Laurence D. Higgins

The Relationship Between Surgeon and Hospital Volume and Outcomes for Shoulder Arthroplasty

BACKGROUND As far as we know, no previous study has determined the relationship between volume and outcomes for shoulder arthroplasty. We hypothesized that surgeons and hospitals with higher caseloads of total shoulder arthroplasties and hemiarthroplasties have better outcomes as measured by decreased mortality rate, shorter length of stay in the hospital, reduced postoperative complications, and routine disposition of patients on discharge. METHODS Data on patients undergoing shoulder arthroplasty were extracted from the Nationwide Inpatient Sample databases for the years 1988 through 2000. Logistic regression with generalized estimating equations and multiple linear regression models were used to estimate the adjusted association between surgeon and hospital volume and outcomes for total shoulder arthroplasty and hemiarthroplasty after adjusting for comorbidity, age, race, household income, and sex. RESULTS The mortality rates for patients who had a total shoulder arthroplasty performed by surgeons who did fewer than two procedures per year (0.36%) or who did between two and fewer than four procedures per year (0.32%) were higher than those for patients who had a total shoulder arthroplasty performed by surgeons who did four procedures or more per year (0.20%). The risk-adjusted rate of postoperative complications after hemiarthroplasty was significantly higher for patients managed by surgeons who performed fewer than two procedures per year (1.68%) than for those managed by surgeons with a volume of five procedures or more per year (0.97%). The possibility of postoperative complications when total shoulder arthroplasty was performed in hospitals with a volume of fewer than five procedures (1.44%) or in those with a volume of five to ten procedures per year (1.45%) was significantly higher than that in hospitals where ten procedures or more were performed every year (0.64%). The mean lengths of stay in the hospital after total shoulder arthroplasty and hemiarthroplasty were significantly longer when the operations were performed by surgeons who did fewer than two procedures per year or when they were done in hospitals with a volume of fewer than five procedures per year or with a volume of five to fewer than ten procedures per year than when they were done in hospitals or by surgeons in the highest volume category (p < 0.001). CONCLUSIONS Patients who have a total shoulder arthroplasty or hemiarthroplasty performed by a high-volume surgeon or in a high-volume hospital are more likely to have a better outcome. LEVEL OF EVIDENCE Therapeutic study, Level III-2 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.

Comorbidities increase complication rates in patients having arthroplasty

The objective of our study was to assess the effect of comorbidities (hypertension, diabetes, obesity, and their combinations) on postoperative complications and discharge status in patients having shoulder, hip, and knee arthroplasty (n = 959,839). The association between outcomes and each of the comorbidities was assessed using multivariable logistic regression after adjusting for age, race, household income, gender, and hospital volume. In the multivariable models, postoperative complications were more likely in patients with hypertension, diabetes, or obesity as compared with patients without these comorbidities (for hypertension, odds ratio = 1.07; 95% confidence interval range, 1.04-1.11; for obesity, odds ratio = 1.3; 95% confidence interval range, 1.22-1.41). The likelihood of a nonhomebound disposition of patients on discharge was 1.30 times (95% confidence interval range, 1.27-1.32) in patients with diabetes and 1.45 times (95% confidence interval range, 1.40-1.49) in patients who were obese as compared with patients without these respective comorbidities. Patients with a combination of comorbidities also had a higher likelihood of postoperative complications and nonhomebound discharge. Results of our study showed that hypertension, diabetes, and obesity are independent predictors of increased postoperative complications and non-homebound discharge in patients undergoing shoulder, hip, or knee arthroplasty. Level of Evidence: Prognostic study, Level II-1 (retrospective study). See the Guidelines for Authors for a complete description of levels of evidence.

The Treatment of Symptomatic Os Acromiale

During a four-year period, fourteen individuals (fifteen shoulders) who had been seen at the shoulder service of our institution because of pain in the shoulder had a radiographic finding of an os acromiale. On clinical examination, the pain appeared to be due to an unstable os acromiale because the patients had point tenderness over the acromion and pain on forward elevation of the shoulder. The diagnosis of an os acromiale was confirmed on radiographs, magnetic resonance images, or a bone scan. Eight patients had an associated tear of the rotator cuff. The os acromiale was located in the pre-acromion in one shoulder, the meso-acromion in eleven shoulders, and the meta-acromion in three shoulders. At the operation, the anterior aspect of the acromion was found to be unstable in all shoulders. Eleven patients (twelve shoulders) had open reduction of the os acromiale and insertion of an autogenous iliac-crest bone graft. Of those patients, four (five shoulders) had open reduction and internal fixation with a tension-band procedure with use of pins and wires. Only one of those shoulders had a solid osseous union, and the other four shoulders had a non-union that was due to a disruption of the fixation. The remaining seven patients (seven shoulders) had open reduction and internal fixation with use of cannulated screws and a tension-band construct; a solid osseous union was achieved in all but one of them. One patient had excision of the pre-acromion, which relieved the pain. Two patients who had had failed open reduction and internal fixation had excision of a grossly unstable os acromiale in the meso-acromion; both patients had pain and weakness after this procedure. Of the twelve shoulders that had open reduction and bone-grafting, seven had union of the os acromiale; the average time to radiographic and clinical union was nine weeks (range, seven to twenty weeks). We concluded that, although it is rare, symptomatic unstable os acromiale does occur and can be effectively treated with use of autogenous bone-grafting and internal fixation with a rigid tension-band construct and cannulated screws.

Results of Arthroscopic Capsulolabral Repair: Bankart Lesion Versus Anterior Labroligamentous Periosteal Sleeve Avulsion Lesion

PURPOSE The purpose of this study was to evaluate the results of arthroscopic capsulolabral repair for traumatic anterior shoulder instability and to compare the outcome in patients who have Bankart lesions versus those with anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions. METHODS This study included 99 patients (93 shoulders), 72 male and 17 female, with a mean age of 32 years, who underwent arthroscopic Bankart repair for traumatic, recurrent anterior shoulder instability, by use of suture anchors. In 67 shoulders (72%) a discrete Bankart lesion was repaired, and in 26 shoulders (28%) an ALPSA lesion was repaired. The 2 groups were analyzed with regard to the number of preoperative dislocations and number of postoperative recurrences. RESULTS At a mean follow-up of 47 months (range, 24 to 98 months), recurrence of instability was documented in 10 shoulders (10.7%). Of the shoulders, 5 had Bankart lesions (7.4%) and 5 had ALPSA lesions (19.2%) (P = .0501). The mean number of dislocations or subluxations before the index surgery was significantly higher in the ALPSA group (mean, 12.3 [range, 2 to 57]) than in the Bankart group (mean, 4.9 [range, 2 to 24]) (P < .05). However, there were no significant differences in the number of anchors used, incidence of minor glenoid erosion, or incidence of bony Bankart lesions between the groups (P > .05 for all). CONCLUSIONS Patients with ALPSA lesions present with a higher number of recurrent dislocations than those with discrete Bankart lesions. In addition, the failure rate after arthroscopic capsulolabral repair is higher in the ALPSA group than in the Bankart group. LEVEL OF EVIDENCE Level IV, therapeutic case series.

MRI of Internal Impingement of the Shoulder

OBJECTIVE Internal impingement is a condition that occurs in athletes in which the shoulder is put in extreme abduction and external rotation during overhead movements. During this motion, the posterior fibers of the supraspinatus tendon, anterior fibers of the infraspinatus tendon, or both can get impinged between the humeral head and the posterior glenoid. The purpose of this study was to evaluate the ability of MRI to show the findings of internal impingement of the shoulder. CONCLUSION As opposed to our six patients with clinically and surgically diagnosed internal impingement, the control patients had isolated pathology in the rotator cuff, labrum, or humeral head. We found that the constellation of findings of undersurface tears of the supraspinatus or infraspinatus tendon and cystic changes in the posterior aspect of the humeral head associated with posterosuperior labral pathology is a consistent finding diagnostic of internal impingement.

Transfer of pectoralis major for the treatment of irreparable tears of subscapularis: DOES IT WORK?

Transfer of pectoralis major has evolved as the most favoured option for the management of the difficult problem of irreparable tears of subscapularis. We describe our experience with this technique in 30 patients divided into three groups. Group I comprised 11 patients with a failed procedure for instability of the shoulder, group II included eight with a failed shoulder replacement and group III, 11 with a massive tear of the rotator cuff. All underwent transfer of the sternal head of pectoralis major to restore the function of subscapularis. At the latest follow-up pain had improved in seven of the 11 patients in groups I and III, but in only one of eight in group II. The subjective shoulder score improved in seven patients in group I, in one in group II and in six in group III. The mean Constant score improved from 40.9 points (28 to 50) in group I, 32.9 (17 to 47) in group II and 28.7 (20 to 42) in group III pre-operatively to 60.8 (28 to 89), 41.9 (24 to 73) and 52.3 (24 to 78), respectively. Failure of the tendon transfer was highest in group II and was associated with pre-operative anterior subluxation of the humeral head. We conclude that in patients with irreparable rupture of subscapularis after shoulder replacement there is a high risk of failure of transfer of pectoralis major, particularly if there is pre-operative anterior subluxation of the humeral head.

Radial Meniscal Tears: Significance, Incidence, and MR Appearance

OBJECTIVE The purpose of this study was to assess the prevalence of radial meniscal tears at arthroscopy and the ability of MRI to detect radial tears preoperatively. In addition, the ability of four radiologic signs to detect radial tears was assessed. Those signs are the truncated triangle, cleft, marching cleft, and ghost meniscus signs. MATERIALS AND METHODS Arthroscopy of the knee was performed by a single orthopedic surgeon on 196 consecutive patients. The surgeon noted each radial tear he encountered. The MR images that were obtained at our institution were reviewed, whereas those patients who were imaged elsewhere were excluded. The preoperative MRI reports were reviewed to assess the ability to prospectively identify radial meniscal tears. In addition, a retrospective analysis of the MRI studies was performed by two radiologists in which four radiologic signs were applied to detect radial tears. RESULTS Twenty-nine patients (15%) had radial tears at arthroscopy. Eighteen of the 29 patients had their imaging performed at our institution and were selected for review. There were 19 radial tears found at surgery. Seven (37%) of the 19 tears were identified as radial prospectively. Retrospectively, using the four signs for radial tears, reviewers identified 17 (89%) of 19 radial tears. CONCLUSION A more accurate preoperative diagnosis may be rendered using the four described signs to detect radial tears, thus allowing informative preoperative counseling and consideration of new therapies that are available for radial meniscal repair.

Comparison of plain radiography, computed tomography, and magnetic resonance imaging in the evaluation of bone tunnel widening after anterior cruciate ligament reconstruction

Bone tunnel widening poses a problem for graft fixation during revision anterior cruciate ligament (ACL) reconstruction. Large variability exists in the utilization of imaging modalities for evaluating bone tunnels in pre-operative planning for revision ACL reconstruction. The purpose of this study was to identify the most reliable imaging modality for identifying bone tunnels and assessing tunnel widening, and specifically, to validate the reliability of radiographs, MRI, and CT using intra- and inter-observer testing. Data was retrospectively collected from twelve patients presenting for revision ACL surgery. Five observers twice measured femoral and tibial tunnels at their widest point using digital calipers in coronal and sagittal planes. Measurements were corrected for magnification. Tunnel identification, diameter measurements, and cross-sectional area (CSA) calculations were recorded. A categorical classification of tunnel measurements was created to apply clinical significance to the measurements. Using kappa statistics, intra- and inter-observer reliability testing was performed. CT demonstrated excellent intra- and inter-observer reliability for tunnel identification. Intra- and inter-observer reliability was significantly less for MRI and radiographs. CT revealed superior reliability versus either radiographs or MRI for CSA analysis. Intra-observer kappa scores for tibial CSA using CT, radiographs, and MRI were 0.66, 0.5, and 0.37, respectively. Inter-observer kappa scores for tibial CSA using CT, radiographs, and MRI were 0.65, 0.39, and 0.32, respectively. Our results demonstrate CT is the most reliable imaging modality for evaluation of ACL bone tunnels as proven by superior intra- and inter-observer testing results when compared to MRI and radiographs. Radiographs and MRI were not reliable, even for simply identifying the presence of a bone tunnel.

Using Time-Driven Activity-Based Costing to Identify Value Improvement Opportunities in Healthcare

EXECUTIVE SUMMARY As healthcare providers cope with pricing pressures and increased accountability for performance, they should be rededicating themselves to improving the value they deliver to their patients: better outcomes and lower costs. Time‐driven activity‐based costing offers the potential for clinicians to redesign their care processes toward that end. This costing approach, however, is new to healthcare and has not yet been systematically implemented and evaluated. This article describes early time‐driven activity‐based costing work at several leading healthcare organizations in the United States and Europe. It identifies the opportunities they found to improve value for patients and demonstrates how this costing method can serve as the foundation for new bundled payment reimbursement approaches.

Proximal Biceps Tendon: Injuries and Management

The long head of the biceps tendon is a known pain generator of the shoulder. There are numerous pathologic entities that may affect this tendon, including tendonitis, partial tearing, and subluxation. These conditions are often associated with rotator cuff tears, especially those involving the subscapularis. Operative interventions include tenotomy and tenodesis. Tenodesis can be preformed in a proximal or distal location. Subpectoral tenodesis may have a lower recurrence rate than proximal-based techniques.