Higher cost of arthroplasty for hip fractures in patients transferred from outside hospitals vs primary emergency department presentation.

BACKGROUND: In 2016 Centers for Medicare and Medicaid Services proposed bundled payments for hip fractures to improve the quality and decrease costs of care. Patients transferred from other facilities may be imposing a financial risk on the hospitals that accept these patients. AIM: To determine the costs associated with patients that either presented to the emergency department or were transferred from another hospital or skilled nursing facility (SNF) with the diagnosis of a hip fracture requiring operative intervention. METHODS: A retrospective single institution review was conducted for all arthroplasty patients from 2010 to 2015. Inclusion criteria included a total or partial hip replacement for a hip fracture. Exclusion criteria included pathologic, periprosthetic, and fracture non-union. Data was collected to compare total observed costs for patients from the emergency department, patients from skilled nursing facilities, and patients from an outside hospital. RESULTS: A total of 223 patients met the inclusion criteria. 135 (60.54%) of these patients presented primarily to the emergency department, 58 patients (26.01%) were transferred from an outside hospital, and 30 patients (13.43%) were transferred from a SNF. Cost data analysis showed that outside hospital patients demonstrated significantly greater total cost for their hospitalization ($43302) compared to emergency department patients ($28875, P = 0.000) and SNF patients ($28282, P = 0.000). CONCLUSION: Patients transferred from an outside hospital incurred greater costs for their hospitalization than patients presenting from an emergency department or SNF. This is a strong argument for risk-adjustment models when bundling payments for the care of hip fracture patients.

Creation and Validation of a Shorthand Magnetic Resonance Imaging Bone Age Assessment Tool of the Knee as an Alternative Skeletal Maturity Assessment.

BACKGROUND: In managing pediatric knee conditions, an accurate bone age assessment is often critical for diagnostic, prognostic, and treatment purposes. Historically, the Greulich and Pyle atlas (hand atlas) has been the gold standard bone age assessment tool. In 2013, a shorthand bone age assessment tool based on this atlas (hand shorthand) was devised as a simpler and more efficient alternative. Recently, a knee magnetic resonance imaging (MRI) bone age atlas (MRI atlas) was created to circumvent the need for a left-hand radiograph. PURPOSE: To create a shorthand version of the knee MRI atlas. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A shorthand bone age assessment method was created utilizing the previously published MRI atlas, which utilizes several criteria that are visualized across a series of images. The MRI shorthand draws on characteristic criteria for each age that are best observed on a single MRI scan. For validation, we performed a retrospective assessment of skeletally immature patients. One reader performed the bone age assessment using the MRI atlas and the MRI shorthand on 200 patients. Then, 4 readers performed the bone age assessment with the hand atlas, hand shorthand, MRI atlas, and MRI shorthand on a subset of 22 patients in a blinded fashion. All 22 patients had a knee MRI scan and a left-hand radiograph within 4 weeks of each other. Interobserver and intraobserver reliability, as well as variability among observers, were evaluated. RESULTS: A total of 200 patients with a mean age of 13.5 years (range, 9.08-17.98 years) were included in this study. Also, 22 patients with a mean age of 13.3 years (range, 9.0-15.6 years) had a knee MRI scan and a left-hand radiograph within 4 weeks. The intraobserver and interobserver reliability of all 4 assessment tools were acceptable (intraclass correlation coefficient [ICC] ≥ 0.8; P < .001). When comparing the MRI shorthand with the MRI atlas, there was excellent agreement (ICC = 0.989), whereas the hand shorthand compared with the hand atlas had good agreement (ICC = 0.765). The MRI shorthand also had perfect agreement in 50% of readings among all 4 readers, and 95% of readings had agreement within 1 year, whereas the hand shorthand had perfect agreement in 32% of readings and 77% agreement within 1 year. CONCLUSION: The MRI shorthand is a simple and efficient means of assessing the skeletal maturity of adolescent patients with a knee MRI scan. This bone age assessment technique had interobserver and intraobserver reliability equivalent to or better than the standard method of utilizing a left-hand radiograph.

Super Obesity Is an Independent Risk Factor for Complications After Primary Total Hip Arthroplasty.

BACKGROUND: Recent studies have reported higher postoperative complication rates in obese and morbidly obese patients undergoing total hip arthroplasty (THA). Less data are available regarding super-obese (body mass index [BMI] >50 kg/m2) patients. This study aims to quantify the risk of complications after THA in super-obese patients on a national scale and to put these risks in context by comparing them to patients of other BMI classes as well as those undergoing revision THA. METHODS: Utilizing a national insurance database, complication rates after THA in super-obese patients (n = 3244) were compared to nonobese, obese, and morbidly obese patients undergoing primary THA and all patients undergoing revision THA. A logistic regression analysis controlling for demographic and comorbidity variables was utilized to determine the independent effect of super obesity on complication rates after THA. RESULTS: Super-obese patients had significantly higher rates of most complications than nonobese, obese, morbidly obese, and revision THA patients, including venous thromboembolism, infection, blood transfusion, medical complications, dislocation, readmission, and revision THA. CONCLUSION: Super-obese patients (BMI >50 kg/m2) have higher rates of postoperative complications after THA than nonobese, obese, morbidly obese, and revision THA patients. Super obesity is an independent risk factor for increased rates of most postoperative complications including the need for early revision THA.

Morbid Obesity and Lumbar Fusion in Patients Older Than 65 Years: Complications, Readmissions, Costs, and Length of Stay.

STUDY DESIGN: Retrospective database review. OBJECTIVE: The aim of this study was to determine how both morbid obesity (body mass index [BMI] ≥40) and obesity (BMI 30-39.9) modify 90-day complication rates and 30-day readmission rates following 1- to 2-level, primary, lumbar spinal fusion surgery for degenerative pathology in an elderly population. SUMMARY OF BACKGROUND DATA: In the United States, both obese and elderly patients are known to have increased risk of complication, yet both demographics are increasingly undergoing elective lumbar spine surgery. METHODS: Medicare data from 2005 to 2012 were queried for patients who underwent primary 1- to 2-level posterolateral lumbar fusion for degenerative pathology. Elderly patients undergoing elective surgery were selected and separated into three cohorts: morbidly obese (BMI ≥40; n = 2594), obese (BMI ≥30, < 40] (n = 5534), and nonobese controls (n = 48,210). Each pathologic cohort was matched to a unique subcohort from the control population. Ninety-day medical and surgical complication rates, 30-day readmission rates, length of stay (LOS), and hospital costs were then compared. RESULTS: Both morbidly obese and obese patients had significantly higher odds of experiencing any one major medical complication (odds ratio [OR] 1.79; P < 0.0001 and OR 1.32; P < 0.0001, respectively). Wound infection (OR 3.71; P < 0.0001 and OR 2.22; P < 0.0001) and dehiscence (OR 3.80; P < 0.0001 and OR 2.59; P < 0.0001) rates were increased in morbidly obese and obese patients, respectively. Thirty-day readmissions, length of stay, and in-hospital costs were increased, with patients with morbid obesity incurring charges almost $8000 greater than controls. CONCLUSION: Patients with both obesity and morbid obesity are at significantly increased risk of major medical complications, wound complications, and 30-day readmissions. Additionally, both groups of patients have significantly increased LOS and hospital costs. Both obese and morbidly obese patients should be appropriately counseled of these risks and must be carefully selected to reduce postoperative morbidity. LEVEL OF EVIDENCE: 3.

Increased incidence of postoperative stiffness after arthroscopic compared with open biceps tenodesis.

PURPOSE: To determine the incidence of postoperative stiffness after open and arthroscopic biceps tenodesis, compare the incidence between each method, and determine relevant risk factors for its occurrence. METHODS: A consecutive series of patients who underwent biceps tenodesis during a 3-year period were retrospectively reviewed. RESULTS: We evaluated 249 patients, which included 143 who underwent open subpectoral tenodesis and 106 who underwent arthroscopic suprapectoral tenodesis. The mean overall follow-up period for the arthroscopic group was 9.9 months (range, 5.1 to 33.5 months). The mean overall follow-up period for the open group was 9.5 months (range, 4.7 to 49.2 months). There was no significant difference in overall follow-up duration between groups (P = .627). A significantly increased incidence of postoperative stiffness was found in the arthroscopic group compared with the open group (17.9% v 5.6%, P = .002). Within the arthroscopic group, patients with postoperative stiffness were more frequently female patients than those without stiffness (63.2% v 33.3%, P = .016) and were more likely to be smokers than those without stiffness (36.8% v 16.1%, P = .040). The tenodesis site was located significantly more proximal in the arthroscopic group of patients with postoperative stiffness compared with patients without postoperative stiffness (32.44 ± 7.8 mm from the top of the humeral head v 50.34 ± 7.8 mm, P < .0001). CONCLUSIONS: Our results show a notably increased incidence of postoperative stiffness after arthroscopic suprapectoral biceps tenodesis compared with open subpectoral biceps tenodesis. This appears to occur more commonly in female patients and smokers and may have a relation to the position of the tenodesis, with a more superiorly placed tenodesis site being a potential influencing factor. On the basis of this series, this complication most commonly will improve over time and with symptom-based management. LEVEL OF EVIDENCE: Level III, therapeutic case-control study.

Biceps tenodesis is a viable option for salvage of failed SLAP repair.

BACKGROUND: Outcomes of arthroscopic superior labral anterior-posterior (SLAP) repairs have been well reported with generally favorable outcomes. Unfortunately, a percentage of patients remain dissatisfied or suffer further injury after SLAP repair and may seek additional treatment. The purpose of this study was to evaluate the surgical outcomes of biceps tenodesis for failed SLAP repairs. METHODS: A retrospective review of all patients undergoing biceps tenodesis was completed. Inclusion criteria were previous SLAP repair and subsequent revision biceps tenodesis. Exclusion criteria were additional shoulder procedures including rotator cuff repair, instability procedures, and preoperative frozen shoulder. Objective outcomes were postoperative assessments with Constant score, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation, Simple Shoulder Test, and Veterans RAND 36-Item Health Survey. Physical examination was conducted to determine postoperative range of motion and strength compared with the nonoperative shoulder. RESULTS: A cohort of 24 patients was identified, and of these, 17 patients (71%) completed the study at 2 years' follow-up. The average postoperative Constant score was 84.4; American Shoulder and Elbow Surgeons score, 75.5; Single Assessment Numeric Evaluation score, 73.1%; Simple Shoulder Test score, 9.2; and Veterans RAND 36-Item Health Survey score, 76.1. Postoperative range of motion of the operative shoulder returned to near that of the asymptomatic nonoperative shoulder. Workers' compensation status led to inferior results. CONCLUSIONS: Options for patients with a failed prior SLAP repair are limited. As a salvage operation for failed SLAP repair, biceps tenodesis serves the majority of patients well, with favorable outcomes by validated measures and excellent shoulder range of motion and elbow strength at 2 years' follow-up. Workers' compensation status may predispose patients to poorer outcomes.