Preoperative planning with three-dimensional CT vs. three-dimensional magnetic resonance imaging does not change surgical management for shoulder instability.

Background: This study aims to determine the effect of time and imaging modality (three-dimensional (3D) CT vs. 3D magnetic resonance imaging (MRI)) on the surgical procedure indicated for shoulder instability. The hypothesis is there will be no clinical difference in procedure selection between time and imaging modality. Methods: Eleven shoulder surgeons were surveyed with the same ten shoulder instability clinical scenarios at three time points. All time points included history of present illness, musculoskeletal exam, radiographs, and standard two-dimensional MRI. To assess the effect of imaging modality, survey 1 included 3D MRI while survey 2 included a two-dimensional and 3D CT scan. To assess the effect of time, a retest was performed with survey 3 which was identical to survey 2. The outcome measured was whether surgeons made a "major" or "minor" surgical change between surveys. Results: The average major change rate was 14.1% (standard deviation: 7.6%). The average minor change rate was 12.6% (standard deviation: 7.5%). Between survey 1 to the survey 2, the major change rate was 15.2%, compared to 13.1% when going from the second to the third survey (P = .68). The minior change rate between the first and second surveys was 12.1% and between the second to third interview was 13.1% (P = .8). Discussion: The findings suggest that the major factor related to procedural changes was time between reviewing patient information. Furthermore, this study demonstrates that there remains significant intrasurgeon variability in selecting surgical procedures for shoulder instability. Lastly, the findings in this study suggest that 3D MRI is clinically equivalent to 3D CT in guiding shoulder instability surgical management. Conclusion: This study demonstrates that there is significant variability in surgical procedure selection driven by time alone in shoulder instability. Surgical decision making with 3D MRI was similar to 3D CT scans and may be used by surgeons for preoperative planning.

Risk factors for intracellular fatty accumulation in rotator cuff muscle: a histologic analysis.

BACKGROUND: Fatty accumulation in rotator cuff muscles has been associated with shoulder dysfunction, risk of repair failure, and poor postoperative outcomes. This study sought to assess risk factors associated with true fatty accumulation based on histologic analysis and determine whether preoperative function directly correlated with this fatty rotator cuff accumulation. METHODS: Supraspinatus muscle biopsy specimens obtained prospectively from patients undergoing arthroscopic rotator cuff repair were stained with LipidTOX to quantify lipid accumulation. Two-step cluster analysis with Goutallier classification was used to define the fatty and non-fatty rotator cuff groups. We further performed a receiver operating characteristic curve analysis to confirm the group cutoff values. RESULTS: In total, 51 patients (aged 60.1 ± 10.5 years) were included. There were 19 high-grade partial tears, 10 small tears, 7 medium tears, 10 large tears, and 5 massive tears. Both cluster and receiver operating characteristic curve analyses yielded a cutoff value of 30% LipidTOX/4',6-diamidino-2-phenylindole (DAPI) separating the fatty vs. non-fatty groups. In the univariate analysis, patients with fatty rotator cuffs were aged 63.2 years on average compared with 59.7 years in the non-fatty group (P = .038). Female patients made up 57.1% of the fatty cohort, which was statistically higher than the non-fatty group (P = .042). Massive and large tears were more likely to occur in the fatty group (P = .005). In the multivariate analysis, full tendon tears had the largest predictive status of falling into the fatty group (odds ratio, 15.4; P = .008), followed by female sex (odds ratio, 4.9; P = .036). Patients in the fatty group had significantly higher American Shoulder and Elbow Surgeons scores (P = .048) and lower visual analog scale scores (P = .002). DISCUSSION AND CONCLUSION: This prospective histologic assessment revealed that full-thickness rotator cuff tears and female sex were the largest risk factors for intracellular lipid accumulation. Although tear size correlated with fatty accumulation, the sex disparity is a noteworthy finding that warrants further research.

Trends in the surgical treatment of posterior shoulder instability in the United States from 2016 to 2020.

Background: The purpose of this study was to describe trends in the incidence of open versus arthroscopic management of posterior shoulder instability (PSI) as well as the patients undergoing these procedures in the United States over time. Methods: The PearlDiver Patient Records Database was utilized for this study. Cases of PSI and surgery were identified via the appropriate ICD-10-CM and CPT codes. Linear regression and two-sample Student's t-test were used to analyze incidence rates, procedure type, number of instability events, and patient age. Results: A total of 5655 patients were identified as having PSI, undergoing a total of 686 capsulorraphies. The incidence of PSI treated surgically increased across the years of the study at a rate of 0.0293 per 100,000 person-years with an incidence in 2019-2020 greater than in 2016-2018 (p = 0.0151). Patients undergoing arthroscopic capsulorrhaphy were on average younger than those undergoing open capsulorrhaphy (p = 0.0021). Patients experienced a higher number of posterior instability events before open surgery compared to arthroscopic (p = 0.0274). Discussion: The incidence of surgical treatment of PSI in the United States is steadily rising, with greater than 90% of cases being treated arthroscopically. Those undergoing arthroscopic posterior stabilization are both younger and face fewer instability events prior to surgery.

The Primary Cost Drivers of Outpatient Distal Radius Fracture Fixation: A Cost-Minimalization Analysis of 15,379 Cases.

Background Distal radius fractures are the most common fracture of the upper extremity. While some distal radius fractures can be managed with closed reduction and immobilization, operative treatment is the standard of care, with open reduction internal fixation (ORIF) as a predominant operative method. Questions/Purpose To investigate how patient and surgical characteristics affect the overall costs of internal fixation of distal radius fractures in adults. Patients and Methods The 2014 State Ambulatory Surgery and Services Databases for six states were used to identify cases and surgical characteristics of distal radius fracture ORIF in adult patients. Results Surgical variables that significantly increased cost were postoperative admission within 30 days, regional anesthesia, simultaneous endoscopic carpal tunnel release, and increasing operating room time. Conclusion Substantial contributors to total cost are postoperative hospital admission within 30 days of surgery, use of regional anesthesia, simultaneous endoscopic carpal tunnel release, and longer operative time. Level of Evidence Level III, retrospective cohort study.

Cadaveric Analysis of Key Anatomic Structures of Athletic Pubalgia.

PURPOSE: This study proposes to establish in-depth inspection of the anatomic structures involved with the pathology of athletic pubalgia in a cadaver model. METHODS: Eight male fresh frozen cadavers were dissected in a layered fashion. The rectus abdominis (RA) and adductor longus (AL) tendon insertions were isolated to quantify the size of the anatomic footprint and distance from the surrounding anatomy. RESULTS: The RA insertional footprint was 1.65 cm (SD, 0.18) in width by 1.02 cm (SD, 0.26) in length, and the AL insertional footprint on the underside of the pubis was 1.95 cm (SD, 0.28) in length by 1.23 cm (SD, 0.33) in width. The ilioinguinal nerve was 2.49 cm (SD, 0.36) lateral to the center of the RA footprint and 2.01 cm (SD, 0.37) lateral to the center of the AL footprint. The spermatic cord and the genitofemoral nerve were just lateral to the ilioinguinal nerve and were 2.76 cm (SD, 0.44) and 2.66 cm (SD, 0.46) from the rectus and AL footprints, respectively. CONCLUSION: Surgeons should be cognizant of these anatomic relations during both initial dissection and tendon repair to optimize repair and avoid iatrogenic injury to critical structures in the anterior pelvis.

Treatment Following a First-Time Shoulder Dislocation: What Should I Do?

A first-time shoulder dislocation is a challenging topic that requires consideration of anatomic and patient-specific factors. Initial management is predicated on determining functional demands, activity level, and expectations of the patient, in addition to assessing the risk of recurrent instability. When considering surgical indications, it is imperative to understand the biomechanical implications of injury to the glenohumeral joint complex and how specific surgical procedures can restore stability. It is important to provide an overview of the current treatment algorithm for management of first-time shoulder dislocation, with a special focus on diagnosis and intervention in the young athlete.

Reverse shoulder arthroplasty with and without baseplate wedge augmentation in the setting of glenoid deformity and rotator cuff deficiency-a multicenter investigation.

INTRODUCTION: Glenoid baseplate augments have recently been introduced as a way of managing glenoid monoplanar or biplanar abnormalities in reverse shoulder arthroplasty (RSA). The purpose of this study is to evaluate the difference in clinical outcomes, complications, and revision rates between augmented and standard baseplates in RSA for rotator cuff arthropathy patients with glenoid deformity. METHODS: A multicenter retrospective analysis of 171 patients with glenoid bone loss who underwent RSA with and without augmented baseplates was performed. Preoperative inclusion criteria included minimum follow-up of 2 years and preoperative retroversion of 15°-30° and/or a beta angle 70°-80°. Version and beta angle were measured on computed tomographic scans, when available, and plain radiographs. Shoulder range of motion (ROM) and patient-reported outcomes were obtained from preoperative and multiple postoperative time points. RESULTS: The study consisted of 84 standard baseplate patients and 87 augmented baseplate patients. The augment cohort had greater mean preoperative glenoid retroversion (17° vs. 9°, P < .001). At >5-year follow-up, the increase in postoperative active abduction (52° vs. 31°, P = .023), forward flexion (58° vs. 35°, P = .020), and internal rotation score (2.8° vs. 1.1°, P = .001) was significantly greater in the augment cohort. Additionally, >5-year follow-up American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score (87.0 ± 16.6 vs. 75.9 ± 22.4, P = .022), Constant score (78.0 ± 9.7 vs. 64.6 ± 15.1, P < .001), and Shoulder Arthroplasty Smart score (81.2 ± 6.5 vs. 71.2 ± 13.6, P = .003) were significantly higher in the augment cohort. Revision rate was low overall, with no difference between the augment and no augment groups (0.7% vs. 3.0%, P = .151). CONCLUSION: In comparing augments to standard nonaugment baseplates in the setting of RSA with glenoid deformity, our results demonstrate greater postoperative improvements in multiple planes of active ROM in the augment cohort. Additionally, the augment cohort demonstrated greater postoperative level and improvement in scores for multiple clinical outcome metrics up to >5 years of follow-up with no difference in complication or revision rates, supporting the use of augmented glenoid baseplates in RSA with glenoid deformity.

Posterior Glenoid Osteotomy With Capsulolabral Repair Improves Resistance Forces in a Critical Glenoid Bone Loss Model.

Background: There is no widespread consensus on the surgical treatment of posterior shoulder instability with critical posterior glenoid bone loss. Hypothesis: That opening posterior glenoid wedge osteotomy with soft tissue repair would improve the resistance forces of instability when compared with soft tissue repair alone in the setting of 20% critical bone lose. Study Design: Controlled laboratory study. Methods: Native glenoid retroversion was measured on 9 shoulders using computed tomography (CT) scans. The humerus was potted in 90° of forward flexion and 30° of internal rotation relative to the scapula, and a posterior dislocation was performed to create a posterior capsulolabral injury model. The specimens were each taken through a fixed sequence of testing: (1) posteroinferior capsulolabral tear, (2) no glenoid bone loss with posteroinferior capsulolabral repair, (3) 20% posterior glenoid bone loss with posteroinferior capsulolabral repair, and (4) 20% glenoid bone loss with posterior glenoid opening wedge osteotomy and posteroinferior capsulolabral repair. Bone loss was created using a sagittal saw. The resultant peak forces with 1 cm of posterior translation were measured. A 1-way repeated-measures analysis of variance was used to compare mean force values. Results: After the initial dislocation event, all shoulders had a resultant posterior capsulolabral injury. The resulting labral injury was extended from 6- to 9-o'clock in all specimens to homogenize the extent of injury. Repairing the capsulolabral complex in the 20% posterior glenoid bone loss group did not result in a statistically significant increase in resistance force compared with the labral deficient group (34.1 vs 22.2 N; P = .068). When 20% posterior bone loss was created, the posterior glenoid osteotomy with capsulolabral repair was significantly stronger (43.8 N) than the posterior repair alone both with (34.1 N) and without (31.8 N) bone loss (P = .008 and .045, respectively). Conclusion: In the setting of critical posterior glenoid bone loss, an opening wedge posterior glenoid osteotomy with capsulolabral repair improved resistance to posterior humeral translation significantly compared with capsulolabral repair alone. Clinical Relevance: The results of this biomechanical cadaveric study may aid in surgical planning for this complex patient population.

Humeral Avulsion of the Glenohumeral Ligament: Diagnosis and Management.

¼: The most common type of humeral avulsion of the glenohumeral ligament (HAGL) is a purely ligamentous avulsion involving the anterior inferior glenohumeral ligament (IGHL), but other variants are seen, including posterior lesions and those with an osseous avulsion. ¼: A central lesion between the intact anterior and posterior bands of the IGHL is gaining recognition as a distinct clinical entity. ¼: HAGL lesions are most commonly seen in patients with anterior instability without a Bankart tear or in those with persistent symptoms despite having undergone a Bankart repair. ¼: Magnetic resonance imaging is the most sensitive imaging modality. An arthrogram is helpful with subacute and chronic lesions when the joint is not distended. Arthroscopy is the gold standard for diagnosis. ¼: While some have reported success with nonoperative management, surgical repair with either arthroscopic or open techniques has provided a high rate of successful outcomes; however, the literature is limited to mostly Level-IV and V evidence.

A quality assessment of YouTube content on shoulder instability.

OBJECTIVES: The Internet is a widely used resource for patients seeking health information, yet little editing or regulations are imposed on posted material. We sought to assess the quality and accuracy of information presented on shoulder instability on the online video platform YouTube. We hypothesize that YouTube videos concerning shoulder instability will be of little quality, accuracy, and reliability. METHODS: The first 50 YouTube videos resulting from the keyword query 'shoulder instability' were analyzed. The Journal of American Medical Association (JAMA) benchmark criteria (score range, 0-4) was used to assess video accuracy and reliability, and the Global Quality Score (GQS; score range, 0-5) was used to assess the quality of the video's educational content along with a generated Shoulder-Specific Score (SSS). RESULTS: The 50 videos observed collectively had 5,007,486 views, with the mean number of views being 100,149.72 ± 227,218.04. Of all videos observed, 32% were from a medical source and 56% had content relating to pathology information. The mean JAMA score was 2.84 ± 0.74, with the highest scores coming from academic sources. The mean GQS and SSS scores were 2.68 ± 0.84 and 5.30 ± 3.78. The mean GQS score was highest in videos from medical sources (3.3 ± 0.8) and videos about surgical technique/approach (3.2 ± 1.1). Advertisements were negative predictors of the JAMA score (ß = -0.324, P = 0.014), and academic (ß = 0.322, P = 0.015) and physician sources (ß = 0.356, P = 0.008) were positive predictors. CONCLUSION: YouTube videos on shoulder instability are of low quality and accuracy and are not reliable. Care providers should be aware of the overall low quality of information available on YouTube regarding shoulder instability.

Predictors of Surgery and Cost of Care Associated with Patellar Instability in the Pediatric and Young Adult Population.

PURPOSE: To determine how patient demographics, socioeconomic status, history of recurrence, and initial point of presentation for health care influenced the decision for surgical treatment following a patellar instability episode. METHODS: The New York SPARCS database from 2016 to 2018 was queried for patients aged 21 and younger who were diagnosed with a patellar instability episode. These were linked to later surgeries with Current Procedural Terminology (CPT) codes 27405 (MPFL repair), 27418 (tibial tubercle osteotomy), 27420 (dislocating patella reconstruction), 27422 (Campbell/Roux-Goldthwait procedure), and 27427 (extra-articular knee ligamentous reconstruction). χ2-analysis and binary logistic regression were used to assess demographic and injury-specific variables for association with operative management. A generalized linear model was used to estimate charges associated with patellar instability. RESULTS: There were 2,557 patients with patellar instability, 134 (5.2%) of whom underwent surgery. Patients with recurrent instability had 1.875 times higher odds of undergoing surgery (P = .017). Compared to white patients, black patients had 0.428 times the odds of surgery (P = .004). None of the patients without insurance had surgery. In the cost model, an initial visit to an outpatient office was associated with $1,994 lower charges compared to an emergency department (ED) visit (P < .001). Black patients had $566 more in charges than White patients (P = .009). Compared with nonoperative treatment, surgeries with CPT 27405 added $13,124, CPT 27418 added $10,749, CPT 27422 added $18,981, CPT 27420 added $23,700, and CPT 27427 added $25,032 (all P < .001). CONCLUSIONS: Patients with recurrent instability had higher odds of surgery, while Black and uninsured patients had lower odds of surgery. ED visits were associated with significantly higher charges compared to office visits, and Black patients had higher charges than white patients. Minority and uninsured patients may face barriers in access to orthopedic care. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Increased Total Cost and Lack of Diagnostic Utility for Emergency Department Visits After ACL Injury.

BACKGROUND: Patients are commonly evaluated at the emergency department (ED) with acute anterior cruciate ligament (ACL) tears, but providers without orthopaedics training may struggle to correctly diagnose these injuries. HYPOTHESIS: It was hypothesized that few patients would be diagnosed with an ACL tear while in the ED and that these patients would be of lower socioeconomic status and more likely to have public insurance. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The 2017 State Ambulatory Surgery and Services Database (SASD) and State Emergency Department Database (SEDD) from the state of Florida were utilized in this study. Cases with Current Procedural Terminology code 29888 (arthroscopically aided ACL reconstruction [ACLR]) were selected from the SASD, and data from the SEDD were matched to patients who had an ED visit for a knee injury within 120 days before ACLR. Chi-square analysis was used to test for differences in patient and surgical variables between the ED visit and nonvisit patient groups. A generalized linear model was created to model the effect of ED visit on total cost for an ACL injury. RESULTS: While controlling for differences in patient characteristics and concomitant procedure usage, a visit to the ED added $4587 in total cost (P < .001). The ED visit cohort contained a greater proportion of patients with Medicaid (20.2% vs 9.1%), patients who were Black (18.4% vs 10.3%), and patients in the lowest income quartile (34.4% vs 25.0%) (P < .001 for all). In the ED visit cohort, 14.4% of patients received an allograft versus 10.1% in the non-ED visit cohort (P = .001) despite having a similar mean age. An ACL sprain was diagnosed in only 29 of the 645 (4.5%) patients who visited the ED. CONCLUSION: Utilizing the ED for care after an ACL injury was expensive, averaging a $4587 increase in total cost associated with ACLR. However, patients rarely left with a definitive diagnosis, with only 4.5% of patients who underwent ACLR being correctly diagnosed with an ACL tear in the ED. This additional cost was levied disproportionately on patients of low socioeconomic status and patients with Medicaid.

Cost Comparison of Open and Arthroscopic Treatment Options for SLAP Tears.

PURPOSE: To identify cost drivers of open biceps tenodesis, arthroscopic biceps tenodesis, and arthroscopic SLAP repair in the setting of isolated SLAP tears and to perform a direct cost comparison between the procedures. METHODS: The 2014 State Ambulatory Surgery and Services Databases from 6 US states were used. Cases with Current Procedural Terminology codes 23430 (tenodesis of long tendon of biceps), 29807 (shoulder arthroscopy, repair of SLAP lesion), and 29828 (shoulder arthroscopy, biceps tenodesis) were selected, excluding patients who were >50 years old or had a concomitant rotator cuff repair. Generalized linear models were used to model costs based on surgical and patient variables. RESULTS: The mean patient age was 41.8 years for open biceps tenodesis, 31.6 for arthroscopic SLAP repair, and 41.3 for arthroscopic biceps tenodesis (P < .001). Open biceps tenodesis had cost reductions of $5,664 over arthroscopic biceps tenodesis (P = .001) and $2,320 over arthroscopic SLAP repair (P = .043). Male sex was associated with $3,798 more in costs (P < .001), presence of ≥1 comorbidities added $1,829 (P = .002), and each minute in the operating room added $37 (P < .001). Operative time for open biceps tenodesis averaged 114 minutes, and both arthroscopic procedures averaged 94 minutes (P < .001). Low-volume facilities were associated with $5,536 higher costs for arthroscopic biceps tenodesis (P = .001). CONCLUSION: In patients aged ≤50 years with isolated SLAP tears, open biceps tenodesis provides cost savings over arthroscopic methods of treatment. There was no significant cost difference between arthroscopic SLAP repairs and arthroscopic biceps tenodesis. Given the increased emphasis on cost containment, surgeons should be aware of the procedural costs associated with the treatment of SLAP tears. LEVEL OF EVIDENCE: III, retrospective cohort study.

Socioeconomic and Demographic Disparities in Early Surgical Stabilization Following Emergency Department Presentation for Shoulder Instability.

PURPOSE: To describe which patients are the most likely to undergo surgical management within the same calendar year as their emergency department visit for anterior shoulder instability. METHODS: The State Emergency Department Databases and State Ambulatory Surgery and Services Databases from Florida were used. All patients presenting to the emergency department for anterior shoulder subluxation or dislocation between January 1 and September 30, 2017, were selected. Bivariate analysis was performed for associations with demographic variables. A binary logistic regression was performed with all significant factors to assess which were predictors of undergoing surgery the same calendar year. RESULTS: While controlling for all significant factors, we found that patients with recurrent dislocations were 3.14 times more likely to have surgery within the same year (P = .037). Patients younger than 40 years were also 2.04 times more likely to have surgery than those aged 40 years or older (P < .001). White patients were 2.47 times more likely to have surgery than black patients (P < .001). On bivariate analysis, there was an association between greater income quartile and higher odds of undergoing surgery within 30 days. CONCLUSIONS: Following an emergency department visit for acute shoulder instability, the following variables were associated with undergoing surgical stabilization within the same calendar year: previous dislocation, age younger than 40, and white race. Patients living in the greatest income quartile of patients had a significantly greater percentage of patients having surgery within 30 days. This demonstrates that disparities and barriers to care may exist for patients with shoulder instability. LEVEL OF EVIDENCE: Level III, Retrospective Comparative Study.

Anterior Cruciate Ligament Tear Following Operative Treatment of Pediatric Tibial Eminence Fractures in a Multicenter Cohort.

BACKGROUND: Postoperative ipsilateral anterior cruciate ligament (ACL) tears after tibial eminence fracture fixation has been previously noted in the literature. This study aims to describe the prevalence of and risk factors for postoperative ACL tears in a cohort of patients operatively treated for tibial eminence fracture. METHODS: A retrospective review of children undergoing treatment of a tibial eminence fracture at 10 tertiary care children's hospitals was performed. The primary outcome of interest was subsequent ACL rupture. Incidence of ACL tear was recorded for the entire cohort. Patients who sustained a postoperative ACL tear were compared with those without ACL tear and analyzed for demographics and risk factors. A subgroup analysis was performed on patients with a minimum of 2-year follow-up data or those who had met the primary outcome (ACL tear) before 2 years. RESULTS: A total of 385 pediatric patients were reviewed. 2.6% of the cohort experienced a subsequent ACL tear. The median follow-up time was 6.5 months (SD=6.4 mo). Subsequent ACL tears occurred at a median of 10.2 months (SD=19.5 mo) postoperatively. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL tear (P=0.01). Patients with a subsequent ACL tear were older on average (13.5 vs. 12.2 y old), however, this difference was not statistically significant (P=0.08). Subgroup analysis of 46 patients who had a 2-year follow-up or sustained an ACL tear before 2 years showed a 21.7% incidence of a subsequent ACL tear. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL rupture (P=0.006) in this subgroup. Postoperative ACL tears occurred in patients who were older at the time that they sustained their original tibial eminence fracture (13.4 vs. 11.3 y old, P=0.035). CONCLUSIONS: Ipsilateral ACL tears following operatively treated pediatric tibial eminence fractures in a large multicenter cohort occurred at a rate of 2.6%. However, in those with at least 2 years of follow-up, the incidence was 21.7%. Subsequent ACL tear was more likely in those with completely displaced (type III or IV) tibial eminence fractures and older patients. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Cost comparison of arthroscopic rotator cuff repair with arthroscopic vs. open biceps tenodesis.

PURPOSE: To use a nationwide database to determine differences in cost between patients who underwent arthroscopic rotator cuff tear with open vs. arthroscopic biceps tenodesis (BT). METHODS: The 2014 State Ambulatory Surgical and Services Databases from 6 US states was utilized. All cases with CPT codes 29827 (arthroscopic rotator cuff repair [RCR]) and either 23430 (tenodesis of long tendon of biceps) or 29828 (arthroscopic BT) were selected. Cases that included both 23430 and 29828 were excluded, as were those missing demographic data. Generalized linear models were used to model costs based on the surgical and patient variables that were significant in the initial bivariate analysis (P < .05). RESULTS: A total of 3635 RCR and BT cases were identified. There were 2847 (78.3%) with arthroscopic BT and 788 (21.7%) with open BT. Patients undergoing arthroscopic BT were 3.1 years older than patients undergoing open BT (P < .001). For arthroscopic BT, 39.2% of the cases were women compared with 22.6% of the open cases (P < .001). For operative variables, arthroscopic BT required 9 fewer minutes in the OR than open cases (P = .002). Concomitant distal clavicle resection was performed in 35.5% of arthroscopic BT cases compared with 29.8% of open cases (P = .004). While controlling for other significant factors, open BT was associated with $5542 lower costs than arthroscopic BT in the setting of RCR (P < .001). In either case, concomitant subacromial decompression added $10,669 (P < .001), and distal clavicle resection added $3210 (P < .001). High-volume surgical facilities were associated with $4107 lower costs (P < .001). CONCLUSIONS: In a large series of patients undergoing arthroscopic RCR with open vs. arthroscopic BT, open BT was associated with $5542 lower costs than arthroscopic. Given that both techniques have been shown to be similarly effective in long-term follow-up, surgeons should be aware of opportunities for cost saving, particularly with the advent of bundled surgical reimbursements.

Trends in the Surgical Treatment of Articular Cartilage Lesions in the United States from 2007 to 2016.

Management of cartilage lesions of the knee can be complex, time consuming, and controversial, especially without a widely agreed upon "gold-standard" management. The PearlDiver database (www.pearldiverinc.com, Fort Wayne, IN) was queried for surgical management of cartilage lesions specified by Current Procedure Terminology (CPT) codes: 29877, chondroplasty; 29879, microfracture/drilling; 29866, arthroscopic osteochondral autograft; 29867, arthroscopic osteochondral allograft; 27412, autologous chondrocyte implantation (ACI); 27415, open osteochondral allograft; or 27416, open osteochondral autograft. Procedures were categorized as palliative (chondroplasty), microfracture/drilling, or restorative (arthroscopic osteochondral autograft; arthroscopic osteochondral allograft; ACI; open osteochondral allograft; or open osteochondral autograft). Linear regression was performed to determine the significance of yearly trend across each procedure.From 2007 to 2016, a total of 35,506 surgical procedures were performed. The average yearly incidence was 7.8 per 10,000 patients. Overall, palliative techniques (chondroplasty) were more common (1.8:1 ratio for chondroplasty to microfracture and 34:1 ratio chondroplasty to restoration procedure). There was a trend of decreasing incidence of palliative procedures seen by a significant decrease in the ratio of palliative to microfracture/restorative procedures of 0.2512 each year from 2007 to 2016 (p < 0.001). This decrease followed a linear trend (R 2 = 0.9123). In 2013, the number and incidence of the palliative procedures declined below that of microfracture procedures, with microfracture being most common from 2013 to 2016. Palliative chondroplasty was no longer the most commonly performed procedure for cartilage lesions in the United States from 2007 to 2016, as more surgeons opted for microfracture procedures instead. Restorative procedures (ACI, osteochondral autograft transfer system) remained unchanged over the study period, in accordance with the sports medicine literature; however, early functional outcomes studies do show the equivalency and in some cases superiority compared with microfracture. This is Level III study.

Preoperative malnutrition increases odds of hospital admission and extended length of stay following arthroscopic rotator cuff repair.

BACKGROUND: Rotator cuff repair (RCR) is a common orthopedic procedure frequently performed in the outpatient setting. Malnutrition, as assessed by preoperative serum albumin <3.5 g/dL, has been independently associated with significantly higher risks of multiple adverse outcomes in several orthopedic procedures. The effect of preoperative hypoalbuminemia on short-term outcomes of RCR was previously unknown. HYPOTHESIS: we hypothesized that preoperative serum albumin <3.5 g/dL would be associated with higher odds of post-operative admission and prolonged length of stay. METHODS: This study represents a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database (NSQIP) for patients undergoing RCR between 2011 and 2015. RESULTS: Multivariate regression analysis adjusted for sex, ASA classification, age, BMI, and diabetes status (Table 3) showed preoperative hypoalbuminemia conferred a significantly increased adjusted odds ratio of postoperative admission (adjusted odds ratio 1.711, CI 1.134-2.583, p = 0.011) and extended length of stay (adjusted odds ratio 2.073, CI 1.073-4.003, p = 0.030). CONCLUSION: Malnutrition as assessed by preoperative serum albumin <3.5 g/dL is significantly associated with increased odds of hospital admission and extended length of stay following arthroscopic RCR. This has clinical implications in surgical patient selection and risk stratification. LEVEL OF EVIDENCE: III, Retrospective cohort study.