In Patients With Rotator Cuff Tears, Female, Hispanic, African American, Asian, Socially Deprived, Federally Insured, and Uninsured Patients Are Less Commonly Treated Surgically.

PURPOSE: The purpose of the current study is to evaluate socioeconomic related factors affecting whether a patient undergoes rotator cuff repair after a diagnosis of a rotator cuff tear. METHODS: From 2009-2018, claims for adult (≥18 years of age) patients who were diagnosed with a primary rotator cuff injury were identified in the New York Statewide Planning and Research Cooperative System (SPARCS) database via ICD-9-Clinical Modification (CM) and ICD-10-CM diagnostic codes. SPARCS is a comprehensive all-payer database collecting all inpatient and outpatient pre-adjudicated claims in New York. International Classification of Diseases 9 and 10 Clinical Modification codes were used to identify the initial diagnosis for each patient. Current Procedural Terminology (CPT) codes were used to identify subsequent rotator cuff surgery. The procedures identified were linked with the initial diagnosis and patients were noted as either having rotator cuff surgery, or not having rotator cuff surgery. Logistic regression analysis was performed for variables including age, sex, race, Social Deprivation Index (SDI), Charlson Comorbidity Index (CCI), and primary insurance type to determine the effect of patient factors on the likelihood of having surgery after a diagnosis of rotator cuff injury. RESULTS: Of the 67,584 rotator cuff patients included in the analysis, 19,770 (29.3%) of the patients underwent surgical intervention. From the logistic regression, females relative to males (OR=0.798, p<.0001), increased social deprivation index (SDI) (OR=0.994, p<.0001), African American compared to white race (OR=0.694, p<.0001), Asian compared to white (OR=0.832, p<.0001), Hispanic compared to white (OR=0.693, p<.0001), other race (OR=0.58, p<.0001), those with Medicare (OR=0.601, p<.0001) or Medicaid (OR=0.614, p<.0001) relative to private insurance, and self-pay relative to private insurance (OR=0.727, p<.0001) were all associated with decreased odds of undergoing rotator cuff surgery. Older patients (OR=1.012, p<.0001) and worker's compensation relative to private insurance (OR=1.664, p<.0001) had increased odds of undergoing surgery. CONCLUSION: The results of the current study identified disparities in the likelihood of undergoing rotator cuff repair after a diagnosis of a rotator cuff tear based on patient demographic and socioeconomic factors. Individuals with higher Social Deprivation Index (SDI), African American, Asian, Hispanic, or other non-white races, and those with Medicare, Medicaid, or self-pay insurance had decreased odds of surgery while older age and worker's compensation insurance were associated with increased odds of undergoing surgery.

Location of Shoulder Glenoid Labral Tears: A Study of 1763 Consecutive Patients.

BACKGROUND: Anterior shoulder labral tearing has historically been considered the most common location of shoulder labral pathology. Recently, smaller studies have reported that posterior labral involvement may be more common than previously recognized. PURPOSE: To examine the location of surgically repaired labral tears by a single surgeon over a consecutive 23-year period. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 1763 consecutive patients who underwent arthroscopic or open shoulder labral repair by a single seniorsports medicine fellowship-trained orthopaedic surgeon between April 2000 and April 2023 were retrospectively reviewed. Current Procedural Terminology codes were used to identify patients, which included 29806, 29807, 29822, and 29823. Exclusion criteria included isolated shoulder manipulation or glenohumeral joint or labral debridement that did not include repair. Intraoperative glenoid labral tears observed were categorized into 7 broad categories: (1) anterior labral tears, (2) posterior labral tears, (3) superior labral anterior posterior (SLAP) type II tears (A, B, or C), (4) SLAP type V tears, (5) SLAP type VIII tears, or (6) circumferential labral tears (combined SLAP, anterior, and posterior labral tear). Shoulders diagnosed with multiple tear patterns (ie, anterior and posterior) were also noted. RESULTS: During the 23-year period, 1763 patients underwent arthroscopic or open labral repair; they included 1295 male and 468 female patients, ranging in age from 12 to 70 years, with a mean age of 23.2 years and median age of 19 years. Overall, 28.4% of tears involved the anterior labrum, 64.9% involved the posterior labrum, and 59.6% involved the superior labrum. Regarding isolated tears, 9.3% were isolated anterior labral tears, 19.7% were isolated posterior labral tears, 11.5% involved the anterior and posterior labrum, 22.2% were isolated superior (SLAP type II-IV) tears, 3.63% were isolated SLAP type V tears, 29.8% were isolated SLAP type VIII tears, and 4.1% were circumferential tears. CONCLUSION: Posterior shoulder labral tearing was more common than anterior tearing in a large consecutive series of 1763 patients who underwent surgical repair. This highlights the importance of posterior labral pathology, which sometimes may be overlooked because of more vague complaints, with pain and loss of function being the most common.

A Posterior Acromial Bone Block Augmentation Is Biomechanically Effective at Restoring the Force Required To Translate the Humeral Head Posteriorly in a Cadaveric, Posterior Glenohumeral Instability Model.

PURPOSE: To assess the biomechanical utility of a posterior acromial bone block (PABB) for the treatment of posterior glenohumeral instability. METHODS: Ten fresh-frozen cadaveric specimens were obtained based upon an a priori power analysis. A 2.5-cm scapular spine autograft was harvested from all shoulders. A custom robot device was used to apply a 50-N compressive force to the glenohumeral joint. The humeral head was translated 10 mm posteroinferiorly at 30 degrees from the center of the glenoid at a rate of 1.0 mm/s in 6 consecutive conditions: (1) intact specimen, (2) intact with PABB, (3) posterior capsulolabral tear, (4) addition of the PABB, (5) removal of the PABB and repair of the capsulolabral tear (LR), and (6) addition of the PABB with LR. The maximum force required to obtain this translation was recorded. Paired t tests were performed to compare relevant testing conditions. RESULTS: Ten cadavers with a mean ± SD age of 54.4 ± 13.1 years and mean ± SD glenoid retroversion of 6.5 ± 1.0 degrees were studied. The PABB provided greater resistance force to humeral head translation compared to the instability state (instability, 29.3 ± 15.3 N vs PABB, 47.6 ± 21.0 N; P = .001; 95% confidence interval [CI], -27.6 to -10.0). When comparing PABB to LR, the PABB produced higher resistance force than LR alone (PABB, 47.6 ± 21.0 N; LR, 34.2 ± 20.5 N; P = .012; 95% CI, -23.4 to -4.1). An instability lesion treated with the PABB, with LR (P = .056; 95% CI, -0.30 to 20.4) or without LR (P = .351; 95% CI, -6.8 to 15.7), produced resistance forces similar to the intact specimen. CONCLUSIONS: A PABB is biomechanically effective at restoring the force required to translate the humeral head posteriorly in a cadaveric, posterior glenohumeral instability model. A posterior acromial bone block is a biomechanically feasible option to consider in patients with recurrent posterior instability. CLINICAL RELEVANCE: Augmentation of the posterior acromion may be a biomechanically feasible option to treat posterior shoulder instability.

Role of Quadriceps Tendon Autograft in Primary and Revision Anterior Cruciate Ligament Reconstruction.

¼ The quadriceps tendon (QT) autograft is becoming increasingly popular in both primary and revision anterior cruciate ligament reconstruction (ACLR).¼ The biomechanical properties of the QT are similar to those of the native ACL, the hamstring tendon (HT), and bone-patellar tendon-bone (BTB) autografts.¼ QT autograft allows surgeons to be flexible with their graft size and reconstruction technique.¼ The QT autograft performs in a similar fashion to the BTB and HT autografts, with excellent patient-reported outcomes, consistent postoperative knee stability, and low rates of postoperative complications including graft failure and donor site morbidity.¼ There are emerging data that the QT autograft is a viable option in revision ACLR.

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.

Salter-Harris Type III Fracture of the Distal Phalanx: A Rare Juxtaphyseal Variant.

Juxtaphyseal fractures of the distal phalanges of upper extremity digits are most commonly of the Salter-Harris II variety and occur most commonly in the thumb. The diagnosis of this injury is essential as it may present as an open fracture with a nailbed injury ("Seymour fracture"). However, an intra-articular, epiphyseal fracture may also occur and mimic a mallet deformity or Seymour fracture. Prompt diagnosis is essential to rule out an open fracture and obtain anatomical alignment and stability to attempt to reduce complications such as physeal arrest. Here, we present a patient with a displaced Salter-Harris type III fracture of his thumb distal phalanx and review his management and early-term outcome. We present this case to bring attention to this rare and unique injury, review the available literature, and discuss management and outcomes.

Bridge-Enhanced Anterior Cruciate Ligament Repair: The Next Step Forward in ACL Treatment.

Anterior cruciate ligament (ACL) injuries are common in young and active patients. In this patient population, surgical treatment with an autograft tendon is recommended to reconstruct a new ACL. ACL reconstruction has a high patient satisfaction, improved patient reported outcomes and allows young patients to return to an active lifestyle, including sports. However, long-term follow-up shows these patients are at higher risk for degenerative arthritis, frequently at a young age. Recent research has focused on re-investigating the utility of performing an ACL repair rather than a reconstruction in the hopes that maintaining a patient's native ligament may not only restore knee stability, but provide improved knee kinematics and lessen the risk of late osteoarthritis and also limit donor site morbidity from autograft harvests. Historically, patients undergoing ACL repair suffered poor outcomes due to issues with intra-articular healing of the ligament; but now, with new bioengineering techniques, bridge-enhanced ACL repairs may provide a feasible alternative in the treatment of ACL injuries.

Diagnosis and Management of Hip Abductor Insufficiency.

Greater Trochanteric Pain Syndrome (GTPS) is a common cause of lateral hip pain, with an incidence of 1.8 per 1000 patients, most commonly occurring between the fourth and sixth decades of life. When GTPS fails to improve with conservative management, hip abductor insufficiency should be suspected. The diagnosis of hip abductor insufficiency is made by a combination of physical exam findings and imaging studies, with Magnetic Resonance Imaging (MRI) being the diagnostic study of choice. Initial conservative management consists of activity modification, physical therapy, non-steroidal anti-inflam- matories and corticosteroid injections. If conservative management fails, this may be suggestive of a hip abductor tear. Surgical intervention has been shown to provide excellent outcomes, and may be necessary if a tear is present. The purpose of this paper is to review and raise awareness of hip abductor insufficiency as an under- diagnosed and under-treated condition that can limit patient mobility and quality of life.

Diagnostic Criteria and Clinical Outcomes in Sarcopenia Research: A Literature Review.

By the sixth decade of life, nearly one quarter of the population has substantial muscle atrophy, or sarcopenia. Despite the creation of a standardized definition of sarcopenia by the European Working Group on Sarcopenia in Older People, variability may exist in the diagnostic criteria utilized for clinical sarcopenia research. The primary objectives of this review were to characterize diagnostic criteria used for measurement of sarcopenia in original studies, and to describe associations between sarcopenia and important clinical outcomes. We performed a literature review of the term "sarcopenia" in PubMed. Inclusion criteria were English language, original data, a clear and specific definition for diagnosing sarcopenia, and the analysis of sarcopenia's effect on a clinical outcome. A total of 283 studies met inclusion criteria. More than half of the included sarcopenia investigations were level IV studies (54.1%), while 43.1% provided level II evidence. Under one third (27.6%) of studies examined sarcopenia with regard to surgical outcomes. In terms of diagnostic criteria for sarcopenia, 264 (93.3%) studies used measures of skeletal muscle mass, with dual energy X-ray absorptiometry (DEXA) being the most common modality (43.6%). Sarcopenia was found to be a consistent predictor of chronic disease progression, all-cause mortality, poorer functional outcomes, and postoperative complications. In conclusion, there is substantial evidence that sarcopenia impacts both medical and surgical outcomes. However, current research has utilized heterogeneous diagnostic criteria for sarcopenia. Further efforts to standardize the modalities used to diagnose sarcopenia in clinical research and practice will help strengthen our ability to study this important phenomenon.

Factors influencing survival following hip fracture among octogenarians and nonagenarians in the United States.

INTRODUCTION: Hip fractures account for a significant disease burden in the Unites States. With an aging population, this disease burden is expected to increase in the upcoming decades. MATERIALS AND METHODS: This represents a retrospective cohort study to assess mortality following hip fracture in the octogenarian and nonagenarian populations. Odds ratios for postoperative mortality were constructed using normalized patients from United States Social Security death tables. Kaplan Meier analysis and binary logistic regression were used to assess the impact of surgical delay and medical comorbidity (measured by the Carlson Comorbidity Index (CCI)) on postoperative mortality. RESULTS: 189 octogenarians and 95 nonagenarians were included. One-year mortality was nearly three times higher for both the octogenarians (OR: 3.1) and nonagenarians (OR: 3.14), and returned to that of the normal population 4 years post-op for octogenarians and 5 years post-op for nonagenarians. Higher preoperative medical comorbidity (CCI) was associated with higher post-op mortality for both octogenarians (log rank = 0.026) and nonagenarians (log rank = 0.034). A 48-h surgical delay resulted in significantly increased postoperative mortality among healthy patients (CCI of 0 or 1, OR: 18.1), but was protective for patients with significant medical comorbidity (CCI ≥ 3). Age, preoperative CCI, and 48-h surgical delay were all independent predictors of 1-year post-op mortality. CONCLUSIONS: Following hip fracture, there is a 3-fold increase in mortality for octogenarians and nonagenarians at 1 year post-op. A 48-h surgical delay significantly increased mortality for healthier patients but was protective against mortality for sicker patients.

Inpatient costs and blood transfusion rates of sarcopenic patients following thoracolumbar spine surgery.

OBJECTIVE Sarcopenia, the muscle atrophy associated with aging and disease progression, accounts for nearly $18.5 billion in health care expenditures annually. Given the high prevalence of sarcopenia in patients undergoing orthopedic surgery, the goal of this study was to assess the impact of sarcopenia on inpatient costs following thoracolumbar spine surgery. METHODS Patients older than 55 years undergoing thoracolumbar spine surgery from 2003 to 2015 were retrospectively analyzed. Sarcopenia was measured using total psoas area at the L-4 vertebra on perioperative CT scans. Hospital billing data were used to compare inpatient costs, transfusion rate, and rate of advanced imaging utilization. RESULTS Of the 50 patients assessed, 16 were sarcopenic. Mean total hospital costs were 1.75-fold greater for sarcopenic patients compared with nonsarcopenic patients ($53,128 vs $30,292, p = 0.04). Sarcopenic patients were 2.1 times as likely to require a blood transfusion (43.8% vs 20.6%, p = 0.04). Sarcopenic patients had a 2.6-fold greater usage of advanced imaging (68.8% vs 26.5%, p = 0.002) with associated higher diagnostic imaging costs ($2452 vs $801, p = 0.01). Sarcopenic patients also had greater pharmacy, laboratory, respiratory care, and emergency department costs. CONCLUSIONS This study is the first to show that sarcopenia is associated with higher postoperative costs and rates of blood transfusion following thoracolumbar spine surgery. Measuring the psoas area may represent a strategy for predicting perioperative costs in spine surgery patients.

Patient-Specific Orthopaedic Implants.

Patient-specific orthopaedic implants are emerging as a clinically promising treatment option for a growing number of conditions to better match an individual's anatomy. Patient-specific implant (PSI) technology aims to reduce overall procedural costs, minimize surgical time, and maximize patient outcomes by achieving better biomechanical implant fit. With this commercially-available technology, computed tomography or magnetic resonance images can be used in conjunction with specialized computer programs to create preoperative patient-specific surgical plans and to develop custom cutting guides from 3-D reconstructed images of patient anatomy. Surgeons can then place these temporary guides or "jigs" during the procedure, allowing them to better recreate the exact resections of the computer-generated surgical plan. Over the past decade, patient-specific implants have seen increased use in orthopaedics and they have been widely indicated in total knee arthroplasty, total hip arthroplasty, and corrective osteotomies. Patient-specific implants have also been explored for use in total shoulder arthroplasty and spinal surgery. Despite their increasing popularity, significant support for PSI use in orthopaedics has been lacking in the literature and it is currently uncertain whether the theoretical biomechanical advantages of patient-specific orthopaedic implants carry true advantages in surgical outcomes when compared to standard procedures. The purpose of this review was to assess the current status of patient-specific orthopaedic implants, to explore their future direction, and to summarize any comparative published studies that measure definitive surgical characteristics of patient-specific orthopaedic implant use such as patient outcomes, biomechanical implant alignment, surgical cost, patient blood loss, or patient recovery.

Effect of Sarcopenia on Postoperative Morbidity and Mortality After Thoracolumbar Spine Surgery.

Sarcopenia is the loss of muscle mass associated with aging and advanced disease. This study retrospectively examined patients older than 55 years (N=46) who underwent thoracolumbar spine surgery between 2003 and 2015. Each patient's comorbidity burden was determined using the Charlson Comorbidity Index, and the Mirza Surgical Invasiveness Index was used to measure procedural complexity. Sarcopenia was diagnosed by measuring the total cross-sectional area of the psoas muscle at the L4 vertebrae using perioperative computed tomography scans. Of the 46 patients assessed, 16 were in the lowest third for L4 total psoas area (sarcopenic). Average follow-up time was 5.2 years (range, 6 days to 12.7 years). The cohort of patients with sarcopenia was significantly older than the cohort without sarcopenia (mean age, 76.4 vs 69.9 years; P=.01) but did not have a significantly different mean Charlson Comorbidity Index (3.3 vs 2.0; P=.32) or mean Mirza Surgical Invasiveness Index (7.1 vs 7.0; P=.49). Patients with sarcopenia had a hospital length of stay 1.7-fold longer than those without sarcopenia (8.1 vs 4.7 days; P=.02) and a 3-fold increase in postoperative in-hospital complications (1.2 vs 0.4; P=.02), and they were more likely to require discharge to a rehabilitation or nursing facility (81.2% vs 43.3%; P=.006). Patients with sarcopenia had a significantly lower cumulative survival (log rank=0.007). All 4 deaths occurred among patients with sarcopenia. Patients with sarcopenia have a significantly increased risk of in-hospital complications, longer length of stay, increased rates of discharge to rehabilitation facilities, and increased mortality following thoracolumbar spinal surgery, making sarcopenia a useful perioperative risk stratification tool. [Orthopedics. 2016; 39(6):e1159-e1164.].