Temporal Analysis of Medicare Physician Reimbursement and Procedural Volume for all Hip and Knee Arthroplasty Procedures Billed to Medicare Part B From 2000 to 2019

BACKGROUND

The purpose of this study was to evaluate trends in annual arthroplasty volume among the Medicare population, as well as assess true Medicare reimbursement to physicians for all hip and knee arthroplasty procedures billed to Medicare since year 2000.

METHODS

The publicly available Medicare Part B National Summary Data File from years 2000 to 2019 was utilized. Collected data included true physician reimbursements for all primary total hip and knee, unicompartmental knee, and revision hip/knee arthroplasty procedures from 2000 to 2019. Monetary data was adjusted for inflation to year 2019 dollars. Change was assessed and compared by procedure type.

RESULTS

From 2000 to 2019, physicians billed Medicare Fee-for-service for 8,363,821 hip and knee arthroplasty procedures. During this time, the annual number of included arthroplasty procedures billed to Medicare increased by 100%. From 2000 to 2019 across all included procedures, the mean physician reimbursement after adjusting for inflation decreased by -$729.82 (-38.9%) per procedure. This varied by procedure type. Unicompartmental knee arthroplasty was the only procedure to experience an increased mean reimbursement when adjusting for inflation, increasing by $241.40 (+16.6%) per procedure from 2000 to 2019.

CONCLUSION

This study demonstrates decreasing Medicare reimbursement to physicians within hip and knee arthroplasty from 2000 to 2019 when adjusting for inflation. This study is important for informing the potential development of more equitable payment models and maintaining access for arthroplasty care moving forward.

Does Laterality Matter? The Effect of Unilateral v. Bilateral Sacroiliac Screw Fixation on Personal Hygiene

STUDY DESIGN

Retrospective comparative analysis of prospective cohort.

OBJECTIVE

To determine whether sacroiliac (SI) screw fixation ipsilateral to hand dominance compared to bilateral fixation impacts personal hygiene (wiping) after toileting.

METHODS

Inclusion criteria were adult spinal deformity (ASD) patients with long arthrodesis (≥T12-pelvis) who had undergone primary unilateral or bilateral SI fixation with a minimum of 2-years-follow-up.

RESULTS

117 consecutive patients were included and separated into 2 groups: bilateral SI fixation (BL, n = 61) and unilateral SI fixation (UNI, n = 56), with no difference in age. Of UNI patients, 10.7% (6) performed personal hygiene with a different hand after surgery, compared to 6.6% (4) of patients who received BL fixation (P = 0.422). All UNI patients who switched hands were right-hand dominant, and 5/6 received right-sided fixation. There was no statistical difference found between number of levels fused (<8, 9-11, or >11 levels) and changes in personal hygiene habits. Over a third of patients from both groups had difficulty performing personal hygiene after fusion (UNI = 39.3% BL = 36.1%, P = 0.719).

CONCLUSION

SI screws increase the difficulty of performing personal hygiene; yet, the side of unilateral screws does not significantly change personal hygiene habits when compared to bilateral screw placement. Moreover, the length of the construct does not have a significant impact on ability to perform personal hygiene, cause changes in habits, or require the assistance of another individual. However, among our sample of individuals, bilateral fixation did result in a higher rate of revision instrumentation.

Treatment of the Wave Sign With Femoral Osteoplasty With and Without Chondrolabral Stabilization Using Suture Anchors

PURPOSE

To discuss the surgical outcomes of patients identified to have the wave sign without an accompanying labral tear treated with and without stabilization of the chondrolabral junction in conjunction with femoral osteoplasty.

METHODS

A retrospective study was performed in patients with cartilage delamination (wave sign) treated with femoral osteoplasty alone (FO group) or femoral osteoplasty with chondrolabral stabilization (CLS group). Patient-reported outcomes including the modified Harris Hip Score, Hip Outcome Score (HOS)-Activities of Daily Living, and HOS-Sports-Specific Subscale were obtained at a minimum of 2 years postoperatively. Other outcomes included rates of revision hip arthroscopy and conversion to hip arthroplasty.

RESULTS

The study consisted of 47 patients in the FO group and 38 in the CLS group. Both groups showed significant increases in all patient-reported outcomes over the study period compared with preoperative values. The final modified Harris Hip Score was 72.8 ± 9.2 in the FO group and 79.9 ± 9.3 in the CLS group (P < .001). The HOS-Activities of Daily Living in the FO and CLS groups was 81.4 ± 10.3 and 87.2 ± 7.5, respectively (P < .001). There was no difference in the HOS-Sports-Specific Subscale between the FO group (74.4 ± 10.3) and the CLS group (78.0 ± 14.6) at final follow-up (P = .198). Revision hip arthroscopy was required in 5 patients in the FO group (13%) and 3 in the CLS group (6.3%). No patient in either group required conversion to hip arthroplasty throughout the study period.

CONCLUSIONS

Chondrolabral stabilization in conjunction with femoral osteoplasty is an effective treatment in patients with the wave sign without labral tears.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Increasing severity of anemia is associated with poorer 30-day outcomes for total shoulder arthroplasty

Background

Total shoulder arthroplasty (TSA) has increased in utilization over the past several decades. Anemia is a common preoperative condition among patients undergoing TSA and has been associated with poorer outcomes in other surgical procedures. To the best of our knowledge, no study has analyzed the association between anemia severity and TSA outcomes. Therefore, the purpose of this study is to determine the effects that increasing severity of anemia may have on the postoperative outcomes in patients receiving primary TSA.

Methods

A retrospective analysis was performed using the American College of Surgeons National Surgery Quality Improvement Project database from the years 2015 to 2018. Current Procedure Terminology code 23472 was used to identify all primary TSA procedures recorded during this time frame. Patients with greater than 38% preoperative hematocrit (HCT) were classified as having normal HCT levels. Patients with HCT values between 33% and 38% were classified as having mild anemia. All patients with less than 33% HCT were classified as having moderate/severe anemia. Patient demographic information, preoperative risk factors, and postoperative outcomes were compared among the 3 cohorts. A multivariate logistic regression including demographic factors and comorbidities was performed to determine whether increasing severity of anemia is independently associated with poorer postoperative outcomes.

Results

Of the 15,185 patients included in this study, 11,404 had normal HCT levels, 2962 patients were mildly anemic, and 819 patients had moderate to severe anemia. With increasing severity of anemia, there was an increased average hospital length of stay (1.6 vs. 2.1 vs. 3.0 days, P < .001), rate of readmissions (2.3% vs. 4.8% vs. 7.0%, P < .001), and rate of all reoperations (1.1% vs. 1.8% vs. 3.1%, P < .001). There was a statistically significant increase in both minor (1.9% vs. 2.7% vs. 4.4%, P < .001) and major (1.2% vs. 2.4% vs. 4.3%, P < .001) postoperative complication rates as well. Multivariate analysis identified anemia as an independent predictor of readmissions, reoperations, minor complications, and major complications.

Conclusion

We found increasing severity of anemia to be associated with progressively worse 30-day postoperative outcomes. This is consistent with the outcomes found for increasing severity of anemia in patients receiving other total joint procedures. Using preoperative HCT levels may be a useful tool for predicting the risk of postoperative complications in patients undergoing TSA. This information could be used to further optimize patient selection for primary TSA.

Dual-Posteromedial Portal Technique for Complex Arthroscopy in the Posterior Knee

Arthroscopy in the posterior knee continues to improve as new techniques arise. Traditionally, posterior techniques included posteromedial and posterolateral portals. Although frequently used, these techniques do have some limitations. We propose the use of dual posteromedial portals for complex arthroscopy cases to improve access and instrumentation in the posterior knee. Applications include, but are not limited to, resection of tumors or masses in the posterior knee, meniscal posterior horn repair, ramp lesion repair, repair of posterior cruciate ligament avulsions, and use as accessory portals for arthroscopic posterior cruciate ligament reconstruction. We describe a technique for establishing dual posteromedial portals for complex arthroscopy in the posterior knee, specifically in relation to a case of a posterior knee mass biopsy and resection.

Ninety-Day Readmission in Elective Revision Lumbar Fusion Surgery in the Inpatient Setting

STUDY DESIGN

Retrospective review.

OBJECTIVES

(1) Identify the 90-day rate of readmission following revision lumbar fusion, (2) identify independent risk factors associated with increased rates of readmission within 90 days, (3) and identify the hospital costs associated with revision lumbar fusion and subsequent readmission within 90 days.

METHODS

Utilizing 2014 data from the Nationwide Readmissions Database, patients undergoing elective revision lumbar fusion were identified. With this sample, multivariate logistic regression was utilized to identify independent predictors of readmission within 90 days. An analysis of total hospital costs was also conducted.

RESULTS

In 2014, an estimated 14 378 patients underwent elective revision lumbar fusion. The readmission rate at 90 days was 3.1% (n = 446). Diabetes with chronic complications was the only comorbidity found to carry significantly increased odds of readmission. Surgical complications such as deep venous thrombosis, surgical wound disruption, hematoma, and pneumonia (experienced during the index admission) were also independent predictors of readmission. Anterior approaches were associated with increased odds of readmission. The most common related diagnoses on readmission were hardware issues, postoperative infection, and disc herniation. Readmissions were associated with an average of $96 152 in increased hospital costs per patient compared with those not readmitted.

CONCLUSION

Relevant patient comorbidities and surgical complications were associated with increased readmission within 90 days. Readmission within 90 days was associated with significant increases in hospital costs.

Hand and Wrist Injuries in Men's and Women's National Collegiate Athletic Association Basketball

Background:

Hand and wrist injuries (HWIs) are common in National Collegiate Athletic Association (NCAA) basketball players and can negatively affect performance. There is limited literature available on this topic.

Purpose:

To open a discussion on prevention strategies and encourage future research on HWIs in basketball athletes.

Study Design:

Descriptive epidemiology study.

Methods:

HWIs sustained by male and female NCAA basketball players during the 2009-2010 through 2013-2014 academic years and reported to the NCAA Injury Surveillance Program (NCAA-ISP) database were utilized to characterize the epidemiology thereof. Rates and distributions of HWIs were identified within the context of mechanism of injury, injury recurrence, and time lost from sport.

Results:

Over the 5-year period, 81 HWIs in women and 171 HWIs in men were identified through the NCAA-ISP database. These were used to estimate 3515 HWIs nationally in women’s basketball athletes and 7574 HWIs nationally in men’s basketball athletes. The rate of HWIs in women was 4.20 per 10,000 athlete-exposures (AEs) and in men was 7.76 per 10,000 AEs, making men 1.85 times more likely to sustain HWIs compared with women. In men, HWIs were 3.31 times more likely to occur in competition compared with practice, while in women, HWIs were 2.40 times more likely to occur in competition than in practice. Based on position, guards, both men and women, were the most likely to suffer HWIs.

Conclusion:

HWIs were common in collegiate basketball players. Most injuries were new, and the majority of players were restricted from participation for less than 24 hours. Men were more likely to be injured compared with women, and injuries were most common in the setting of competition for both sexes. The majority of injuries was considered minor and did not extensively limit participation; however, prevention and detection remain important for optimal performance.

Hip Arthroscopy in the High-Level Athlete: Does Capsular Closure Make a Difference?

BACKGROUND

Hip arthroscopy has been shown to be effective in athletes who have femoral acetabular impingement and labral tearing. The effect of complete capsular closure versus nonclosure on return to play is unknown.

HYPOTHESIS

Complete capsular closure after hip arthroscopy would lead to a higher rate and faster return to sports in high-level athletes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A nonrandomized retrospective review was performed of high school, collegiate, and professional athletes undergoing hip arthroscopy by a single high-volume hip arthroscopic surgeon. Athletes were divided into those undergoing complete capsular closure (CC group) and non-capsular closure (NC group) after hip arthroscopy. Rate and time to return to play were determined between the 2 groups. Patient-reported outcomes including modified Harris Hip Score (mHHS), Hip Outcome Score Activities of Daily Living (HOS-ADL), and Hip Outcome Score Sport-Specific Subscale (HOS-SSS) were obtained at a minimum of 2 years.

RESULTS

A total of 111 athletes with a minimum 2-year follow-up were included in the study. There were 62 in the CC group and 49 in the NC group. A higher percentage of athletes in the CC group returned to play compared with that in the NC group (90.3% vs 75.5%, respectively; P = .03). The CC group returned to play at a mean ± SD of 4.7 ± 1.9 months compared with 5.8 ± 2.6 months in the NC group (P < .001). Patients in the CC group met the minimal clinically important difference for the mHHS, HOS-ADL, and HOS-SSS patient-reported outcomes at higher percentages: mHHS, 98.3% vs 87.7% for CC vs NC, respectively (P = .02); HOS-ADL, 98.3% vs 87.7% (P = .02); and HOS-SSS, 96.7% vs 89.7% (P = .13). The difference between groups was statistically significant for mHHS and HOS-ADL.

CONCLUSION

Complete capsular closure after hip arthroscopy was associated with faster return to play and a higher rate of return compared with that of nonclosure of the capsule in this sample population of high-level athletes. At a minimum 2-year follow-up, complete capsular closure was associated with significantly higher patient-reported outcomes compared with those of nonclosure in athletes who underwent hip arthroscopy.

Is Labral Size Predictive of Failure With Repair in Hip Arthroscopy?

PURPOSE

To assess whether labral size is predictive of labral repair failure or shows an association with patient outcomes after hip arthroscopy.

METHODS

We performed a retrospective chart review of patients who underwent arthroscopic hip labral repair. Labral size was measured in 4 quadrants with an arthroscopic probe. The average size across torn labral segments was assessed for failure as determined by the change in patient-reported outcomes, the rate at which subjects achieved the minimal clinically important difference and patient acceptable symptomatic state, and the need for additional surgery. Outcomes were evaluated for any continuous correlation as well as significant differences between the middle 50% of labral sizes and classes of labral sizes derived from upper and lower quartile and decile ranges. Included hips were those from patients aged between 18 and 55 years with 2-year postoperative follow-up and lateral center-edge angles between 25° and 40°.

RESULTS

The study included 571 hips. Labral width did not show a significant difference between hips requiring revision and those not requiring revision (P = .4054). No significant correlation was found between labral width and the change in the International Hip Outcome Tool 12 score (R² = 0.05780), modified Harris Hip Score (R² = 0.19826), or Nonarthritic Hip Score (R² = 0.23543) from preoperatively to 2 years postoperatively. Hips with labral sizes in the upper decile of our cohort showed significantly decreased improvement in the International Hip Outcome Tool 12 score (P = .0287) and Nonarthritic Hip Score (P = .0490) compared with the middle 50% of labral sizes. No statistically significant difference was found in the rate at which the groups achieved the minimal clinically important difference or patient acceptable symptomatic state.

CONCLUSIONS

Hypertrophic labra in the largest 10th percentile showed lower postoperative outcome scores. However, no detectable clinical benefit was found in terms of patient-perceived clinical difference or acceptable symptomatic state. For most patients, labral size does not appear to significantly alter patient outcomes or the need for arthroplasty.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Frequency, Cost, and Clinical Significance of Incidental Findings on Preoperative Planning Images for Computer-Assisted Total Joint Arthroplasty

BACKGROUND

The frequency of incidental findings with computer-assisted total joint arthroplasty (CA TJA) preoperative imaging and their clinical significance are currently unknown.

METHODS

We reviewed 573 patients who underwent primary CA TJA requiring planning imaging. Incidental findings were defined as reported findings excluding those related to the planned arthroplasty. Secondary outcomes were additional tests or a delay in surgery. Associated charges were obtained from our institution's website. Charge and incidence data were combined with TJA volumes obtained from the 2016 National Inpatient Sample to model costs to the healthcare system.

RESULTS

Overall, 262 patients (45.7%) had at least 1 incidental finding, 144 patients (25.1%) had 2, and 65 (11.3%) had 3. The most common finding types were musculoskeletal (MSK, 67.7%), digestive (19.5%), cardiovascular (4.9%), and reproductive (4.7%). Also, 9.3% of patients had at least 1 non-MSK incidental finding. Both MSK and non-MSK incidental findings were more common with total hip arthroplasty compared to total knee arthroplasty (67.9% vs 42.2%, P < .0001, and 15.4% vs 8.3%, P < .05, respectively). Further testing was required in 6 cases (1.0%); 1 case required delay in surgery (0.2%). Using the 2016 volume of TJA procedures and assuming a 10%, 15%, and 25%, utilization rate of image-based CA TJA, the annual cost of additional testing was $2.7 million (95% confidence interval, $1.1-$6.3 million), $4.1 million ($1.6-$9.5 million), and $6.9 million (95% confidence interval, $2.7-$15.8 million), respectively.

CONCLUSION

Incidental findings are relatively common on planning images. Stakeholders should be aware of the hidden costs of incidental findings given the increasing popularity of image-based CA TJA.

Minimally Invasive Robotic-Assisted Patellofemoral Arthroplasty

Isolated patellofemoral arthritis is a common debilitating condition in adults older than 40 years of age. Surgical options such as patellofemoral arthroplasty exist for those who failed to respond to nonoperative treatment. However, early patellofemoral arthroplasty techniques often resulted in poor outcomes due to mal-tracking and malalignment of components. Robotic-assisted surgery recently has been introduced as an alternative to classic patellofemoral arthroplasty, with the potential to improve the anatomical fit and reproducibility of implant positioning. We present the technique for minimally invasive robotic-assisted patellofemoral arthroplasty system.

Bilateral Hip Arthroscopy in High-Level Athletes: Results of a Shorter Interval Between Staged Bilateral Hip Arthroscopies

BACKGROUND

Hip arthroscopy is a safe and effective mechanism for treating femoroacetabular impingement symptoms in high level athletes. Bilateral symptoms occur in a subset of this population.

PURPOSE

To discuss outcomes of bilateral hip arthroscopy in high-level athletes and compare a standard staged timeline for bilateral hip arthroscopic surgery versus an accelerated timeline.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective review of all staged bilateral hip arthroscopies was performed on high-level athletes over a 3-year period. Patients were categorized into cohorts based upon when the second procedure was performed (4-6 weeks after the index procedure or >6 weeks after the index procedure). Exclusion criteria included any prior hip surgery, advanced arthritis, previous pelvic or femoral fracture, or inflammatory arthropathy. Demographics, radiographic measurements, operative reports of procedures performed, and patient-reported outcomes (Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sport Specific Subscale, modified Harris Hip Score, return to sports, return to same level of play) were compared between groups at 6-month, 1-year, and 2-year intervals, with the Student t test used for continuous data and a chi-square test used for categorical data.

RESULTS

50 patients were identified: 22 in the accelerated surgery (AS) group and 28 in the standard surgery (SS) group. Age and number of collegiate participants were greater in the AS group, whereas the number of high school participants and the time away from sports were higher in the SS group. Preoperative alpha angles were significantly larger among the AS group, but no differences were found in postoperative alpha angles, center edge angles, or Tönnis grades. No significant difference was seen in patient-reported outcomes between the 2 groups at 6-month, 1-year, and 2-year follow-up.

CONCLUSION

Bilateral hip arthroscopy performed 4 to 6 weeks apart is a safe and effective treatment option for athletes with bilateral femoroacetabular impingement and labral tears; the procedures entail a high rate of return to sports, return to the same level of sports, and decreased time lost from sports. This information could be useful for an athlete deciding on whether to proceed with bilateral hip arthroscopy and deciding on the timing for the procedures.

Hip and Groin Injuries in National Collegiate Athletic Association Women's Soccer Players

Background:

Hip and groin injuries are common in competitive soccer players and have been shown to be significant sources of time loss. There are few studies describing the epidemiology of hip and groin injuries in female National Collegiate Athletic Association (NCAA) soccer players.

Purpose:

To describe the epidemiology of hip and groin injuries in women’s collegiate soccer players.

Study Design:

Descriptive epidemiology study.

Methods:

The NCAA Injury Surveillance System/Program (ISS/ISP) was analyzed from 2004 through 2014 for data related to hip and groin injuries in female collegiate soccer players. Injuries and athlete-exposures (AEs) were reported by athletic trainers. Data were stratified by time of season, event type, injury type, treatment outcome, time loss, and player field position.

Results:

Between 2004 and 2014, there were 439 recorded hip or groin injuries in female soccer players and an overall rate of injury of 0.57 per 1000 AEs. Injuries were 12.0 times more likely to occur during the preseason (4.41/1000 AEs) as opposed to during the regular season (0.37/1000 AEs) (injury rate ratio [IRR], 12.01; 95% confidence interval [CI], 9.92-14.55) or postseason (0.38/1000 AEs) (IRR, 11.55; 95% CI, 7.06-18.91). Rates of injury were similar during the regular season and postseason (IRR, 0.96; 95% CI, 0.59-1.58). Rates of injury were higher during competition (0.69/1000 AEs) than during practice (0.52/1000 AEs) (IRR, 1.33; 95% CI, 1.08-1.63). Most injuries were new (87.5%; n = 384) and unlikely to recur (12.5%; n = 55).

Conclusion:

Hip and groin injuries in female NCAA soccer players are uncommon, and fortunately, most players return to play quickly without recurrence. Future prospective studies should evaluate the effectiveness of strength and conditioning programs in preventing these injuries.

Superior capsule reconstruction for irreparable rotator cuff tears: a systematic review of biomechanical and clinical outcomes by graft type

BACKGROUND

Superior capsular reconstruction (SCR) has recently been proposed as a surgical solution to the irreparable rotator cuff tear and has gained popularity because of promising early results. Therefore, the purpose of this study is to review the biomechanical and clinical outcomes in shoulders with this condition treated with SCR.

METHODS

A systematic review was conducted following PRISMA guidelines using PubMed, EMBASE, and Cochrane databases. Studies were included if they reported biomechanical, radiographic, or clinical outcomes data after undergoing SCR in shoulders with irreparable rotator cuff tears. Studies were broken down into 3 categories: cadaveric biomechanical studies, autograft clinical outcome studies, and allograft clinical outcome studies. Biomechanical, radiographic, patient-reported, and functional outcomes data were recorded for each study.

RESULTS

Eight cadaveric biomechanical studies, 5 autograft clinical studies, and 4 allograft clinical studies met inclusion criteria. In biomechanical studies, subacromial contact pressure and superior humeral translation were decreased in most tested scenarios. An increase in American Shoulder and Elbow Surgeons (ASES) scores, forward elevation and external rotation values, and acromiohumeral distance (AHD) were found in all autograft clinical studies reporting. Allograft clinical studies reported increases in ASES scores, forward elevation values, and AHD but decreases in visual analog scale scores in all studies reporting.

CONCLUSIONS

SCR is emerging as a viable surgical option to address the irreparable rotator cuff tear. Biomechanical studies suggest that the humeral head-stabilizing effect of SCR appears to translate into improved clinical outcomes. Future research should focus on further defining the indications, limitations, and optimal technique.

Risk factors for delay in surgery for patients undergoing elective anterior cervical discectomy and fusion

BACKGROUND

Anterior cervical discectomy and fusion (ACDF) is well-tolerated by most patients and commonly necessitates only a short hospital admission. Surgical delay after hospital admission, however, may result in longer hospital stays, consequently increasing hospital resource utilization. The current study evaluates risk factors for surgical delay in patients undergoing elective ACDF.

METHODS

A retrospective analysis of ACS-NSQIP data from 2006-2015 was performed. Patients undergoing elective ACDF were selected using current procedural terminology (CPT) codes (22251, 22252, 22554). A surgical delay was defined as surgery that occurred one day or later after initial hospital admission. Differences in outcomes between the non-delayed and delayed cohorts were evaluated with univariate analysis. Multivariate logistic regression was performed to identify risk factors for surgical delay.

RESULTS

There were a total of 771 (2.0%) surgical delays out of 39,371 patients undergoing elective ACDF from 2006-2015. Multivariate analysis found partially dependent functional status (OR 5.88; 95% CI: 4.48-7.71; P<0.001), totally dependent functional status (OR 18.22; 95% CI: 9.60-34.59; P<0.001), ASA class 4 (OR 2.73; 95% CI: 1.70-4.38; P<0.001), bleeding disorders (OR 1.75; 95% CI: 1.08-2.85; P=0.024), male sex (OR 1.19; 95% CI: 1.03-1.38; P=0.019), and chronic steroid use (OR 1.76; 95% CI: 1.30-2.37; P<0.001) as independent predictors of delay. Univariate analysis found surgical delay was associated with a higher rate of post-operative major adverse events (4.8% vs. 1.1%; P<0.001), mortality (1.0% vs. 0.2%; P<0.001) and greater than five-fold increase in total length of stay (9.52 vs. 1.65 days; P<0.001).

CONCLUSIONS

Impaired pre-operative functional status, a higher comorbidity burden, and chronic steroid use are risk factors for surgical delay, increased complications, and length of stay in patients undergoing elective ACDF. This is helpful information to consider given a rising incidence of cervical fusions in the Medicare population, a wide variation in costs, and increasing popularity of bundled-payment models.

LEVEL OF EVIDENCE

3.

Epidemiology of Lumbar Spine Injuries in Men's and Women's National Collegiate Athletic Association Basketball Athletes

Background:

Lumbar spine injuries (LSIs) are common in both men’s and women’s National Collegiate Athletic Association (NCAA) basketball players and can frequently lead to reinjuries and persistent pain.

Purpose:

To describe the epidemiology of an LSI in collegiate men’s and women’s basketball during the 2009-2010 through 2013-2014 academic years.

Study Design:

Descriptive epidemiology study.

Methods:

The incidence and characteristics of LSIs were identified utilizing the NCAA Injury Surveillance Program (ISP). Rates of injury were calculated as the number of injuries divided by the total number of athlete-exposures (AEs). AEs were defined as any student participation in 1 NCAA-sanctioned practice or competition. Incidence rate ratios (IRRs) were then calculated to compare the rates of injury between season, event type, mechanism, injury recurrence, and time lost from sport.

Results:

The NCAA ISP reported 124 LSIs from an average of 28 and 29 men’s and women’s teams, respectively. These were used via validated weighting methodology to estimate a total of 5197 LSIs nationally. The rate of LSIs in women was 2.16 per 10,000 AEs, while men suffered LSIs at a rate of 3.47 per 10,000 AEs. Men were 1.61 times more likely to suffer an LSI compared with women. In men, an LSI was 3.48 times more likely to occur in competition when compared with practice, while in women, an LSI was 1.36 times more likely to occur in competition than in practice. Women suffered the highest LSI rate during the postseason, while the highest rate in men was during the regular season. The majority of both female (58.9%; n = 1004) and male (73.1%; n = 2353) athletes returned to play within 24 hours of injury.

Conclusion:

To date, this is the largest study to characterize LSIs in NCAA basketball and provides needed information on the prevalence and timing of these injuries. The majority of injuries in both sexes were new, and most athletes returned to play in less than 24 hours. Injury rates were highest during competition in both sexes.

Analysis of 90-Day Readmissions After Total Shoulder Arthroplasty

Background

The number of total shoulder arthroplasty (TSA) procedures performed annually is increasing as a result of an aging population and an increased access to subspecialty-trained upper extremity arthroplasty surgeons. An up-to-date analysis of the incidence of, risk factors for, and reasons for 90-day readmissions in primary anatomic TSA has yet to be performed.

Purpose

To characterize 90-day readmissions on a national level. An understanding of these data will help to predict resource utilization and expenses in shoulder arthroplasty.

Study Design

Case-control study; Level of evidence, 3.

Methods

All adult patients undergoing elective primary TSA in 2014 who were included in the National Readmission Database were included in the analysis. Two cohorts were created according to 90-day readmission status. Multivariable analysis was then performed to determine predictors of 90-day readmissions. Reasons for 30-, 60-, and 90-day readmissions were identified, and total hospital resource utilization was calculated.

Results

An estimated 26,023 patients were identified. The 30-, 60-, and 90-day rates of readmissions were 0.6%, 1.2%, and 1.7%, respectively. There was no difference in comorbidity burden between the cohorts. Medicare payer status (odds ratio [OR], 1.63; 95% CI, 1.00-2.65; P = .05), transfer to a skilled nurse facility (OR, 1.50; 95% CI, 1.05-2.14; P = .02), and chronic obstructive pulmonary disease (OR, 1.32; 95% CI, 1.04-1.66; P = .02) were identified as predictors of 90-day readmission. Female sex decreased odds of 90-day readmission (OR, 0.72; 95% CI, 0.59-0.87; P = .001). Ninety-day readmissions were associated with significant cost increases (P < .001). The most common identifiable reason for related readmissions was a hardware-related complication at all time points.

Conclusion

While uncommon, 90-day readmissions after primary TSA are associated with significant patient morbidity and ultimately substantial hospital costs. Truncating readmission analysis at a 30-day period will miss most arthroplasty-related hospital readmissions.

Elbow Injuries in National Collegiate Athletic Association Football Players: An Epidemiological Study Spanning 5 Academic Years

Background

National Collegiate Athletic Association (NCAA) football players are at a high risk of injuries. Elbow injuries are uncommon, but there are insufficient data specifically on elbow injuries sustained in NCAA football players.

Purpose

To define the epidemiology of elbow injuries in NCAA football players during the 2009-2010 to 2013-2014 seasons using data from the NCAA Injury Surveillance Program (NCAA-ISP).

Study Design

Descriptive epidemiology study.

Methods

Using the NCAA-ISP database, a convenience sample of NCAA football athletes was reviewed to determine the types, rates, and trends in elbow injuries. Several factors were examined, including the diagnosis, injury setting, time lost from sport, surgical necessity, and injury recurrence. Raw injury data were obtained as well as weighted totals from the NCAA-ISP to generate national estimates and adjust for underreporting. Injury rates were calculated by dividing the number of injuries by the total number of athlete-exposures (AEs). The rate ratios of injuries during competition versus practice were compared, as were the rate ratios of preseason, regular-season, and postseason injuries by type.

Results

We identified 4874 total elbow injuries from the 2009-2010 to 2013-2014 seasons. The rate of injuries overall was 1.892 per 10,000 AEs. The rate for competition was 9.053 per 10,000 AEs and 1.121 per 10,000 AEs for practice. The rate ratio between competition and practice was 8.08 (95% CI, 6.04-10.80). Injury rates for the preseason, regular season, and postseason were 1.851, 1.936, and 1.406 per 10,000 AEs, respectively. Acute elbow instability was the most common injury type (65.43%). The most common mechanism was a contact injury (86.77%); 96.82% of injuries did not require surgery, and most elbow injuries required less than 24 hours of participation restriction (67.33%).

Conclusion

Although elbow injuries in NCAA football players are uncommon, it is important to recognize and treat these injuries appropriately. Dislocations and ulnar collateral ligament injuries caused athletes to miss extended periods of play. Fortunately, a majority of injuries resulted in less than 24 hours of participation restriction. Particular attention should be given to preventing elbow injuries, especially ulnar collateral ligament strains, hyperextension injuries, and acute instability.

Elbow Injuries in National Collegiate Athletic Association Athletes: A 5-Season Epidemiological Study

Background:

Little research has focused on the rates and patterns of elbow injuries in National Collegiate Athletic Association (NCAA) student-athletes.

Purpose:

To describe the epidemiological patterns of elbow injuries in NCAA athletes during 5 seasons over the academic years 2009 through 2014 using the NCAA Injury Surveillance Program (NCAA-ISP) database.

Study Design:

Descriptive epidemiology study.

Methods:

A voluntary convenience sample of NCAA varsity teams from 11 sports was examined to determine the rates and patterns of elbow injuries. Rates and distributions of elbow injuries were identified within the context of sport, event type, time in season, mechanism, time lost from sport, surgical treatment, and injury type. Rates of injury were calculated as the number of injuries divided by the total number of athlete-exposures (AEs). An AE was defined as any student participation in 1 NCAA-sanctioned practice or competition with an inherent risk of exposure to potential injury. Injury rate ratios (IRRs) and injury proportion ratios (IPRs) were then calculated to compare the rates within and between sports by event type, season, sex, mechanism, surgical treatment, and time lost from sport. Comparisons between sexes were made using only sports data that had both male and female samples.

Results:

Overall, 373 elbow injuries were reported in the NCAA-ISP data set during the 2009-2010 through 2013-2014 academic years among 11 varsity sports. The overall rate of injury was 1.76 per 10,000 AEs. The rate of elbow injuries in men was 0.74 per 10,000 AEs, while women experienced injuries at a rate of 0.63 per 10,000 AEs. In sex-comparable sports, men were 1.17 times more likely to experience an elbow injury compared with women. Men’s wrestling (6.00/10,000 AEs) and women’s tennis (1.86/10,000 AEs) were the sports with the highest rates of elbow injuries by sex, respectively. The top 3 highest injury rates overall occurred in men’s wrestling, baseball, and tennis. Elbow injuries were 3.5 times more likely to occur during competition compared with practice. Athletes were 0.76 times less likely to sustain an elbow injury during the preseason compared with in-season. Contact events were the most common mechanism of injury (67%). For sex-comparable sports, men were 2.41 times more likely than women to have contact as their injury mechanism (95% CI, 0.78-7.38). The majority of athletes missed less than 24 hours of participation time (67%), and only a minority (3%) of patients with elbow injuries went on to have surgical intervention. Elbow ulnar collateral ligament injuries were most common (26% of total injuries).

Conclusion:

Analysis of the study data demonstrated a significant rate of elbow injuries, 1.76 injuries per 10,000 AEs in NCAA collegiate athletes. Higher injury rates can be expected in males within sex-comparable sports. Elbow injuries are most common in the setting of competitions and most commonly occur secondary to contact-type mechanisms. Injuries were more likely to occur during in-season play. The majority of injuries required less than 24 hours of time away from sport and did not require surgical intervention.

Ten-Year Epidemiology of Ankle Injuries in Men's and Women's Collegiate Soccer Players

CONTEXT

Data from the National Collegiate Athletic Association (NCAA) Injury Surveillance Program (ISP) have indicated that ankle injuries are the most common injuries among NCAA soccer players.

OBJECTIVE

To review 10 years of NCAA-ISP data for soccer players' ankle injuries to understand how the time period (2004-2005 through 2008-2009 versus 2009-2010 through 2013-2014), anatomical structure injured, and sex of the athlete affected the injury rate, mechanism, and prognosis.

DESIGN

Descriptive epidemiology study.

SETTING

Online injury surveillance.

MAIN OUTCOME MEASURE(S)

The NCAA-ISP was queried for men's and women's soccer ankle data from 2004 to 2014. Ankle-injury rates were calculated on the basis of injuries per 1000 athlete-exposures. Rate ratios (RRs) were used to compare injury rates. Injury proportion ratios (IPRs) were used to compare injury characteristics.

RESULTS

When compared with the 2004-2005 through 2008-2009 seasons, the 2009-2010 through 2013-2014 seasons showed a similar rate of injuries (RR = 0.94, 95% confidence interval [CI] = 0.85, 1.04) but fewer days missed (P < .001) and fewer recurrent injuries (IPR = 0.55, 95% CI = 0.41, 0.74). The 4 most common ankle injuries, which accounted for 95% of ankle injuries, were lateral ligament complex tears (65.67%), tibiofibular ligament (high ankle) sprains (10.3%), contusions (10.1%), and medial (deltoid) ligament tears (9.77%). Of these injuries, high ankle sprains were most likely to cause athletes to miss ≥30 days (IPR = 1.9, 95% CI = 1.24, 2.90). Men and women had similar injury rates (RR = 1.02, 95% CI = 0.94, 1.11). Men had more contact injuries (IPR = 1.28, 95% CI = 1.16, 1.41) and contusion injuries (IPR = 1.34, CI = 1.03, 1.73) but fewer noncontact injuries (IPR = 0.86, 95% CI = 0.78, 0.95) and lateral ligamentous complex injuries (IPR = 0.92, 95% CI = 0.86, 0.98).

CONCLUSIONS

Although the rate of ankle injuries did not change between the 2004-2005 through 2008-2009 seasons and the 2009-2010 through 2013-2014 seasons, the prognoses improved. Among the 4 most common ankle injuries, high ankle sprains resulted in the worst prognosis. Overall, male and female NCAA soccer players injured their ankles at similar rates; however, men were more likely to sustain contact injuries.

Lower Back Injuries in National Collegiate Athletic Association Football Players: A 5-Season Epidemiological Study

Background:

Low back injuries are common in collegiate football players and can frequently lead to persistent pain, reinjuries, and time lost from participation.

Purpose:

To describe the epidemiology of back injuries in National Collegiate Athletic Association (NCAA) football players during the 2009/2010 through 2013/2014 academic years utilizing the NCAA Injury Surveillance Program (ISP) database.

Study Design:

Descriptive epidemiology study.

Methods:

A convenience sample of NCAA varsity football teams was utilized to determine the rates and patterns of back injuries as well as to generate national injury estimates. The rates and distribution of back injuries were identified within the context of mechanism of injury, injury chronicity, and time lost from sport. Injury rates were calculated as the number of injuries divided by the total number of athlete-exposures (AEs). Incidence rate ratios were calculated to compare the rates of injury between season, event type, mechanism of injury, injury chronicity, and time lost from sport.

Results:

Nationally, there were 267 low back injuries reported in the database. These were used to estimate 7076 back injuries over the 5-year period, approximately 82% of which were new injuries. The injuries occurred at a rate of 2.70 per 10,000 AEs. Overall, injuries were 3.12 times more likely to occur in competitions than in practices. Athletes were 4.67 times more likely to sustain a back injury during the preseason compared with the postseason but were 1.41 times more likely to sustain a low back injury during the preseason compared with the regular season. Both contact and noncontact were reported equally as the mechanism of injury (37.8% and 38.3%, respectively), and unspecified low back pain was the most common injury (64.2%). Only 1.6% of patients required surgery for their injury, and the majority of athletes (59.6%) returned to play within 24 hours.

Conclusion:

There was a relatively high rate of lumbar back injuries at the collegiate level (2.70/10,000 AEs), the majority of which were new injuries. About 18% of reported injuries were reinjuries. Although very few required surgery, a careful examination and work-up should be conducted to evaluate each injury. Regimented physical therapy and reconditioning programs are recommended to avert reinjuries.

A Decade of Hip Injuries in National Collegiate Athletic Association Football Players: An Epidemiologic Study Using National Collegiate Athletic Association Surveillance Data

CONTEXT

The complex, high-energy nature of football puts players at risk for hip injuries.

OBJECTIVE

To analyze National Collegiate Athletic Association (NCAA) Injury Surveillance Program data for men's football hip injuries from 2004-2005 through 2013-2014.

DESIGN

Descriptive epidemiologic study.

SETTING

National Collegiate Athletic Association football teams.

PATIENTS OR OTHER PARTICIPANTS

Data on collegiate football players was provided by the NCAA Injury Surveillance System from 2004-2005 through 2013-2014.

MAIN OUTCOME MEASURE(S)

The incidence, risk factors, rates, and distribution of hip injuries over the 10-year period from 2004-2005 through 2013-2014 were determined. Rates and distribution of injuries were analyzed by injury type, time loss, event type, time of season, recurrence, mechanism of injury, player position, and if surgery was required. Injury rate ratios were calculated to compare rates between event types and by time of season.

RESULTS

A total of 1618 hip injuries occurred during 3 121 380 athlete-exposures (AEs), resulting in an overall hip injury rate of 5.18 per 10 000 AEs. Adductor strains (38.63%) were the most common type, followed by hip-flexor strains (28.55%) and hip contusions (18.23%). Players were 3.56 (95% confidence interval [CI] = 3.19, 3.98) times more likely to sustain a hip injury during competitions compared with practices. They were 2.37 (95% CI = 2.15, 2.62) and 3.56 (95% CI = 2.49, 5.08) times more likely to sustain a hip injury during the preseason than in-season or the postseason, respectively.

CONCLUSIONS

During the 10-year period, NCAA football players sustained higher rates of hip injuries during competitions and the preseason. The majority were noncontact injuries, resulted in time loss of less than 6 days, and did not require surgery. The injuries varied with player position and occurred most often to defensive backs. Muscle strains were the most frequent group of hip injuries, while adductor strains, hip-flexor strains, and hip contusions were the most common injury types.

Arthroscopic Evaluation of Knee Cartilage Using Optical Reflection Spectroscopy

Articular cartilage is critical for painless and low-friction range of motion; however, disruption of articular cartilage, particularly in the knee joint, is common. Treatment options are based on the size and depth of the chondral defect, as well as involvement of subchondral bone. The gold standard for evaluation of articular cartilage is with arthroscopy, but it is limited by its ability to objectively judge the depth and severity of chondral damage. Optical reflection spectroscopy has been introduced to objectively assess the thickness of cartilage. We present a technique to systematically evaluate the articular cartilage of the knee using BioOptico optical reflection spectroscopy (Arthrex) to better evaluate those with visible chondral and subchondral defects.

Ninety-day readmissions following reverse total shoulder arthroplasty

Background

An adequate characterization of 90-day readmissions after primary reverse total shoulder arthroplasty (RTSA) on a national level remains to be undertaken. As bundled payment models become more prevalent, an improved understanding of readmission data will help to predict resource utilization and expenses.

Methods

All adult patients who underwent elective primary RTSA in 2014 in the National Readmission Database were included in the analysis. Two cohorts were created based on 90-day readmission status. Multivariate analysis was then performed to determine predictors of 90-day readmissions. Reasons for 30-, 60-, and 90-day readmissions were identified. Total hospital resource utilization was calculated.

Results

An estimated 25,196 patients were identified. The 30-, 60-, and 90-day rates of readmissions were 0.6%, 1.2%, and 1.7%, respectively. Diabetes (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.14-1.78), hypertension (OR, 1.63; 95% CI, 1.28-2.08), paralysis (OR, 3.61; 95% CI, 1.63-7.97), and solid tumor without metastasis (OR, 2.72; 95% CI, 1.21-6.12) were identified as independent predictors of 90-day readmission. Ninety-day readmissions were associated with a significant increase in cost (P = .02). The most common related reason for 90-day readmission was hardware-related complications at all time points.

Conclusion

Although uncommon, 90-day readmissions after primary RTSA are associated with significant patient morbidity and consequently substantial hospital costs.

Lumbar Spine Injuries in National Collegiate Athletic Association Athletes: A 6-Season Epidemiological Study

Background:

Lumbar spine injuries in National Collegiate Athletic Association (NCAA) athletes have not been well studied.

Purpose:

To describe the epidemiology of lumbar spine injuries in NCAA athletes during the 2009/2010 through 2014/2015 academic years utilizing the NCAA Injury Surveillance Program (ISP).

Study Design:

Descriptive epidemiology study.

Methods:

A voluntary convenience sample of NCAA varsity teams from 25 sports was examined. Mechanism of injury, injury recurrence, and time lost from sport were recorded. Injury rates were calculated as the number of injuries divided by the total number of athlete-exposures (AEs). AEs were defined as any student participation in 1 NCAA-sanctioned practice or competition. Injury rate ratios and injury proportion ratios were calculated to compare the rates within and between sports by event type, season, patient sex, mechanism, injury recurrence, and time lost from sport. Comparisons between sexes were made utilizing data that had both male and female samples.

Results:

An estimated 37,435 lumbar spine injuries were identified. The overall rate of injuries was 6.01 per 1000 AEs. The rate of injuries was 4.94 per 1000 AEs in men compared with 3.94 per 1000 AEs in women for sex-comparable sports. Men were 1.25 times more likely than women to suffer a lumbar spine injury. Men’s football (24.62 injuries/1000 AEs) and women’s gymnastics (11.46 injuries/1000 AEs) had the highest rates of lumbar spine injuries. Athletes were 1.83 and 3.71 times more likely to sustain a lumbar spine injury during the preseason than the regular season or postseason, respectively. Noncontact was the most common mechanism of injury (38%). Injury recurrence was most common in men’s outdoor track (58%). Most injuries resulted in less than 24 hours of time loss from event participation (61%).

Conclusion:

The rate of lumbar spine injuries was high in NCAA athletes, and injuries commonly recurred (20%). In general, men were more likely to sustain a lumbar spine injury compared with women. Higher injury rates occurred during competition and via a noncontact mechanism of injury. In addition to prevention programs, reconditioning programs should be considered to prevent these injuries.