Marcus P. Coe

The cost-effectiveness of reverse total shoulder arthroplasty compared with hemiarthroplasty for rotator cuff tear arthropathy

BACKGROUND Hemiarthroplasty (humeral head replacement [HHR]) and reverse shoulder arthroplasty (RSA) are surgical options for cuff tear arthropathy (CTA). RSA may provide better pain relief and functional outcomes, but it costs more and may have a higher complication rate. The goal of this study was to compare the cost-effectiveness of these two treatments and to use sensitivity analysis to determine the drivers of the model. MATERIALS AND METHODS A Markov decision model was used. Outcome and complication probabilities were obtained from existing literature. Costs were based on average Medicare reimbursement and implant prices. Utilities were derived from responses to health state surveys (Short Form 6D) from 31 patients at one institution who underwent RSA or HHR for CTA. Incremental cost-effectiveness ratios were used to compare treatments. RESULTS Our model showed RSA could be a cost-effective strategy for treatment of CTA, using

Current Concepts Review: Noninsertional Achilles Tendinopathy

100,000 per quality-adjusted life-year gained as a cutoff and the Short Form 6D for utilities. The model was extremely sensitive to the complication rate and the utility of each procedure and was also sensitive to implant price, with an implant price <

Neck ligament strength is decreased following whiplash trauma

13,000 making RSA cost-effective. CONCLUSIONS Currently available cost and outcome data show that RSA could be a cost-effective alternative to HHR for CTA. The cost-effectiveness of RSA depends most on the health utility gained from the operation, the utility lost due to complications from the operation, and the cost of the implant. Dropping the implant price to <

Minimal clinically important difference and the effect of clinical variables on the ankle osteoarthritis scale in surgically treated end-stage ankle arthritis.

7,000 increases cost-effectiveness to <

Report of ganglion cyst in the anterior cruciate ligament of a 6-year-old child

50,000 per quality-adjusted life-year gained. Further head-to-head studies evaluating the clinical and quality of life outcomes of these two treatments are warranted.

Measuring the Operative Treatment Effect in End-Stage Ankle Arthritis: Are We Asking the Right Questions? A COFAS Multicenter Study

Achilles tendinopathy is characterized by the clinical triad of pain, limitation in activities, and focal swelling associated with degenerative change in the tendon.27,45 The histologic change in the area of swelling and degeneration is best defined as Achilles tendinosis. Pathologic findings include areas of disorganized collagen and abnormal neovessels in the absence of inflammatory cells. Often, Achilles tendinopathy is improperly referred to as Achilles tendonitis. The clinical entity of Achilles tendinopathy often occurs in elite and recreational athletes but is also seen in more sedentary populations.68 Achilles tendinopathy is the most common tendinopathy associated with running and was diagnosed in 56% of one group of elite middle-aged runners.36 It can be characterized as insertional (at the calcaneus-Achilles tendon junction) or noninsertional (2 to 6 cm proximal to the insertion of the Achilles tendon into the calcaneus). Each type has its own pathophysiology and treatment strategies. This review will address noninsertional Achilles tendinopathy only. Considerable controversy surrounds the management of noninsertional Achilles tendinopathy. Rest, eccentric and concentric stretching exercise, nonsteroidal anti-inflammatory medications, noninvasive modalities, injections, and surgery have all been utilized. A 2001 Cochrane Review, however, found little evidence to support the use of any one particular therapy for this condition.53 The application of cytokines, growth factors, gene therapy, and stem cells for the future management of this disorder are under investigation. This

Native joint Propionibacterium septic arthritis

BackgroundPrevious clinical studies have documented successful neck pain relief in whiplash patients using nerve block and radiofrequency ablation of facet joint afferents, including capsular ligament nerves. No previous study has documented injuries to the neck ligaments as determined by altered dynamic mechanical properties due to whiplash. The goal of the present study was to determine the dynamic mechanical properties of whiplash-exposed human cervical spine ligaments. Additionally, the present data were compared to previously reported control data. The ligaments included the anterior and posterior longitudinal, capsular, and interspinous and supraspinous ligaments, middle-third disc, and ligamentum flavum.MethodsA total of 98 bone-ligament-bone specimens (C2–C3 to C7-T1) were prepared from six cervical spines following 3.5, 5, 6.5, and 8 g rear impacts and pre- and post-impact flexibility testing. The specimens were elongated to failure at a peak rate of 725 (SD 95) mm/s. Failure force, elongation, and energy absorbed, as well as stiffness were determined. The mechanical properties were statistically compared among ligaments, and to the control data (significance level: P < 0.05; trend: P < 0.1). The average physiological ligament elongation was determined using a mathematical model.ResultsFor all whiplash-exposed ligaments, the average failure elongation exceeded the average physiological elongation. The highest average failure force of 204.6 N was observed in the ligamentum flavum, significantly greater than in middle-third disc and interspinous and supraspinous ligaments. The highest average failure elongation of 4.9 mm was observed in the interspinous and supraspinous ligaments, significantly greater than in the anterior longitudinal ligament, middle-third disc, and ligamentum flavum. The average energy absorbed ranged from 0.04 J by the middle-third disc to 0.44 J by the capsular ligament. The ligamentum flavum was the stiffest ligament, while the interspinous and supraspinous ligaments were most flexible. The whiplash-exposed ligaments had significantly lower (P = 0.036) failure force, 149.4 vs. 186.0 N, and a trend (P = 0.078) towards less energy absorption capacity, 308.6 vs. 397.0 J, as compared to the control data.ConclusionThe present decreases in neck ligament strength due to whiplash provide support for the ligament-injury hypothesis of whiplash syndrome.

Stress Fractures of the Calcaneus, Sesamoids, and Metatarsals

BACKGROUND There is much debate regarding the best outcome tool for use in foot and ankle surgery, specifically in patients with ankle arthritis. The Ankle Osteoarthritis Scale (AOS) is a validated, disease-specific score. The goals of this study were to investigate the clinical performance of the AOS and to determine a minimal clinically important difference (MCID) for it, using a large cohort of 238 patients undergoing surgery for end-stage ankle arthritis. METHODS Patients treated with total ankle arthroplasty or ankle arthrodesis were prospectively followed for a minimum of two years at a single site. Data on demographics, comorbidities, AOS score, Short Form-36 results, and the relationship between expectations and satisfaction were collected at baseline (preoperatively), at six and twelve months, and then yearly thereafter. A linear regression analysis examined the variables affecting the change in AOS scores between baseline and the two-year follow-up. An MCID in the AOS change score was then determined by employing an anchor question, which asked patients to rate their relief from symptoms after surgery. RESULTS Surgical treatment of end-stage ankle arthritis resulted in a mean improvement (and standard deviation) of 31.2 ± 22.7 points in the AOS score two years after surgery. The MCID of the AOS change score was a mean of 28.0 ± 17.9 points. The change in AOS score was significantly affected by the preoperative AOS score, smoking, back pain, and age. CONCLUSIONS Patients undergoing arthroplasty or arthrodesis for end-stage ankle arthritis experienced a mean improvement in AOS score that was greater than the estimated MCID (31.2 versus 28.0 points).

Bandverletzungen als Folge einer Distorsion der Halswirbelsäule

BACKGROUND Intra-articular ganglion cysts of the knee are extremely rare within the pediatric population. To our knowledge, only seven case reports have been published in the medical literature identifying pediatric patients with intra-articular cysts of the anterior cruciate ligament (ACL). Intra-articular cysts of the knee are a rare cause of knee discomfort and mechanical symptoms such as locking of the knee. To our knowledge, up until now the youngest patient reported in the medical literature with an intra-articular ganglion cyst of the ACL was a 7-year-old boy. CASE REPORT We describe a 6-year-old boy who presented with a unilateral intra-articular ganglion cyst of the ACL in the right knee. In addition to the diagnostic work-up of radiographs and MRI, the cyst was successfully treated with arthroscopic resection and debridement to decompress the cyst. CLINICAL RELEVANCE We provide a review of the proposed pathogenesis, diagnostic modalities, differential diagnosis, treatment options, and complications of treatment for intra-articular cysts of the ACL. LEVEL OF EVIDENCE Level V, case report.

Dynamic mechanical properties of intact human cervical spine ligaments

Background: Foot and ankle surgeons are increasingly relying on patient-reported outcome measures (PROMs) such as the Ankle Osteoarthritis Scale (AOS) to evaluate treatment options. The objectives of this retrospective cohort study were 2-fold: (1) to examine the AOS instrument using psychometric analysis and (2) to revise the questions on the AOS to improve the effect of questions on the score and remove redundancies. Methods: Pre- and postoperative patient scores were obtained from AOS questionnaires in the COFAS Prospective Ankle Reconstruction Database, a cohort of patients operatively treated for end-stage ankle arthritis. A split-sample approach was used to evaluate the AOS and to propose a revised instrument. Results: A total of 380 patients who had been treated with total ankle replacement or ankle arthrodesis were prospectively followed to the 2-year postoperative time point. Correlation analysis demonstrated that a number of questions on the AOS were highly correlated with other similar questions, frequently incomplete, or showed little variation between respondents. Eight of the original AOS questions were retained in the newly proposed Ankle Arthritis Score (AAS) [3 from the AOS Pain subscale and 5 from the AOS Disability subscale]. Principal components analysis (PCA) showed that these questions equally clustered into 2 domains in AAS: Basic Activity and Advanced Activity. Conclusions: The AAS is shorter and has improved psychometric properties as compared to the AOS. Further investigation is required to better characterize the clinical utility of this proposed new patient-reported outcome score. Level of Evidence: Level III, retrospective cohort study.