reduction in patient out-of-pocket expenditure per hip arthroscopy. CONCLUSIONS: ASCs provide a significant cost difference for hip arthroscopy. Although there is an increasing trend toward ASC utilization, it remains relatively low at 32.4% in 2017. Thus, there are opportunities for expanded ASC utilization, which is associated with significant immediate procedure reimbursement difference of $3,310 and patient out-of-pocket expenditure difference of $47 per hip arthroscopy case, ultimately benefiting healthcare systems, surgeons, and patients alike. LEVEL OF EVIDENCE: Level III, retrospective comparative trial.

Ambulatory Surgery Centers Significantly Decrease Total Health Care Expenditures in Primary Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) is a commonly performed orthopaedic procedure. The volume and cost of ACLR procedures are increasing annually, but the drivers of these cost increases are not well described. PURPOSE: To analyze the modifiable drivers of total health care utilization (THU), immediate procedure reimbursement, and surgeon reimbursement for patients undergoing ACLR using a large national commercial insurance database from 2013 to 2017. STUDY DESIGN: Descriptive epidemiology study. METHODS: For this study, the cohort consisted of patients identified in the MarketScan Commercial Claims and Encounters database who underwent outpatient arthroscopic ACLR in the United States from 2013 to 2017. Patients with Current Procedural Terminology code 29888 were included. THU was defined as the sum of any payment related to the ACLR procedure from 90 days preoperatively to 180 days postoperatively. A multivariable model was utilized to describe the patient- and procedure-related drivers of THU, immediate procedure reimbursement, and surgeon reimbursement. RESULTS: There were 34,862 patients identified. On multivariable analysis, the main driver of THU and immediate procedure reimbursement was an outpatient hospital as the surgical setting (US$6789 increase in THU). The main driver of surgeon reimbursement was an out-of-network surgeon (US$1337 increase). Health maintenance organization as the insurance plan type decreased THU, immediate procedure reimbursement, and surgeon reimbursement (US$955, US$108, and US$38 decrease, respectively, compared with preferred provider organization; P < .05 for all). CONCLUSION: Performing procedures in more cost-efficient ambulatory surgery centers had the largest effect on decreasing health care expenditures for ACLR. Health maintenance organizations aided in cost-optimization efforts as well, but had a minor effect on surgeon reimbursement. Overall, this study increases transparency into what drives reimbursement and serves as a foundation for how to decrease health care expenditures related to ACLR.

Trends in Health Care Expenditures and Patient Out-of-Pocket Expenses in Primary Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) is one of the most commonly performed orthopaedic procedures in the United States, and the number of procedures is increasing annually, as is the cost. Patients are expected to shoulder a larger out-of-pocket expenditure. PURPOSE: To answer the following questions: (1) How is reimbursement changing for ACLR, and how is this affecting patients' out-of-pocket expenditures? (2) How are reimbursements from payers and patients' out-of-pocket expenses for ACLR distributed, and how is this changing? (3) Does performing ACLR in an ambulatory surgery center (ASC) result in lower costs for payers and patients? STUDY DESIGN: Economic and decision analysis study; Level of evidence, 4. METHODS: A total of 37,763 patients who underwent outpatient primary arthroscopic ACLR in the United States between 2013 and 2017 were identified using the IBM MarketScan Commercial Claims and Encounters Database. Patients with concomitant procedures and revision ACLR were excluded. Recorded outcomes were total patient payments and reimbursed claim totals in US dollars. RESULTS: Day-of-surgery reimbursement decreased 4.3% from $11,536 in 2013 to $11,044 in 2017, while patient out-of-pocket expenses increased 36% from $1085 in 2013 to $1480 in 2017. Day-of-surgery charges were the highest expense for patients, followed by physical therapy and magnetic resonance imaging (MRI) costs. Total reimbursement for MRI decreased 22.5%, while patient out-of-pocket expenses for MRI increased 166%. ACLR performed in an outpatient hospital resulted in 61% greater day-of-surgery expenditure for payers compared with ACLR performed in an ASC; however, the median total patient out-of-pocket savings for ACLRs performed in an ASC versus outpatient hospital was only $11. CONCLUSION: Out-of-pocket expenses for patients are increasing as they are forced to cover a larger percentage of their health care costs despite overall payer reimbursement decreasing. High-deductible health plans reimbursed the least out of all insurance types while having the highest patient out-of-pocket expenditure.

Trends in Private Equity Acquisition of Orthopaedic Surgery Practices in the United States.

BACKGROUND: Independent orthopaedic practices in the United States have become attractive targets for acquisition by hospital systems and private equity (PE) firms because of the increasing demand for outpatient surgery. Consolidation in this market will have notable effects on the delivery and cost of orthopaedic services. In this study, we identified major trends in orthopaedic practice acquisitions over the past decade. METHODS: A list of acquisition deals between 2010 and 2019 was compiled from four business databases: S&P Capital IQ, CB Insights, Thomson ONE, and Zephyr. Deals were categorized as PE-backed or not PE-backed. Headquarter locations of the buying and selling companies and transaction value were obtained for each deal when available. RESULTS: A total of 68 deals were obtained of which 5 (7.4%) were PE-backed. The buyer and seller were located in the same state in 50 (73.5%) of the deals. Transaction values were available for only four deals ranging from $2.52 million to $35 million. CONCLUSION: Our results suggest that consolidation of orthopaedic practices from 2010 to 2019 was driven by large healthcare entities rather than PE firms. Furthermore, intrastate acquisitions were markedly more common than interstate acquisitions, possibly because of greater legal feasibility and ease of clinical integration.

Utilization, effectiveness, and safety of tranexamic acid use in hip fracture surgery: A population-based study.

OBJECTIVE: To assess the effect of tranexamic acid (TXA) use in hip fracture surgery. METHODS: A retrospective cohort study was performed using the Premier Healthcare database. A propensity score matching approach was applied to assess associations between TXA use and blood transfusion, perioperative complications, length of stay (LOS), and hospitalization cost. RESULTS: In 153,169 patients, TXA use was associated with a 17% decrease in odds of blood transfusion, no increase in the risk of perioperative complications, 16% shorter LOS, and minimal effects on hospitalization cost. CONCLUSION: Our results are in support of a wider use of TXA in hip fracture surgery. LEVEL OF EVIDENCE: Level III.

Impact of Increasing Comorbidity Burden on Resource Utilization in Patients With Proximal Humerus Fractures.

INTRODUCTION: Proximal humerus fractures (PHF) are a common upper extremity fracture in the elderly cohort. An aging and more comorbid cohort, along with recent trends of increased operative intervention, suggests that there could be an increase in resource utilization caring for these patients. We sought to quantify these trends and quantify the impact that comorbidity burden has on resource utilization. METHODS: Data on 83,975 patients with PHFs were included from the Premier Healthcare Claims database (2006 to 2016) and stratified by Deyo-Charlson index. Multivariable models assessed associations between Deyo-Charlson comorbidities and resource utilization (length and cost of hospitalization, and opioid utilization in oral morphine equivalents [OME]) for five treatment modalities: (1) open reduction internal fixation (ORIF), (2) closed reduction internal fixation (CRIF), (3) hemiarthroplasty, (4) reverse total shoulder arthroplasty, and (5) nonsurgical treatment (NST). We report a percentage change in resource utilization associated with an increasing comorbidity burden. RESULTS: Overall distribution of treatment modalities was (proportion in percent/median length of stay/cost/opioid utilization): ORIF (19.1%/2 days/$11,183/210 OME), CRIF (1.1%/4 days/$11,139/220 OME), hemiarthroplasty (10.7%/3 days/$17,255/275 OME), reverse total shoulder arthroplasty (6.4%/3 days/$21,486/230 OME), and NST (62.7%/0 days/$1,269/30 OME). Patients with an increased comorbidity burden showed a pattern of (1) more pronounced relative increases in length of stay among those treated operatively (65.0% for patients with a Deyo-Charlson index >2), whereas (2) increases in cost of hospitalization (60.1%) and opioid utilization (37.0%) were more pronounced in the NST group. DISCUSSION: In patients with PHFs, increased comorbidity burden coincides with substantial increases in resource utilization in patients receiving surgical and NSTs. Combined with known increases in operative intervention, trends in increased comorbidity burden may have profound effects on the cohort level and resource utilization for those with PHFs, especially because the use of bundled payment strategies for fractures increases. LEVEL OF EVIDENCE: Level III.

Soft tissue resurfacing for glenohumeral arthritis: a systematic review.

BACKGROUND: Severe glenohumeral arthritis in the young/active patient remains challenging. Historically, glenohumeral arthrodesis was recommended with limited return of function. Total shoulder arthroplasty has shown increasing survivorship at 15 years; however it is still not ideal for young patients. Biologic resurfacing of the glenoid with humeral head replacement has shown promising results. METHODS: The PubMed and Embase databases were queried for studies evaluating outcomes of glenoid biologic resurfacing with autograft or allograft. Two independent reviewers performed a systematic review according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. RESULTS: Eleven studies (268 shoulders, 264 patients) were included. Minimum follow-up was 24 months in all but one study; patient age ranged from 14 to 75 years. Glenoid grafts used included 44.3% lateral meniscus allografts, 25.4% human acellular dermal matrix, 14.2% Achilles tendon allografts, 11.6% shoulder joint capsules, and 4.5% fascia lata autografts. Studies reported significantly improved American Shoulder and Elbow Surgeons, Visual Analog Scale, and Simple Shoulder Test scores postoperatively; 43.3% were failures (Neer's evaluation of unsatisfactory or requiring revision). Infection occurred in 12/235. CONCLUSIONS: Biologic resurfacing of the glenoid with a metallic humeral component can provide a significant improvement in pain, motion, and standardized outcomes scores in the well-indicated situation. Appropriate counseling is required with an appreciated complication rate of over 36% and a revision rate of 34%.

Outcomes of Primary Biceps Subpectoral Tenodesis in an Active Population: A Prospective Evaluation of 101 Patients.

PURPOSE: To evaluate the surgical outcomes of a primary subpectoral biceps tenodesis for long head of the biceps tendon (LHBT) pathology in a large cohort of prospectively, serially collected, patients in a young active population that has known high physical demands and requirements of their shoulder to perform their vocation. METHODS: A retrospective review of prospectively collected data from an active military personnel with a diagnosis of a Type II SLAP tear or biceps tenosynovitis was performed. Outcomes were evaluated at a minimum follow-up time of 18 months based on preoperative and postoperative assessments of the Single Assessment Numeric Evaluation, Western Ontario Rotator Cuff index, biceps position, and return to active duty. Inclusion criteria were (1) SLAP tears on magnetic resonance arthrogram (classified into SLAP group), and (2) no SLAP tear but examination findings of biceps tendonitis (placed in the LHBT tendonitis group). Patients were excluded for full-thickness rotator cuff tears, high-grade partial thickness tears requiring repair, acromioclavicular joint pathology, and labral pathology outside of the SLAP lesion. Patients from both groups subsequently were treated with open, subpectoral tenodesis. RESULTS: Over a 6-year period at a mean follow-up of 2.75 years (range 1.5-5.7 years), 125 active-duty military personnel with mean age of 42.6 years (range 26.3-56.5) were enrolled. A total of 101 of 125 patients (81%) completed study requirements at a mean of 2.75 years (range 1.5-5.7 years). In total, 40 patients were diagnosed with type II SLAP tears (39.6%) and 61 with biceps tendonitis without SLAP tear (60.4%). Following open, subpectoral tenodesis, there was a significant improvement in patient outcomes (Western Ontario Rotator Cuff = 54% preoperative vs 89% postoperative, Single Assessment Numeric Evaluation = 58 preoperative vs 89.5 postoperative, P < .01). In total, 82% of patients returned to full activity at a mean of 4.1 months. The biceps muscle measured relative to the antecubital fossa of operative (mean 3.20 cm) versus nonoperative (3.11 cm) was not clinically different (P = .57). There was an 8% complication rate, including 3 requiring revision, 2 superficial infections, and 3 transient neurapraxias. CONCLUSIONS: Primary subpectoral open biceps tenodesis for SLAP tears or pathology of the LHBT provides significant improvement in shoulder outcomes with a reliable return to activity level with low risk for complications. LEVEL OF EVIDENCE: Level IV (Case series).

Effectiveness of intravenous acetaminophen for postoperative pain management in shoulder arthroplasties: A population-based study.

BACKGROUND: Intravenous acetaminophen (IV APAP) is an option in multimodal postoperative analgesia. Prior trials focus on hip and knee arthroplasties, whereas large-scale data on utilization and effectiveness in shoulder arthroplasties are lacking. METHODS: Data on 67,494 (452 hospitals) partial/total shoulder arthroplasties were extracted from the Premier claims database (2011-2016). Patients were categorized by receipt and dosage of IV APAP. Multilevel models measured associations between IV APAP and opioid utilization (in oral morphine equivalents), length/cost of stay and opioid-related complications. Effect estimates (adjusted % change) with 95% confidence intervals (CIs) are reported. RESULTS: IV APAP was used in 17.7% (n = 11,949) of patients with an increasing utilization trend. Most patients received only one dose on the day of surgery (69.5%; n = 8308). When adjusting for relevant covariates, IV APAP was not associated with meaningful effects on outcomes. Specifically, its use (versus no use) was not associated with decreased (but rather somewhat increased) opioid utilization: + 5.4% (CI 3.6-7.1%; P < 0.05). CONCLUSION: In this first large-scale study that assesses IV APAP in shoulder arthroplasties, IV APAP use was not associated with decreased opioid utilization or the length/cost of stay. These results do not support routine use of IV APAP in this cohort, especially given its high cost. THE TRANSLATIONAL POTENTIAL FOR THIS ARTICLE: Multimodal pain control to assist in reducing the opioid pain medications are seen as a route to improved postoperative patient outcomes, better pain control and expedited hospital discharge. Acetaminophen plays a significant role in these protocols in many institutions, but it is not established if this expensive IV formulation is superior to the oral formulation. This study evaluates the use and effectiveness of IV acetaminophen following shoulder arthroplasty at a large number of institutions.

Utilization and Real-world Effectiveness of Tranexamic Use in Shoulder Arthroplasty: A Population-based Study.

INTRODUCTION: Tranexamic acid (TXA) is increasingly used to reduce blood loss in lower extremity arthroplasty, but limited data exist for its effectiveness in patients undergoing shoulder arthroplasty. We aimed to use national data to assess the frequency of use and effectiveness of TXA in patients undergoing shoulder arthroplasty. METHODS: Using national claims data from patients undergoing shoulder arthroplasty (Premier Healthcare; 2010 to 2016; n = 82,512; 429 hospitals), we categorized patients according to whether they received perioperative TXA. Multilevel multivariable regression models measured associations between TXA and blood transfusion risk, combined complications (including thromboembolic events, acute renal failure, cerebral infarction, and acute myocardial infarction), and length and cost of hospitalization. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported. RESULTS: Overall, TXA was used in 12.8% (n = 10,582) of patients with a strong increasing trend. After adjustment for relevant covariates, TXA use (compared with no TXA use) was associated with a 36% decrease in transfusion risk (OR, 0.64; 95% CI, 0.52 to 0.77; P < 0.05) and a 35% decreased risk for combined complications (OR, 0.65; 95% CI, 0.50 to 0.83; P < 0.05). Moreover, TXA use was associated with 6.2% shorter hospital stay (95% CI, -8.0% to -4.4%; P < 0.05), whereas no difference was observed with the cost of hospitalization. CONCLUSION: In this first large-scale study assessing TXA use and effectiveness in patients undergoing shoulder arthroplasty, we found that although TXA utilization is still low, it is associated with a marked decrease in transfusion risk with no increases in complication risk. Effects on the length and cost of hospitalization appeared minor. Future studies should assess whether higher volumes of TXA utilization would translate into more gains on the length and cost of hospitalization. LEVEL OF EVIDENCE: Level III.

Drain Use is Associated with Increased Odds of Blood Transfusion in Total Shoulder Arthroplasty: A Population-Based Study.

BACKGROUND: In the absence of evidence supporting its benefit, the American Academy of Orthopaedic Surgeons (AAOS) strongly recommends against closed wound drainage in TKA; however, drain usage remains common in other joints, including the shoulder. While an extensive body of research exists for drain use in lower extremity joint arthroplasty, large-scale data on drain use and its association with benefits and complications in shoulder arthroplasties is lacking. Such data may be particularly valuable given the rapidly increasing demand for shoulder arthroplasties. QUESTION/PURPOSE: Using national claims data, we (1) evaluated the trends in frequency of drain usage in shoulder arthroplasty procedures over time, as well as the association between drain usage and (2) blood transfusion usage, (3) length of stay (LOS), and (4) readmission or early infection within 30 days. METHODS: This retrospective study used data from the nationwide Premier Healthcare claims database (2006-2016; n = 105,116, including total, reverse, and partial shoulder arthroplasties, in which drains were used in 20% [20,886] and no drain was used in 80% [84,230]). Included hospitals were mainly concentrated in the South (approximately 40%) with equal distributions among the Northeast, West, and Midwest (approximately 20% each). The Premier database contains detailed inpatient billing data on approximately 20% to 25% of US hospital discharges, which allows the creation of a variable indicating drain use by evaluating inpatient billing for drains. Baseline demographics differed minimally between patients receiving a drain compared with those who did not, with a median age of 70 years in both groups. The potential for selection bias was addressed by adjusting for measured confounders in mixed-effects models that estimated associations between drain use and blood transfusion usage, LOS, and readmission or (early) infection within 30 days. In addition, alternative statistical approaches were applied to address confounding, including propensity score analysis and instrumental variable analysis where a so-called "instrumental variable" is applied that mimics the treatment assignment process similar to a randomized study. We report odds ratios (OR; or % change for continuous variables) and 95% confidence intervals (CIs). RESULTS: The usage of drains decreased over time, from 1106 of 4503 (25%) in 2006 to 2278 of 14,501 (16%) in 2016. After adjusting for relevant covariates, drain use was associated with an increased usage of blood transfusions (OR, 1.49; 95% CI, 1.35-1.65; p < 0.001) while only associated with a small increase in LOS (+6%, 95% CI, +4% to +7%; p < 0.001). Drain use was not associated with increased odds for early postoperative infection or 30-day readmission. Propensity score analysis and instrumental variable analysis corroborated our main results. CONCLUSIONS: Use of drains in patients undergoing shoulder arthroplasty is associated with an almost 50% increased odds for blood transfusions. Given that our findings parallel close to what is known in patients undergoing lower extremity joint arthroplasty, we believe that our results from a large national database are sufficient to discourage the routine use of drains in patients undergoing shoulder arthroplasty. LEVEL OF EVIDENCE: Level III, therapeutic study.

Outcomes of Patellofemoral Osteochondral Lesions Treated With Structural Grafts in Patients Older Than 40 Years.

Background Chondral lesions in the patellofemoral compartment represent a difficult entity to treat among active patients, with no clear consensus on the optimal treatment strategy. The purpose of this study was to review the functional outcomes of patients >40 years old with primary patellofemoral osteochondral lesions who underwent a cartilage restoration procedure with a structural graft. Methods Following institutional review board approval, 35 patients >40 years treated for patellofemoral chondral or osteochondral injuries were retrospectively identified. Seventeen (47%) had prior surgery (mean 1.4 procedures, range 1-4). Average follow-up was 3.6 ± 1.6 years. Average patient age was 51.5 years (range 40-72 years); 54% were male. Twenty-six (74%) had isolated trochlear lesions, 7 had isolated patellar lesions (20%), while 2 (6%) had bipolar lesions. Twenty patients (57%) were treated with synthetic biphasic scaffold plugs (SS), 9 (26%) with fresh osteochondral allograft (OCA) and 6 (17%) with osteochondral autograft transfer (OAT). Outcomes were measured with validated measures: Activity of Daily Living Score (ADL), International Knee Documentation Committee (IKDC) Subjective Evaluation form, and Marx Activity Scale (MAS). Results The average lesion size for the entire cohort was 3.1 ± 1.7 cm2. Average defect size was 2.6 ± 1.7 cm2 for the SS group, 4.3±1.5 cm2 for the OCA group, and 2.9 ± 0.8 cm2 for the OAT group ( P > 0.051). Outcome scores for the entire population demonstrated significant improvement in ADL ( P = 0.002) and IKDC scores ( P = 0.004) between baseline and final follow-up, while MAS scores were maintained ( P = 0.51). Conclusion Structural grafts are a viable treatment option for symptomatic focal osteochondral lesions of the patellofemoral joint in patients 40 years and older, with anticipated improvements in pain and function and maintenance of preoperative activity levels.

Return to play and performance after anterior cruciate ligament reconstruction in the National Basketball Association: surgeon case series and literature review.

OBJECTIVES: To investigate return to play (RTP) and functional performance after anterior cruciate ligament reconstruction (ACLR) in National Basketball Association (NBA) players and to perform a systematic review of the literature to understand RTP after ACLR in professional basketball. METHODS: NBA players undergoing ACLR between 2008 and 2014 by two surgeons were identified. RTP and performance were assessed based on a review of publically available statistics. A systematic review of the literature was performed using the MEDLINE database. Inclusion criteria were: English language, ACL surgery outcome, professional basketball and RTP outcome. We reviewed studies for RTP rates and RTP performance. RESULTS: Our study included 12 professional basketball players with NBA level experience. Eleven of the 12 players returned to their prior level of play. Eight of the 9 (88.9%) players actively playing in the NBA returned to play in the NBA at a mean 9.8 months. Among players returning to NBA play, during RTP season 1, mean per game statistics decreased for the following: minutes, points, rebounds, assists, steals, blocks, turnovers and personal fouls - none of these changes reached statistical significance. Player efficiency ratings significantly declined from pre-injury (12.5) to the first RTP season (7.6) (p = 0.05). By RTP season 2, player performance metrics approximated pre-injury levels and were not significantly different. Six studies met inclusion criteria; reported RTP rates ranged from 78-86%. Identified studies similarly found a decline in functional performance after RTP. CONCLUSION: There is a high rate (89%) of return to NBA play for NBA players undergoing ACLR. After RTP, however, there is a quantitative decline in initial season 1 RTP statistics with a significant decrease in player efficiency rating. By RTP season 2, performance metrics demonstrated an improvement compared to RTP season 1 but did not reach pre-injury functional performance, though performance metrics are not significantly different between pre-injury and RTP season 2.

Surgical Release of the Pectoralis Minor Tendon for Scapular Dyskinesia and Shoulder Pain.

BACKGROUND: Pectoralis minor (PM) tightness has been linked to pain and dysfunction of the shoulder joint secondary to anterior tilt and internal rotation of the scapula, thus causing secondary impingement of the subacromial space. PURPOSE: To describe outcomes pertaining to nonoperative and operative treatment via surgical release of the PM tendon for pathologic PM tightness in an active population. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Over a 3-year period, a total of 46 patients were enrolled (mean age, 25.5 years; range, 18-33 years). Inclusion criteria consisted of symptomatic shoulder pain, limited range of overhead motion, inability to participate in overhead lifting activities, and examination findings consistent with scapular dysfunction secondary to a tight PM with tenderness to palpation of the PM tendon. All patients underwent a lengthy physical therapy and stretching program (mean, 11.4 months; range, 3-23 months), which was followed by serial examinations for resolution of symptoms and scapular tilt. Of the 46 patients, 6 (13%) were unable to adequately stretch the PM and underwent isolated mini-open PM release. Outcomes were assessed with scapula protraction measurements and pain scales as well as American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) scores. RESULTS: Forty of the 46 patients (87%) resolved the tight PM and scapular-mediated symptoms with a dedicated therapy program (pre- and posttreatment mean outcome scores: 58 and 91 [ASES], 50 and 90 [SANE], 4.9 and 0.8 [VAS]; P < .01 for all), but 6 patients were considered nonresponders (mean score, 48 [ASES], 40 [SANE], 5.9 [VAS]) and elected to have surgical PM release, with improved scores in all domains (mean score, 89 [ASES], 90.4 [SANE], 0.9 [VAS]; P < .01) at final follow-up of 26 months (range, 25-30 months). Additionally, protraction of the scapula improved from 1.2 to 0.3 cm in a mean midline measurement from the chest wall preoperatively to postoperatively ( P < .01), similar to results in nonoperative responders. No surgical complications were reported, and all patients returned to full activities. CONCLUSION: In most patients, PM tightness can be successfully treated with a nonoperative focused PM stretching program. However, in refractory and pathologically tight PM cases, this series demonstrates predictable return to function with notable improvement in shoulder symptoms after surgical release of the PM. Additional research is necessary to evaluate the long-term efficacy of isolated PM treatment.

Prospective Evaluation of Surgical Treatment of Humeral Avulsions of the Glenohumeral Ligament.

BACKGROUND: Humeral avulsion of the glenohumeral ligament (HAGL) is an infrequent but significant contributor to shoulder dysfunction, instability, and functional loss. PURPOSE: To prospectively identify patients with HAGL lesions and then conduct retrospective evaluation of the clinical history, examination findings, and surgical outcomes of these patients. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Over a 6-year period (2006-2011), patients with shoulder dysfunction and a HAGL lesion that was confirmed via magnetic resonance arthrogram (MRA) were prospectively evaluated with a minimum 2-year follow-up. Patient demographics, presentation, examination, and surgical findings were documented. Outcomes of return to activity as well as Western Ontario Shoulder Instability Index (WOSI) and Single Assessment Numeric Evaluation (SANE) scores were recorded at final follow-up. Anterior HAGL (aHAGL) lesions were repaired with a partial subscapularis tenotomy approach, while reverse (rHAGL) lesions were repaired arthroscopically. RESULTS: Of 28 patients, 27 (96%) completed the study requirements at a mean of 36.2 months (range, 24-68 months). The sample contained 12 females (44%) and 15 males (56%), who had a mean age of 24.9 years (range, 18-34 years). The chief complaint reported was pain in 23 patients (85%), while only 4 (15%) patients complained primarily of recurrent instability symptoms. Fourteen patients (52%) had aHAGL lesions, 10 patients (37%) had rHAGL lesions, and 3 patients (11%) had combined aHAGL and rHAGL lesions. Ten patients (37%) had concomitant HAGL lesions and labral tears, whereas 17 patients (63%) had isolated HAGL lesion without labral tear. The 17 patients (63%) with aHAGL lesions or combined lesions underwent a partial subscapularis tenotomy approach, while the remaining 10 patients (37%) with rHAGL lesions underwent arthroscopic surgical repair. After surgery, WOSI outcomes improved from 54% to 88% and SANE outcomes improved from 50% to 91% ( P < .01 for both), with no reports in recurrence of instability symptoms at final follow-up. CONCLUSION: This study demonstrated that patients with symptomatic HAGL lesions predominantly report shoulder pain and dysfunction, with few chief complaints of recurrent instability complaints. After surgery, patients showed predictable return to full activity, improvement in objective and patient-reported outcomes, and satisfaction with treatment outcome.