Relationship between hospital size and teaching status on outcomes for reverse shoulder arthroplasty.

BACKGROUND: The use of reverse shoulder arthroplasty (RSA) continues to grow with expanding indications and increased surgeon awareness. Previous data for other lower extremity joint replacements indicate that high-volume centers have better outcomes, with lower complication rates, decreased length of stay, and complications for both hemiarthroplasty and total shoulder arthroplasty. The purpose of this study is to evaluate the effects of hospital size and setting on adverse events for RSA. MATERIALS AND METHODS: The National Inpatient Sample database was queried for RSA performed using ICD-9 codes. Primary outcomes included length of stay (LOS), total hospital charges, discharge disposition, and postoperative complications. Odds ratios were used to assess the risk of inpatient postoperative complications. RESULTS: A weighted national estimate of 24,056 discharges for patients undergoing RSA was included in the study. Patients at larger hospitals experienced higher total charges, increased average LOS, and slightly higher complication rates compared to those of small and medium hospitals. Patients in larger hospitals had significantly increased rates of genitourinary and central nervous system complications, while patients in small/medium hospitals experienced higher rates of hematoma/seroma. CONCLUSION: Results from this study indicate that large and non-teaching hospitals overall tend to burden the patients with higher hospital charges, longer hospital stay, and more frequent non-routine discharges. Also, larger hospitals are associated with higher risk of genitourinary and central nervous system complications rates, whereas non-teaching hospitals are associated with lower risk of infection and higher risk of anemia after RSA. With the growth in RSA in the USA, continued attention needs to be placed on improving outcomes and resource utilization for RSA patients even in larger hospitals.

The effect of Medicaid payer status on patient outcomes following repair of massive rotator cuff tears.

BACKGROUND: The influence of socioeconomic status and insurance type has not been studied extensively for RCR, particularly not in the high risk massive RCT population. The purpose of this study is to identify relationships between Medicaid payer status and patient outcomes following massive RCR. METHODS: A retrospective review of shoulder surgery database identified 29 patients undergoing massive rotator cuff repair. Patients were stratified based on insurance type into two cohorts, Medicaid (14 patients) and non-Medicaid (15 patients). Missed routine follow-up appointments and comorbidities were recorded and compared between groups. Group comparisons were made for pre- and postoperative patient-reported and functional outcomes. Outcome scores included American Shoulder and Elbow Shoulder Score (ASES), the Penn Shoulder Score, and the Subjective Shoulder Value (SSV). A p value of < 0.05 was considered significant for all statistical analyses. RESULTS: Medicaid patients were on average 7.1 years younger than non-Medicaid patients (49.8 vs. 56.9 years, respectively), and remaining demographics were comparable between groups. Preoperative patient-reported outcomes were only significantly different for ASES and ASES pain (p = 0.010, 0.037). There was excellent average improvement for Medicaid patients but no significant differences compared to non-Medicaid patients for ASES (p = 0.630), PENN scores (p = 0.395), and SSV (p = 0.198). Medicaid patients also had a higher number of missed and canceled appointments (28%) compared to non-Medicaid patients (18%). CONCLUSION: Medicaid coverage will expand to millions of uninsured Americans under current healthcare reform. Medicaid patients with massive RCT appear to significantly improve with surgical treatment.

Extremity fractures associated with ATVs and dirt bikes: a 10-year national epidemiologic study.

BACKGROUND: Morbidity and mortality of all-terrain vehicles and dirt bikes have been studied, as well as the association of helmet use and head injury. HYPOTHESIS/PURPOSE: The purpose of this study is to compare and contrast the patterns of extremity fractures associated with ATVs and dirt bikes. We believe there will be unique and potentially preventable injury patterns associated with dirt bikes and three-wheeled ATVs due to the poor stability of these vehicles. STUDY DESIGN: Descriptive epidemiology study. METHODS: The National Electronic Injury Surveillance System (NEISS) was used to acquire data for extremity fractures related to ATV (three wheels, four wheels, and number of wheels undefined) and dirt bike use from 2007 to 2012. Nationwide estimation of injury incidence was determined using NEISS weight calculations. RESULTS: The database yielded an estimate of 229,362 extremity fractures from 2007 to 2012. The incidence rates of extremity fractures associated with ATV and dirt bike use were 3.87 and 6.85 per 1000 participant-years. The largest proportion of all fractures occurred in the shoulder (27.2%), followed by the wrist and lower leg (13.8 and 12.4%, respectively). There were no differences in the distribution of the location of fractures among four-wheeled or unspecified ATVs. However, three-wheeled ATVs and dirt bikes had much larger proportion of lower leg, foot, and ankle fractures compared to the other vehicle types. CONCLUSIONS: While upper extremity fractures were the most commonly observed in this database, three-wheeled ATVs and dirt bikes showed increased proportions of lower extremity fractures. Several organizations have previously advocated for better regulation of the sale and use of these specific vehicles due to increased risks. These findings help illustrate some of the specific risks associated with these commonly used vehicles.

Quantitative assessment and characterization of glenoid bone loss in a spectrum of patients with glenohumeral osteoarthritis.

PURPOSE: Eccentric posterior bone loss and associated glenoid retroversion represent challenges to glenoid placement during total shoulder arthroplasty. This bone loss can lead to poor stability and perforation of the glenoid during arthroplasty. The purpose of this study was to evaluate the morphology of glenoid bone loss for a spectrum of osteoarthritis patients using 3D computed tomography imaging and simulation software. METHODS: This study included 29 patients with glenohumeral osteoarthritis treated with shoulder arthroplasty. Three-dimensional reconstruction of preoperative CT images was performed. Glenoid bone loss was measured at ten, vertically equidistant axial planes along the glenoid surface at four distinct anterior-posterior points on each plane. The images were fitted with modeled pegged glenoid implants to predict glenoid perforation. RESULTS: The 3D maps demonstrated greatest average bone loss posteriorly in the AP plane at the central axis of the glenoid in the SI plane. The average amount of bone loss was 3.85 mm. Walch A2 and B1 shoulders showed more central bone loss, while Walch B2 shoulders displayed more posterior and inferior bone loss. Patients with predicted peg perforation displayed significantly greater bone loss than those without predicted peg perforation (p = 0.037). Peg perforation was most common in Walch B2 shoulders occurring in the posterior direction involving the central and posterior-inferior peg. CONCLUSIONS: These data demonstrate an anatomic pattern of glenoid bone loss for different classes of glenohumeral arthritis. These findings can be used to develop various models of glenoid bone loss to guide surgeons, predict failures, and develop better glenoid implants. This study has been approved by the Cleveland Clinic IRB: Number 6235.

The effect of deltoid lengthening on functional outcome for reverse shoulder arthroplasty.

PURPOSE: Reverse shoulder arthroplasty (RSA) is based on the biomechanical advantages of lengthening the deltoid while medializing its center of rotation (COR). Little evidence exists describing the clinical benefits of these biomechanical advantages. The purpose of this study is to assess the relationship between deltoid lengthening and medialization of the COR with functional outcomes for RSA patients. METHODS: We retrospectively reviewed patients treated with primary RSA. Radiographic measurements of deltoid length and COR, assessment of forward elevation (FE) and external rotation (ER), and functional outcome scores were obtained pre- and postoperatively. Linear regression analyses were performed to assess the relationship between these radiographic measurements and changes in shoulder functionality. RESULTS: On average, patients improved significantly in function and functional outcome scores. Postoperative COR correlated weakly with postoperative FE. There were weakly negative correlations between increase in acromion to greater tuberosity distance and postoperative FE, and between deltoid lengthening and FE improvement. CONCLUSIONS: Our results suggest that deltoid lengthening does not correlate with improvements in active FE or ER. These findings could indicate that change in deltoid length is less important than previously thought. Furthermore, the negative correlations seen could indicate that there is over-tensioning of the deltoid in specific cases. Further studies are needed to better assess the role of deltoid length and other factors that may impact RSA outcomes.

The effect of glenosphere size on functional outcome for reverse shoulder arthroplasty.

PURPOSE: Reverse shoulder arthroplasty (RSA) is an effective surgery for a variety of patients with difficult shoulder pathology. Since postsurgical outcomes are often variable, there has been great effort made to optimize the design and use of these implants. Previous studies demonstrated an association between increased glenosphere size and improved range of motion. The purpose of this study is to assess the relationship between glenosphere size, range of motion, and functional outcome scores. METHODS: This is a retrospective cohort study of 140 patients (148 shoulders) undergoing reverse shoulder arthroplasty. All patients were assessed pre- and postoperatively for range of motion, Constant score, ASES score, and Subjective Shoulder Value. Improvements in these variables were compared for patients treated with three different glenosphere sizes (36, 40, 42 mm). RESULTS: All groups had a mean improvement in range of motion and functional outcome scores, but there were no statistically significant differences between groups when controlling for preoperative differences. CONCLUSIONS: Our findings do not support a strong role for glenosphere size as a singular factor affecting range of motion or patient-reported outcome following RSA. These problems are most likely due to the multifactorial nature of shoulder dynamics. For this reason, assessing the effect a single surgical or biomechanical parameter on function has been challenging.