Brian R. Wolf

Clinical characteristics and outcomes of Medicare patients undergoing total hip arthroplasty, 1991-2008.

CONTEXT Total hip arthroplasty is a common surgical procedure but little is known about longitudinal trends. OBJECTIVE To examine demographics and outcomes of patients undergoing primary and revision total hip arthroplasty. DESIGN, SETTING, AND PARTICIPANTS Observational cohort of 1,453,493 Medicare Part A beneficiaries who underwent primary total hip arthroplasty and 348,596 who underwent revision total hip arthroplasty. Participants were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes for primary and revision total hip arthroplasty between 1991 and 2008. MAIN OUTCOME MEASURES Changes in patient demographics and comorbidity, hospital length of stay (LOS), mortality, discharge disposition, and all-cause readmission rates. RESULTS Between 1991 and 2008, the mean age for patients undergoing primary total hip arthroplasty increased from 74.1 to 75.1 years and for revision total hip arthroplasty from 75.8 to 77.3 years (P < .001). The mean number of comorbid illnesses per patient increased from 1.0 to 2.0 for primary total hip arthroplasty and 1.1 to 2.3 for revision (P < .001). For primary total hip arthroplasty, mean hospital LOS decreased from 9.1 days in 1991-1992 to 3.7 days in 2007-2008 (P = .002); unadjusted in-hospital and 30-day mortality decreased from 0.5% to 0.2% and from 0.7% to 0.4%, respectively (P < .001). The proportion of primary total hip arthroplasty patients discharged home declined from 68.0% to 48.2%; the proportion discharged to skilled care increased from 17.8% to 34.3%; and 30-day all-cause readmission increased from 5.9% to 8.5% (P < .001). For revision total hip arthroplasty, similar trends were observed in hospital LOS, in-hospital mortality, discharge disposition, and hospital readmission rates. CONCLUSION Among Medicare beneficiaries who underwent primary and revision hip arthroplasty between 1991 and 2008, there was a decrease in hospital LOS but an increase in the rates of discharge to postacute care and readmission.

Risk of Tearing the Intact Anterior Cruciate Ligament in the Contralateral Knee and Rupturing the Anterior Cruciate Ligament Graft During the First 2 Years After Anterior Cruciate Ligament Reconstruction A Prospective MOON Cohort Study

Background The risk of tear of the intact anterior cruciate ligament in the contralateral knee after anterior cruciate ligament reconstruction of the opposite knee and the incidence of rupturing the anterior cruciate ligament graft during the first 2 years after surgery have not been extensively studied in a prospective manner. Clinicians have hypothesized that the opposite normal knee is at equal or increased risk compared with the risk of anterior cruciate ligament graft rupture in the operated knee. Hypothesis The risk of anterior cruciate ligament graft rupture and contralateral normal knee anterior cruciate ligament rupture at 2-year follow-up is equal. Study Design Cohort study; Level of evidence, 2. Methods The Multicenter Orthopaedic Outcome Network (MOON) database of a prospective longitudinal cohort of anterior cruciate ligament reconstructions was used to determine the number of anterior cruciate ligament graft ruptures and tears of the intact anterior cruciate ligament in the contralateral knee at 2-year follow-up. Two-year follow-up consisted of a phone interview and review of operative reports. Results Two-year data were obtained for 235 of 273 patients (86%). There were 14 ligament disruptions. Of these, 7 were tears of the intact anterior cruciate ligament in the contralateral knee (3.0%) and 7 were anterior cruciate ligament graft failures (3.0%). Conclusion The contralateral normal knee anterior cruciate ligament is at a similar risk of anterior cruciate ligament tear (3.0%) as the anterior cruciate ligament graft after primary anterior cruciate ligament reconstruction (3.0%).

Indications for rotator cuff repair : A systematic review

Despite the popularity of surgical repair of rotator cuff tears, literature regarding the indications for and timing of surgery are sparse. We performed a systematic review of the literature to investigate factors influencing the decision to surgically repair symptomatic, full-thickness rotator cuff tears. Specifically, how do demographic variables, duration of symptoms, timing of surgery, physical examination findings, and size of tear affect treatment outcome and indications for surgery? We reviewed the best available evidence, which offers some guidelines for surgical decision making. Variables suggest earlier surgical intervention may be needed in the setting of weakness and substantial functional disability. With regard to demographic variables, the evidence is unclear regarding their association with treatment outcome. However, older chronological age does not seem to portend a worse outcome. Pending workers compensation claims does seem to negatively affect treatment results. Further research is required to define the indications for surgery for full thickness rotator cuff tears. However, the design and conduct of an ethical study to obtain Level I evidence on this issue will be a major challenge.Level of Evidence: Level IV, systematic review. See Guidelines for Authors for a complete description of levels of evidence.

Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study

PURPOSE To assess the effectiveness of a specific nonoperative physical therapy program in treating atraumatic full-thickness rotator cuff tears using a multicenter prospective cohort study design. MATERIALS AND METHODS Patients with atraumatic full-thickness rotator cuff tears who consented to enroll provided data via questionnaire on demographics, symptom characteristics, comorbidities, willingness to undergo surgery, and patient-related outcome assessments (Short Form 12 score, American Shoulder and Elbow Surgeons score, Western Ontario Rotator Cuff score, Single Assessment Numeric Evaluation score, and Shoulder Activity Scale). Physicians recorded physical examination and imaging data. Patients began a physical therapy program developed from a systematic review of the literature and returned for evaluation at 6 and 12 weeks. At those visits, patients could choose 1 of 3 courses: (1) cured (no formal follow-up scheduled), (2) improved (continue therapy with scheduled reassessment in 6 weeks), or (3) no better (surgery offered). Patients were contacted by telephone at 1 and 2 years to determine whether they had undergone surgery since their last visit. A Wilcoxon signed rank test with continuity correction was used to compare initial, 6-week, and 12-week outcome scores. RESULTS The cohort consists of 452 patients. Patient-reported outcomes improved significantly at 6 and 12 weeks. Patients elected to undergo surgery less than 25% of the time. Patients who decided to have surgery generally did so between 6 and 12 weeks, and few had surgery between 3 and 24 months. CONCLUSION Nonoperative treatment using this physical therapy protocol is effective for treating atraumatic full-thickness rotator cuff tears in approximately 75% of patients followed up for 2 years.

A Comparison of Total Hip and Knee Replacement in Specialty and General Hospitals

BACKGROUND The emergence of specialty orthopaedic hospitals has generated widespread controversy, but little is known about the quality of care they deliver. Our objective was to compare the characteristics and outcomes of patients undergoing major joint replacement in specialty orthopaedic and general hospitals. METHODS We conducted a retrospective cohort study of 51,788 Medicare beneficiaries who underwent total hip replacement and 99,765 who underwent total knee replacement in thirty-eight specialty orthopaedic hospitals and 517 general hospitals between 1999 and 2003. We compared demographic data, rates of comorbid illness, and socioeconomic status of patients treated in specialty and general hospitals. Logistic regression was used to calculate the odds of an adverse outcome (death or selected surgical complications) after adjustment for patient characteristics and hospital procedural volume. RESULTS The demographic data and the ratio of primary to revision arthroplasties were similar, but patients who received care in specialty hospitals had less comorbidity and resided in more affluent zip codes than their counterparts in general hospitals in 2003. Specialty hospitals had significantly greater mean procedural volumes in 2003 than did general hospitals for both total hip replacement (thirty-three compared with twenty procedures; p = 0.05) and total knee replacement (seventy-five compared with forty procedures; p = 0.006). The unadjusted rate of adverse outcomes was lower in specialty hospitals than in general hospitals for total hip replacement (3.0% compared with 6.9%; p < 0.001) and total knee replacement (2.1% compared with 3.9%; p < 0.001). After adjusting for patient characteristics and procedural volume, the odds of adverse outcomes occurring were significantly lower for patients in specialty hospitals than for those in general hospitals for both primary joint replacement (odds ratio, 0.64; 95% confidence interval, 0.56 to 0.75; p < 0.001) and revision joint replacement (odds ratio, 0.49; 95% confidence interval, 0.36 to 0.66; p < 0.001). CONCLUSIONS After adjustment for patient characteristics and hospital volume, the specialty orthopaedic hospitals had better patient outcomes, as measured by Medicare administrative data, than did the general hospitals.

Interobserver Agreement in the Classification of Rotator Cuff Tears Using Magnetic Resonance Imaging

Background Although magnetic resonance imaging (MRI) is a standard method of assessing the extent and features of rotator cuff disease, the authors are not aware of any studies that have assessed the interobserver agreement among orthopaedic surgeons reviewing MRI scans for rotator cuff disease. Hypothesis Fellowship-trained orthopaedic shoulder surgeons will have good interobserver agreement in predicting the more salient features of rotator cuff disease such as tear type (full thickness versus partial thickness), tear size, and number of tendons involved but only fair agreement with more complex features such as muscle volume, fat content, and the grade of partial-thickness cuff tears. Study Design Cohort study (diagnosis); Level of evidence, 3. Methods Ten fellowship-trained orthopaedic surgery shoulder specialists reviewed 27 MRI scans of 27 shoulders from patients with surgically confirmed rotator cuff disease. The ability to interpret full-thickness versus partial-thickness tears, acromion type, acromioclavicular joint spurs or signal changes, biceps lesions, size and grade of partial-thickness tears, acromiohumeral distance, number of tendons involved and amount of retraction for full-thickness tears, size of full-thickness tears, and individual muscle fatty infiltration and atrophy were assessed. Surgeons completed a standard evaluation form for each MRI scan. Interobserver agreement was determined and a kappa level was derived. Results Interobserver agreement was highest (>80%) for predicting full- versus partial-thickness tears of the rotator cuff, and for quantity of the teres minor tendon. Agreement was slightly less (>70%) for detecting signal in the acromioclavicular joint, the side of the partial-thickness tear, the number of tendons involved in a full-thickness tear, and the quantity of the subscapularis and infraspinatus muscle bellies. Agreement was less yet (60%) for detecting the presence of spurs at the acromioclavicular joint, a tear of the long head of the biceps tendon, amount of retraction of a full-thickness tear, and the quantity of the supraspinatus. The best kappa statistics were found for detecting the difference between a full- and partial-thickness rotator cuff tear (0.77), and for the number of tendons involved for full-thickness tears (0.55). Kappa for predicting the involved side of a partial-thickness tear was 0.44; for predicting the grade of a partial-thickness tear, it was −0.11. Conclusions Fellowship-trained, experienced orthopaedic surgeons had good agreement for predicting full-thickness rotator cuff tears and the number of tendons involved and moderate agreement in predicting the involved side of a partial-thickness rotator cuff tear, but poor agreement in predicting the grade of a partial-thickness tear.

Are Articular Cartilage Lesions and Meniscus Tears Predictive of IKDC, KOOS, and Marx Activity Level Outcomes After Anterior Cruciate Ligament Reconstruction?

Background: Identifying risk factors for inferior outcomes after anterior cruciate ligament reconstruction (ACLR) is important for prognosis and future treatment. Hypothesis: Articular cartilage lesions and meniscus tears/treatment would predict International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS) (all 5 subscales), and Marx activity level at 6 years after ACLR. Study Design: Cohort study (prognosis); Level of evidence, 1. Methods: Between 2002 and 2004, a total of 1512 ACLR patients were prospectively enrolled and followed longitudinally, with the IKDC, KOOS, and Marx activity score completed at entry, 2 years, and 6 years. A logistic regression model was built incorporating variables from patient demographics, surgical technique, articular cartilage injuries, and meniscus tears/treatment to determine the predictors (risk factors) of IKDC and KOOS scores and Marx activity level at 6 years. Results: A minimum follow-up on 86% (1307/1512) of the cohort was completed at 6 years. The cohort was 56% male and had a median age of 23 years at the time of enrollment, with 76% reporting a noncontact injury mechanism. Incidence of concomitant injury at the time of surgery consisted of the following: articular cartilage (medial femoral condyle [MFC], 25%; lateral femoral condyle [LFC] 20%; medial tibial plateau [MTP], 6%; lateral tibial plateau [LTP], 12%; patella, 20%; trochlear, 9%) and meniscus (medial, 38%; lateral, 46%). Both articular cartilage lesions and meniscus tears were significant predictors of 6-year outcomes on the IKDC and KOOS. Grade 3 or 4 articular cartilage lesions (excluding patella) significantly reduced IKDC and KOOS scores at 6 years. The IKDC demonstrated worse outcomes with the presence of a grade 3 or 4 chondral lesion on the MFC, MTP, and LFC. Likewise, the KOOS score was negatively affected by cartilage injury. The sole significant predictor of reduced Marx activity level was the presence of a grade 4 lesion on the MFC. Lateral meniscus repairs did not correlate with inferior results, but medial meniscus repairs predicted worse IKDC and KOOS scores. Lateral meniscus tears left alone significantly improved prognosis. Small partial meniscectomies (<33%) on the medial meniscus fared worse; conversely, larger excisions (>50%) on either the medial or lateral menisci improved prognosis. Analogous to previous studies, other significant predictors of lower outcome scores were lower baseline scores, higher body mass index, lower education level, smoking, and anterior cruciate ligament revisions. Conclusion: Both articular cartilage injury and meniscus tears/treatment at the time of ACLR were significant predictors of IKDC and KOOS scores 6 years after ACLR. Similarly, having a grade 4 MFC lesion significantly reduced a patient’s Marx activity level score at 6 years.

Effect of Graft Choice on the Outcome of Revision Anterior Cruciate Ligament Reconstruction in the Multicenter ACL Revision Study (MARS) Cohort

Background: Most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome; however, graft choice for revision may be limited due to previously used grafts. Hypotheses: Autograft use would result in increased sports function, increased activity level, and decreased osteoarthritis symptoms (as measured by validated patient-reported outcome instruments). Autograft use would result in decreased graft failure and reoperation rate 2 years after revision ACL reconstruction. Study Design: Cohort study; Level of evidence, 2. Methods: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled by 83 surgeons at 52 sites. Data collected included baseline demographics, surgical technique, pathologic abnormalities, and the results of a series of validated, patient-reported outcome instruments (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating score). Patients were followed up at 2 years and asked to complete the identical set of outcome instruments. Incidences of additional surgery and reoperation due to graft failure were also recorded. Multivariate regression models were used to determine the predictors (risk factors) of IKDC, KOOS, WOMAC, Marx scores, graft rerupture, and reoperation rate at 2 years after revision surgery. Results: A total of 1205 patients (697 [58%] males) were enrolled. The median age was 26 years. In 88% of patients, this was their first revision, and 341 patients (28%) were undergoing revision by the surgeon who had performed the previous reconstruction. The median time since last ACL reconstruction was 3.4 years. Revision using an autograft was performed in 583 patients (48%), allograft was used in 590 (49%), and both types were used in 32 (3%). Questionnaire follow-up was obtained for 989 subjects (82%), while telephone follow-up was obtained for 1112 (92%). The IKDC, KOOS, and WOMAC scores (with the exception of the WOMAC stiffness subscale) all significantly improved at 2-year follow-up (P < .001). In contrast, the 2-year Marx activity score demonstrated a significant decrease from the initial score at enrollment (P < .001). Graft choice proved to be a significant predictor of 2-year IKDC scores (P = .017). Specifically, the use of an autograft for revision reconstruction predicted improved score on the IKDC (P = .045; odds ratio [OR] = 1.31; 95% CI, 1.01-1.70). The use of an autograft predicted an improved score on the KOOS sports and recreation subscale (P = .037; OR = 1.33; 95% CI, 1.02-1.73). Use of an autograft also predicted improved scores on the KOOS quality of life subscale (P = .031; OR = 1.33; 95% CI, 1.03-1.73). For the KOOS symptoms and KOOS activities of daily living subscales, graft choice did not predict outcome score. Graft choice was a significant predictor of 2-year Marx activity level scores (P = .012). Graft rerupture was reported in 37 of 1112 patients (3.3%) by their 2-year follow-up: 24 allografts, 12 autografts, and 1 allograft and autograft. Use of an autograft for revision resulted in patients being 2.78 times less likely to sustain a subsequent graft rupture compared with allograft (P = .047; 95% CI, 1.01-7.69). Conclusion: Improved sports function and patient-reported outcome measures are obtained when an autograft is used. Additionally, use of an autograft shows a decreased risk in graft rerupture at 2-year follow-up. No differences were noted in rerupture or patient-reported outcomes between soft tissue and bone–patellar tendon–bone grafts. Surgeon education regarding the findings of this study has the potential to improve the results of revision ACL reconstruction.

Adverse Outcomes in Hip Arthroplasty: Long-Term Trends

BACKGROUND Total hip arthroplasty is a common surgical procedure, but little is known about longitudinal trends in associated adverse outcomes. Our objective was to describe long-term trends in demographics, comorbidities, and adverse outcomes for older patients who underwent primary and revision total hip arthroplasty. METHODS We identified a retrospective, observational cohort of 1,405,379 Medicare beneficiaries who underwent primary total hip arthroplasty and 337,874 who underwent revision total hip arthroplasty between 1991 and 2008. The primary outcome was a composite representing the occurrence of one or more of the following adverse outcomes during the index admission or during readmission within ninety days after discharge: death, hemorrhage, infection, pulmonary embolism, sepsis, deep venous thrombosis, and myocardial infarction. Secondary outcomes included each of these outcomes assessed individually. RESULTS Between 1991 and 2008, the mean age and the mean comorbidity burden increased for all total hip arthroplasty patients. The length of hospital stay after primary and revision total hip arthroplasty declined by approximately 50% over the study period. However, the rate of readmission for any cause has recently increased and has surpassed 10% for primary total hip arthroplasty and 20% for revision total hip arthroplasty. The composite rate of adverse outcomes after primary total hip arthroplasty declined from 4% to 3.4% over the study period, whereas the composite adverse outcome rate after revision total hip arthroplasty slowly increased from 7% to 10.9%. We observed a steady decline in the rates of most individual adverse outcomes after primary total hip arthroplasty over the majority of the study period. Many of these rates stabilized or began to increase slightly near the end of the study period. In contrast, an increase in the rates of many adverse outcomes was observed in the revision total hip arthroplasty population even after accounting for changes in patient complexity. Postoperative hemorrhage has gradually increased after both primary and revision total hip arthroplasty. CONCLUSIONS Patients undergoing primary and revision total hip arthroplasty are becoming more complex. Despite this increasing complexity, patient outcomes for primary total hip arthroplasty improved markedly before stabilizing in recent years. In contrast, patient outcomes after revision total hip arthroplasty have gradually worsened, likely reflecting the increase in the medical comorbidities and surgical complexity of these patients. Length of hospital stay has demonstrated a substantial decline, which has recently been coupled with an increased readmission rate. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Interobserver agreement in the classification of rotator cuff tears

Background Six classification systems have been proposed for describing rotator cuff tears designed to help understand their natural history and make treatment decisions. Purpose To assess the interobserver variation for these classification systems and identify the method with the best interob-server agreement. Study Design Cohort study (diagnosis); Level of evidence, 2. Methods Six rotator cuff tear classification systems were identified in a literature search. The components of these systems included partial-thickness rotator cuff tears and classification by size, shape, configuration, number of tendons involved, and by extent, topography, and nature of the biceps. Twelve fellowship-trained orthopaedic surgeons who each perform at least 30 rotator cuff repairs per year reviewed arthroscopy videos from 30 patients with a random assortment of rotator cuff tears and classified them by the 6 classification systems. Interobserver variation was determined by a kappa analysis. Results Interobserver agreement was high when distinguishing between full-thickness and partial-thickness tears (0.95, [UNKNOWN]=0.85). The investigators agreed on the side (articular vs bursal) of involvement for partial-thickness tears (observed agreement 0.92, [UNKNOWN]= 0.85) but could not agree when classifying the depth of the partial-thickness tear (observed agreement 0.49, [UNKNOWN]= 0.19). The best agreement for full-thickness tears was seen when the tear was classified by topography (degree of retraction) in the frontal plane (observed agreement 0.70, [UNKNOWN]= 0.54). Conclusion With the exception of distinguishing partial-thickness from full-thickness rotator cuff tears and identifying the side (articular vs bursal) of involvement with partial-thickness tears, currently described rotator cuff classification systems have little interobserver agreement among experienced shoulder surgeons. Researchers should consider describing full-thickness rotator cuff tears by topography (degree of retraction) in the frontal plane.