Total cost and operating room time comparison of rotator cuff repair techniques at low, intermediate, and high volume centers: mini-open versus all-arthroscopic

Clinical outcomes and direct cost analysis of rotator cuff repair surgery

OBJECTIVE

The purpose of this study was to evaluate the clinical and functional outcomes in patients who underwent surgical treatment for rotator cuff tears using open and arthroscopic techniques, and to evaluate the direct costs involved.

METHODS

Retrospective cohort study with analysis of the data of patients who were referred to two private hospitals in Sao Paulo, Brazil for surgical repair of the rotator cuff from January 2018 to September 2019. Clinical outcomes were assessed using functional scores (SPADI and QuickDASH) and a quality of life questionnaire (EuroQoL). Procedure costs were calculated relative to each hospital's costliest procedure.

RESULTS

Data from 362 patients were analyzed. The mean patient age was 57 years (SD= 10.46), with a slight male predominance (53.9%). Arthroscopic procedures were more common than open procedures (95.6% versus 4.4%). Significant clinical improvement was reported in 84.8% of the patients. The factors associated with increased surgery costs were arthroscopic technique (increase of 29.2%), age (increase of 0.6% per year), and length of stay (increase of 18.9% per day of hospitalization).

CONCLUSION

Rotator cuff repair surgery is a highly effective procedure, associated with favorable clinical outcomes and improvement in life quality, and low rates of complications. Arthroscopic surgery tends to be costlier than open surgery.

High Case Volume Predicts Greater Odds of Autograft Use and Meniscal Repair for Anterior Cruciate Ligament Reconstruction

PURPOSE

To evaluate how both annual surgeon and facility volume affect the cost and outcomes of anterior cruciate ligament reconstruction surgery. We also aimed to identify trends in how surgeon caseload predicts graft selection.

METHODS

The 2014 State Ambulatory and Surgical Database from Florida was used. Every case with Current Procedural Terminology code 29888 ("Arthroscopic anterior cruciate ligament reconstruction") was selected. Surgeon and facility identifiers were used to separate high- and low-volume groups, defined as >25 cases for surgeons and >125 cases for facilities. Univariate analysis was performed for patient demographics and surgical characteristics. Multivariate analysis was performed on significant factors to determine how these variables impact cost and odds of allograft usage, postoperative admission, and meniscal repair.

RESULTS

There were 7905 cases performed between January 1, 2014, and December 31, 2014 after excluding same-year revisions. High-volume surgeons had $6155 lower total charges, were 1.949 times more likely to use an autograft, and had 54.5% lower odds of postoperative admission (all P < .001). They were also 1.196 times more likely to perform a meniscal repair (P = .017). In patients younger than 18, low-volume surgeons were 3.7 times more likely to use an allograft (P < .001). Concomitant multiligamentous procedures were also performed at greater rates in the high-volume group. Postoperative admission added $18,698, and allografts added $9174 (both P < .001).

CONCLUSIONS

We found that high-volume surgeons were more likely to perform a meniscal repair and less likely to have their patients admitted postoperatively, which was the second largest cost driver of anterior cruciate ligament reconstruction. They were also significantly less likely to use an allograft, especially in patients younger than the age of 18 years. High-volume surgeons had lower costs despite greater rates of concomitant procedures.

LEVEL OF EVIDENCE

III, retrospective cohort study.

MESENCHYMAL CELLS IN ROTATOR CUFF REPAIR - TECHNIQUE DESCRIPTION AND CASE REPORTS

Objective

To describe a protocol of obtention of mesenchymal stem cells and to report their use as a biological adjuvant in three patients undergoing arthroscopic rotator cuff repair.

Methods

Case series of patients who underwent arthroscopic repair of isolated full-thickness supraspinatus tear using mesenchymal stem cells obtained from the bone marrow as a biological adjuvant. All patients were operated on at the same institution, by a surgeon with 13 years of experience. The cells were applied at the end of the procedure, at the tendon-bone interface, at an approximate concentration of 2,000,000 mesenchymal cells/mm3 and a total volume of 5 ml.

Results

All patients improved with the procedure, with one excellent and two good results. All cases overcame the minimally important clinical difference. All cases reached tendon healing, without partial or complete re-tears. We observed no complications.

Conclusion

Arthroscopic rotator cuff repair with added mesenchymal cells obtained from bone marrow and submitted to a cell expansion process led to good functional results and healing in all cases in the sample, with no complications. Level of Evidence IV, Case Series.

The Primary Cost Drivers of Outpatient Distal Radius Fracture Fixation: A Cost-Minimalization Analysis of 15,379 Cases

Background  Distal radius fractures are the most common fracture of the upper extremity. While some distal radius fractures can be managed with closed reduction and immobilization, operative treatment is the standard of care, with open reduction internal fixation (ORIF) as a predominant operative method. Questions/Purpose  To investigate how patient and surgical characteristics affect the overall costs of internal fixation of distal radius fractures in adults. Patients and Methods  The 2014 State Ambulatory Surgery and Services Databases for six states were used to identify cases and surgical characteristics of distal radius fracture ORIF in adult patients. Results  Surgical variables that significantly increased cost were postoperative admission within 30 days, regional anesthesia, simultaneous endoscopic carpal tunnel release, and increasing operating room time. Conclusion  Substantial contributors to total cost are postoperative hospital admission within 30 days of surgery, use of regional anesthesia, simultaneous endoscopic carpal tunnel release, and longer operative time. Level of Evidence  Level III, retrospective cohort study.

Determinants of Operative Time in Arthroscopic Rotator Cuff Repair

Arthroscopic rotator cuff repairs have been reported to take between 72 and 113 min to complete. This team has adopted its practice to reduce rotator cuff repair times. We aimed to determine (1) what factors reduced operative time, and (2) whether arthroscopic rotator cuff repairs could be performed in under 5 min. Consecutive rotator cuff repairs were filmed with the intent of capturing a <5-min repair. A retrospective analysis of prospectively collected data of 2232 patients who underwent primary arthroscopic rotator cuff repair by a single surgeon was performed using Spearman's correlations and multiple linear regression. Cohen's f² values were calculated to quantify effect size. Video footage of a 4-min arthroscopic repair was captured on the 4th case. Backwards stepwise multivariate linear regression found that an undersurface repair technique (f² = 0.08, p < 0.001), fewer surgical anchors (f² = 0.06, p < 0.001), more recent case number (f² = 0.01, p < 0.001), smaller tear size (f² = 0.01, p < 0.001), increased assistant case number (f² = 0.01, p < 0.001), female sex (f² = 0.004, p < 0.001), higher repair quality ranking (f² = 0.006, p < 0.001) and private hospital (f² = 0.005, p < 0.001) were independently associated with a faster operative time. Use of the undersurface repair technique, reduced anchor number, smaller tear size, increased surgeon and assistant surgeon case number, performing repairs in a private hospital and female sex independently lowered operative time. A <5-min repair was captured.

Arthroscopic versus mini-open rotator cuff repair: A meta-analysis

BACKGROUND

An all-arthroscopic rotator cuff repair (ASR) may result in less postoperative pain and better functional outcomes than the mini-open (MOR) approach. This meta-analysis provides an updated assessment of the current literature which compares the clinical outcomes of mini-open versus all arthroscopic rotator cuff repair techniques.

MATERIAL AND METHODS

The main online databases were accessed in October 2021. All the trials directly comparing primary ASR versus MOR for rotator cuff rupture were accessed. Studies concerning revision settings were not eligible, nor where those combining the surgical procedures with other adjuvants.

RESULTS

A total of 21 articles were retrieved. Data from 1644 procedures (ASR = 995, MOR = 649) were collected. The mean follow-up was 26.7 (6.0-56.4) months. Comparability was found between ASR and MOR groups at baseline with regards to age (P = 0.3), gender (P = 0.7) and mean duration of the follow-up (P = 0.7). No difference was found between ASR and MOR with regard to surgical duration (P = 0.05), Constant score (P = 0.2), University of California at Los Angeles Shoulder (P = 0.3), American Shoulder and Elbow Surgeons Shoulder (P = 0.5), VAS (P = 0.2), forward flexion (P = 0.3), abduction (P = 0.3), external rotation (P = 0.2), internal rotation (P = 0.7), re-tear (P = 0.9), adhesive capsulitis (P = 0.5).

CONCLUSION

Arthroscopic and mini-open rotator cuff repair result in similar clinical outcomes. Male gender and older age lead to greater rates of rotator cuff re-tears, while longer surgical duration was associated with a greater rate of adhesive capsulitis.

Increased Risk of Surgical-Site Infection and Need for Manipulation Under Anesthesia for Those Who Undergo Open Versus Arthroscopic Rotator Cuff Repair

Purpose

Methods

Results

Conclusions

Level of Evidence

Data Resources for Evaluating the Economic and Financial Consequences of Surgical Care in the United States

LEVEL OF EVIDENCE

V.

Measurement of value in rotator cuff repair: patient-level value analysis for the 1-year episode of care

BACKGROUND

Rotator cuff repair (RCR) is one of the most common elective orthopedic procedures, with predictable indications, techniques, and outcomes. As a result, this surgical procedure is an ideal choice for studying value. The purpose of this study was to perform patient-level value analysis (PLVA) within the setting of RCR over the 1-year episode of care.

METHODS

Included patients (N = 396) underwent RCR between 2009 and 2016 at a single outpatient orthopedic surgery center. The episode of care was defined as 1-year following surgery. The Western Ontario Rotator Cuff index was collected at both the initial preoperative baseline assessment and the 1-year postoperative mark. The total cost of care was determined using time-driven activity-based costing (TDABC). Both PLVA and provider-level value analysis were performed.

RESULTS

The average TDABC cost of care was derived at $5413.78 ± $727.41 (95% confidence interval, $5341.92-$5485.64). At the patient level, arthroscopic isolated supraspinatus tears yielded the highest value coefficient (0.82; analysis-of-variance F test, P = .01). There was a poor correlation between the change in the 1-year Western Ontario Rotator Cuff score and the TDABC cost of care (r² = 0.03). Provider-level value analysis demonstrated significant variation between the 8 providers evaluated (P < .01).

CONCLUSION

RCR is one of the most common orthopedic procedures, yet the correlations between cost of care and patient outcomes are unknown. PLVA quantifies the ratio of functional improvement to the TDABC-estimated cost of care at the patient level. This is the first study to apply PLVA over the first-year episode of care. With health care transitioning toward value-based delivery, PLVA offers a quantitative tool to measure the value of individual patient care delivery over the entire episode of care.

Direct and indirect economic burden associated with rotator cuff tears and repairs in the US

OBJECTIVE

This retrospective study examined treatment characteristics and the economic burden associated with rotator cuff tears (RCT) and rotator cuff repairs (RCR). Additionally, this study aimed to explore the economic implications associated with delayed surgical intervention.

METHODS

Adult RCT patients meeting eligibility criteria were identified from 1/1/2013-6/30/2017 using the IBM Watson Health MarketScan Commercial database. Patients with incident RCR within 12 months post-index and 12 months continuous enrollment after the RCR date were also analyzed. Early surgery was defined as RCR within 6 months and 1 month from the partial-thickness tear and full-thickness tear diagnoses, respectively. Patient characteristics, all-cause direct costs (plan paid and patient out-of-pocket), RCT-related costs, pre-surgical costs, post-surgical costs, and healthcare resource utilization were reported by RCT type. Attributable indirect costs, absenteeism and short-term disability (STD), were also estimated.

RESULTS

102,488 RCT patients were identified (partial-thickness tears: 46,856 [45.7%]; full-thickness tears: 55,632 [54.3%]). Fifty per cent RCT patients underwent RCR within 12-months of diagnosis. Full-thickness RCT patients had an average total baseline (one year pre-diagnosis) and post-index costs of $17,096 and $32,110, respectively. Similarly, partial thickness patients had baseline costs of $16,385 and post-index costs of $27,017. Mean all-cause annual post-surgery costs were $34,086 for patients with partial-thickness tears and $34,249 for patients with full-thickness tears, of which 40% and 38% of costs were RCT-related, respectively. Productivity losses due to absenteeism and STD in the 12-month post-surgery period averaged $5843 and $4493, respectively, for partial-thickness tear patients and $5770 and $4382, respectively, for full-thickness tear patients. Average additional spending per delayed surgical patient between diagnosis and surgery was $8524 and $3213 (both p <0.001) for partial- and full-thickness tear patients, respectively.

CONCLUSIONS

This exploratory analysis indicates considerable RCT and RCR economic burden to the healthcare system. High healthcare utilization and costs highlight the importance of efficiently managing patients with RCT diagnosis. Data also suggest that early surgical intervention may be economically beneficial if surgical intervention is anticipated post-RCT.

The efficacy of periarticular injection intraoperatively for mini-open rotator cuff repair: A comparative study

BACKGROUND

The optimal postoperative analgesia after open rotator cuff repair surgery remains unclear. This study compared the use of a multimodal pain regimen including periarticular injection (PAI), with a control condition. We hypothesized that PAI leads to decreased opioid consumption and lower pain scores.

METHODS

The perioperative analgesic regimen was standardized and implemented from January 1, 2017 to December 31, 2017. The PAI was administered from July 1, 2017 to December 31, 2017. The historical control group was enrolled from January 1, 2017 to June 30, 2017. The evaluation items included assessments of pain using a 10-point visual analog scale (VAS) before and after the mini-open rotator cuff repair and on postoperative days 1, 2, and 3. The dose of ketorolac suppository and its side effects were also evaluated.

RESULTS

The VAS score on the day of the operation was significantly low in the PAI group and less incidence of night pain. The time point of the rescue drug was longer in the PAI group than the control group (12.7 hours vs. 0.62 hours; p < 0.01). No cardiac or central nervous system toxicity was observed.

DISCUSSION

In our study, PAI in the shoulder after mini-open rotator cuff repair showed effective pain control on the day of the surgery, postponed the time of the first dosage of intravenous pain medication, and reduced the total dosage of the intravenous pain medication.

Cost analysis and complication rate comparing open, mini-open, and all arthroscopic rotator cuff repair

Hypothesis/Background

Value-based healthcare delivery models are becoming increasingly common and are driving cost effectiveness initiatives. Rotator cuff repair (RCR) is a commonly performed procedure with some variations on the specific surgical technique. The purpose of this study was to perform a comprehensive analysis of the cost, complications, and readmission rates of 3 categories of RCR techniques (open [oRCR], combined arthroscopically assisted and mini-open [CRCR], and all arthroscopic [ARCR]) at a high-volume institution.

Methods

All RCR procedures performed by 2 fellowship-trained shoulder surgeons at a single institution between 2012 and 2017 were retrospectively identified. These consisted of oRCR, CRCR, and ARCR repair techniques. One surgeon performed oRCR and CRCR, and the second surgeon performed ARCR. A cost analysis was designed to include a period of 60 days preoperatively, the index surgical hospitalization, and 90 days postoperatively, including costs of any readmission or reoperation.

Results

The cohort consisted of 95 oRCR, 233 CRCR, and 287 ARCR. Median standardized costs were as follows: preoperative evaluation $486.03; index surgical hospitalization oRCR $9,343.10, CRCR $10,057.20, and ARCR $10,330.60; and postoperative care $875.02. Preoperative and postoperative costs did not vary based on the type of RCR performed. However, significant differences were observed among index surgical costs (P = .0008). The highest standardized cost for hospitalization for both the CRCR group and the ARCR group was related to the cost of the operating room and the implants. The 90-day complication, reoperation, and readmission rates were 1.1%, 1.1%, and 2.1% in the open group; 0.8%, 0.8%, and 1.7% in the combination group; 0%, 0%, and 1.7% in the all arthroscopic group, respectively. There were no significant differences among the 3 surgical procedures with respect to complication (P = .26), reoperation (P = .26), and readmission rates (P = .96).

Discussion/Conclusions

In this investigation, the median standardized costs for RCR inclusive of 60-day workup and 90-day postoperative care were $10,704.15, $11,418.25, and $11,691.65 for oRCR, CRCR (average added cost $714.10), and ARCR (added cost $987.50), respectively. The group complication, reoperation, and readmission rate were 0.5%, 0.5%, and 1.8% with no significant differences between the varying techniques, respectively. This retrospective cost analysis and complication profile may serve as a useful reference as surgeons consider engaging in bundled payment for RCR. As value based initiatives continue to progress, implant cost may serve as an actionable area for cost reduction.

The Relevance of Open Rotator Cuff Repair in 2021

BACKGROUND

The last decade has seen a large increase in rotator cuff surgery and arthroscopic surgery. We were asked to define the relevance of open rotator cuff repair in 2021.

PURPOSE

To define whether there are proven advantages to arthroscopic or open rotator cuff repair surgery.

METHOD

We reviewed the recent literature regarding recent trends, anaesthetic time, rehabilitation, post-operative pain, complications, economic considerations, the learning curve and outcomes. We outlined the senior authors' technique preferences, rationale and patient reported outcomes.

RESULTS

There is no clear evidence of proven advantage in arthroscopic rotator cuff repair compared to open rotator cuff repairs, with regard to outcomes or the other aspects reviewed. There were no differences in the outcomes of arthroscopic and open repairs in the senior authors practice with his procedure indications.

CONCLUSIONS

Open rotator cuff repair surgery remains a valid option and has some appeal in specific indications and in settings where arthroscopic resources are limited. We believe surgeons should learn both techniques and the principles of good patient selection, tissue handling, and fixation techniques are of paramount importance in both arthroscopic and open rotator cuff surgery.

Cost of Arthroscopic Rotator Cuff Repairs Is Primarily Driven by Procedure-Level Factors: A Single-Institution Analysis of an Ambulatory Surgery Center

PURPOSE

To identify intraoperative drivers of cost associated with arthroscopic rotator cuff repairs (RCRs) through analysis of an institutional database.

METHODS

This was a single-institution retrospective review of arthroscopic RCRs performed at an ambulatory surgical center between November 2016 and July 2019. Patient-level factors analyzed included age, sex, insurance type (private, Medicare, Medicaid, self-pay, and other government), American Society of Anesthesiologists grade (I, II, III, and missing), and Charlson comorbidity index (0, 1, 2, and ≥3). Procedure-level factors included use of biologics (decellularized dermal allograft or bioinductive healing implant), anesthesia type (regional block, monitored anesthesia care, or general), number of anchors and sutures, additional procedures (biceps tenodesis, distal clavicle resection, subacromial decompression), and operative time. Multivariate linear regression analysis was used to identify factors significantly associated with higher or lower charges.

RESULTS

A total of 712 arthroscopic RCRs were included. The risk-adjusted operative charges were $19,728 (95% confidence interval $16,543 to $22,913). The above factors predicted nearly 65% of the variability in operative charges. The only patient-level factor significantly associated with lower charges was female sex (- $1,339; P = .002). Procedure-level factors significantly associated with higher charges were use of biologics (+ $17,791; P < .001), concurrent open biceps tenodesis (+ $4,027; P < .001), distal clavicle resection (+ $2,266; P = .039), use of regional block (+ $1,256; P = .004), number of anchors (+ $2,245/anchor; P < .001), and increasing operative time ($26/min). Other factors had no significant association.

CONCLUSIONS

Procedural factors are the most significant drivers of operative cost in arthroscopic RCRs, such as quantity and type of implants; additional procedures such as biceps tenodesis and distal clavicle resection; and perioperative conditions such as type of anesthesia and total operating room time. Overall, patient-level factors were not shown to correlate well with operative costs, other than lower charges with female sex.

LEVEL OF EVIDENCE

IV, economic study.

Cost Comparison of Open and Arthroscopic Treatment Options for SLAP Tears

Purpose

To identify cost drivers of open biceps tenodesis, arthroscopic biceps tenodesis, and arthroscopic SLAP repair in the setting of isolated SLAP tears and to perform a direct cost comparison between the procedures.

Methods

The 2014 State Ambulatory Surgery and Services Databases from 6 US states were used. Cases with Current Procedural Terminology codes 23430 (tenodesis of long tendon of biceps), 29807 (shoulder arthroscopy, repair of SLAP lesion), and 29828 (shoulder arthroscopy, biceps tenodesis) were selected, excluding patients who were >50 years old or had a concomitant rotator cuff repair. Generalized linear models were used to model costs based on surgical and patient variables.

Results

The mean patient age was 41.8 years for open biceps tenodesis, 31.6 for arthroscopic SLAP repair, and 41.3 for arthroscopic biceps tenodesis (P < .001). Open biceps tenodesis had cost reductions of $5,664 over arthroscopic biceps tenodesis (P = .001) and $2,320 over arthroscopic SLAP repair (P = .043). Male sex was associated with $3,798 more in costs (P < .001), presence of ≥1 comorbidities added $1,829 (P = .002), and each minute in the operating room added $37 (P < .001). Operative time for open biceps tenodesis averaged 114 minutes, and both arthroscopic procedures averaged 94 minutes (P < .001). Low-volume facilities were associated with $5,536 higher costs for arthroscopic biceps tenodesis (P = .001).

Conclusion

In patients aged ≤50 years with isolated SLAP tears, open biceps tenodesis provides cost savings over arthroscopic methods of treatment. There was no significant cost difference between arthroscopic SLAP repairs and arthroscopic biceps tenodesis. Given the increased emphasis on cost containment, surgeons should be aware of the procedural costs associated with the treatment of SLAP tears.

Level of Evidence

III, retrospective cohort study.

Clinical outcomes and cost-utility of rotator cuff repair surgery by open and arthroscopic techniques: study protocol for a randomised clinical trial

INTRODUCTION

Rotator cuff injuries account for up to 70% of pain in the shoulder. However, there remains no consensus on the best surgical treatment for patients with rotator cuff injuries, in terms of the cost-effectiveness and cost-utility of open and arthroscopic methods for rotator cuff repair. The objective of this trial is to compare the efficacy, cost-effectiveness and cost-utility of open and arthroscopic procedures for rotator cuff repair.

METHODS AND ANALYSIS

The trial is a two-group, parallel-design, randomised controlled trial. A total of 100 patients with symptomatic rotator cuff lesions will be allocated in either open or arthroscopic technique in a 1:1 ratio, considering smoking (yes or no), lesion size (≤3 cm or >3 cm) and diabetes (present or absent) as stratification factors. All patients will be included in the same rehabilitation programme after the intervention. The primary outcome measure will be the Constant-Murley Score and the EuroQol-5D-3L score at 48 weeks postsurgery. Secondary outcomes include cost-effectiveness, cost-utility, pain, complications and clinical analysis, using the Simple Shoulder Test, Visual Analogue Pain Scale (VAS), integrity of the repair evaluated through MRI, and complications and failures of the proposed methods. For the cost-effectiveness analysis, we will use the VAS and the Constant-Murley Score as measures of effectiveness. For the cost-utility analysis, we will use the EuroQol-5D-3L as a measure of utility in terms of incremental cost per quality-adjusted life-years.

ETHICS AND DISSEMINATION

The study has been approved by the local research ethics committee of both institutions: Hospital Israelita Albert Einstein and Hospital Alvorada Moema/Hospital Pró-Cardíaco. The results will be published in a peer-reviewed, open access journal.

TRIAL REGISTRATION NUMBER

NCT04146987.

Evidence-based Risk Stratification for Sport Medicine Procedures During the COVID-19 Pandemic

Orthopaedic practices have been markedly affected by the emergence of the COVID-19 pandemic. Despite the ban on elective procedures, it is impossible to define the medical urgency of a case solely on whether a case is on an elective surgery schedule. Orthopaedic surgical procedures should consider COVID-19-associated risks and an assimilation of all available disease dependent, disease independent, and logistical information that is tailored to each patient, institution, and region. Using an evidence-based risk stratification of clinical urgency, we provide a framework for prioritization of orthopaedic sport medicine procedures that encompasses such factors. This can be used to facilitate the risk-benefit assessment of the timing and setting of a procedure during the COVID-19 pandemic.

No difference in long-term outcome between open and arthroscopic rotator cuff repair: a prospective, randomized study

Background

Arthroscopic rotator cuff repair techniques have almost replaced open repairs. Short- and mid-term studies have shown comparable outcomes, with no clear superiority of either procedure. The aim of this study was to compare the long-term clinical and imaging outcomes following arthroscopic or open rotator cuff repair.

Methods

Forty patients with magnetic resonance imaging (MRI)–documented, symptomatic supraspinatus or supraspinatus and infraspinatus tears were randomized to undergo arthroscopic or open rotator cuff repair. Clinical and radiographic follow-up was obtained at 6 weeks, 3 months, 1 year, 2 years, and >10 years postoperatively. Clinical assessment included measurement of active range of motion, visual analog scale score for pain, functional scoring according to the Constant-Murley score (CS), and assessment of the Subjective Shoulder Value. Imaging included conventional radiography and MRI for the assessment of cuff integrity and alteration of the deltoid muscle.

Results

We enrolled 20 patients with a mean age of 60 years (range, 50-71 years; standard deviation [SD], 6 years) in the arthroscopic surgery group and 20 patients with a mean age of 55 years (range, 39-67 years; SD, 8 years) in the open surgery group. More than 10 years’ follow-up was available for 13 patients in the arthroscopic surgery group and 11 patients in the open surgery group, with mean follow-up periods of 13.8 years (range, 11.9-15.2 years; SD, 1.1 years) and 13.1 years (range, 11.7-15 years; SD, 1.1 years), respectively. No statistically significant differences in clinical outcomes were identified between the 2 groups: The median absolute CS was 79 points (range, 14-84 points) in the arthroscopic surgery group and 84 points (range, 56-90 points) in the open surgery group (P = .177). The median relative CS was 94% (range, 20%-99%) and 96% (range, 65%-111%), respectively (P = .429). The median Subjective Shoulder Value was 93% (range, 20%-100%) and 93% (range, 10%-100%), respectively (P = .976). MRI evaluation showed a retear rate of 30% equally distributed between the 2 groups. Neither fatty infiltration of the deltoid muscle, deltoid muscle volume, nor the deltoid origin were different between the 2 groups.

Conclusion

In a small cohort of patients, we could not document any difference in clinical and radiographic outcomes at long-term follow-up between arthroscopic and open rotator cuff repair. The postulated harm to the deltoid muscle with the open technique could not be confirmed.

Costs, Complications, and Reoperations Associated With Primary Arthroscopic Rotator Cuff Repair With or Without Acromioplasty and/or Biceps Tenodesis

Purpose

To evaluate the reoperations, complications, and costs up to 5 years following arthroscopic rotator cuff repair (RCR) alone, with acromioplasty (acro), with biceps tenodesis (BT), or with both acro and BT.

Methods

We queried the MarketScan database to identify patients who underwent RCR from 2007 to 2016. Patients were stratified into groups based on concomitant procedures (acro and/or BT) performed on the same day as index RCR. Reoperations, complications, and costs were followed for 5 years post-index procedure. Patients without laterality codes were excluded. A multivariate logistic regression analysis was used to control for confounding factors.

Results

This study identified 147,838 patients (mean age, 53.1 years; standard deviation, 8.3 years) who underwent primary RCR. Patients were stratified into 4 groups: (1) RCR only, (2) RCR + acro, (3) RCR + BT, and (4) RCR + acro + BT. Patients in the RCR only group experienced the highest rate of unadjusted overall postoperative complications (17.2%) versus the other groups (RCR + acro 16.4%, RCR + BT 15.1%, RCR + acro + BT 16.2%, P < .0161). The RCR only group also experienced a significantly greater number of reoperations on the ipsilateral shoulder (P < .0001), whereas the RCR + acro + BT had the highest costs at all timepoints. In the regression analysis, there was no significant differences between complications and reoperations between any groups. After adjusting for covariates, the performance of a BT with an RCR and acromioplasty led to increased costs (odds ratio, 1.47, 1.37-1.59, P < .001).

Conclusions

Concomitant biceps tenodesis does lead to higher total healthcare costs, both in the shorter and longer terms. When adjusting for confounding factors, the performance of concomitant biceps tenodesis with rotator cuff repair does not lead to a difference in postoperative complication rate or risk for revision surgery.

Level of Evidence

Level IV, economic analysis.

Cost Drivers Associated With Anterior Shoulder Stabilization Surgery

Background:

Arthroscopic Bankart repair, open Bankart repair, and the Latarjet procedure are common treatments for anterior shoulder instability; however, little is known of costs by patient- and surgeon-specific factors. This study aimed to identify areas where cost reduction may be achieved.

Hypothesis:

Increased total charges will be associated with low-volume surgeons and surgical facilities, hospital-owned facilities, open surgical techniques, and patients with at least 1 comorbidity.

Study Design:

Economic and decision analysis; Level of evidence, 3.

Methods:

The 2014 State Ambulatory Surgery and Services Databases from 6 states were utilized. There were 3 Current Procedural Terminology codes (23455, 23462, 29806) used to identify open Bankart repair, the Latarjet procedure, and arthroscopic Bankart repair, respectively. Patient demographic and surgical variables were evaluated on a univariate basis, and all significant factors were then included in the multiple linear regression to determine which factors had the largest effect on cost. Total charges billed for the encounter were used as a proxy for cost of surgery.

Results:

For open Bankart repair, arthroscopic Bankart repair, and the Latarjet procedure, longer operative times increased costs, and high-volume surgical facilities had decreased charges. For the arthroscopic Bankart group, additional factors that increased charges included postoperative hospital admission (US$11,516; P < .001), patient residence in a ZIP code with a below-median income (US$2909; P < .001), presence of a comorbidity (US$1982; P < .001), male sex (US$1545; P = .003), Hispanic race (US$2493; P = .005), and use of regional anesthesia (US$1898; P = .025). Additional cost drivers for the Latarjet procedure included postoperative hospital admission (US$7028; P = .022) and older age (US$187/y; P = .039).

Conclusion:

Postoperative admission to the hospital was the largest cost driver for arthroscopic Bankart repair and the Latarjet procedure. Low-volume facilities were the largest cost driver for open Bankart repair. High-volume surgery centers had lower costs when compared with low-volume surgery centers. Regional anesthesia increased costs in the arthroscopic Bankart group. These findings may help to show where cost savings can be achieved, particularly considering increasing trends toward bundled health care payments.

High-Volume and Privately Owned Ambulatory Surgical Centers Reduce Costs in Achilles Tendon Repair

Background:

While Achilles tendon repairs are common, little data exist characterizing the cost drivers of this surgery.

Purpose:

To examine cases of primary Achilles tendon repair, primary repair with graft, and secondary repair to find patient characteristics and surgical variables that significantly drive costs.

Study Design:

Economic and decision analysis; Level of evidence, 3.

Methods:

A total of 5955 repairs from 6 states were pulled from the 2014 State Ambulatory Surgery and Services Database under the Current Procedural Terminology codes 27650, 27652, and 27654. Cases were analyzed under univariate analysis to select the key variables driving cost. Variables deemed close to significance (P < .10) were then examined under generalized linear models (GLMs) and evaluated for statistical significance (P < .05).

Results:

The average cost was $14,951 for primary repair, $23,861 for primary repair with graft, and $20,115 for secondary repair (P < .001). In the GLMs, high-volume ambulatory surgical centers (ASCs) showed a cost savings of $16,987 and $2854 in both the primary with graft and secondary repair groups, respectively (both P < .001). However, for primary repairs, high-volume ASCs had $2264 more in costs than low-volume ASCs (P < .001). In addition, privately owned ASCs showed cost savings compared with hospital-owned ASCs for both primary Achilles repair ($2450; P < .001) and primary repair with graft ($11,072; P = .019). Time in the operating room was also a significant cost, with each minute adding $36 of cost in primary repair and $31 in secondary repair (both P < .001).

Conclusion:

Private ASCs are associated with lower costs for patients undergoing primary Achilles repair, both with and without a graft. Patients undergoing the more complex secondary and primary with graft Achilles repairs had lower costs in facilities with greater caseload.

Can an acute high-grade acromioclavicular joint separation be reduced and stabilized without surgery? A surgeon's experience

INTRODUCTION

While the management of Rockwood type III injuries is still a topic of debate, high-grade Rockwood type V injuries are mostly treated surgically, to anatomically reduce the acromioclavicular (AC) joint and to restore functionality. In this case report, we present a method for non-operative reduction and stabilization of a high-grade AC joint injury.

CASE

A 31-year-old male orthopaedic resident sustained a Rockwood type V injury during a snowboarding accident. His AC joint was reduced and stabilized with an AC joint brace for six weeks. The brace provided active clavicle depression and humeral elevation. After removal of the brace the AC joint showed a nearly anatomic reduction. Six-month follow-up weighted X-ray views showed an AC joint which had healed in a Rockwood type II position and the patient returned to full pre-injury function with a satisfying cosmetic appearance.

CONCLUSION

Non-operative reduction and stabilization of high-grade AC joint separations seems to be a valuable treatment option. A "closed reduction and external fixation" approach with the aid of a dedicated AC joint brace can reduce the AC joint and keep it in place until ligamentous consolidation occurs, thus improving AC joint stability and cosmetic appearance without surgical intervention.

Exploring the Business Case for Improving Quality of Care for Patients With Chronic Rotator Cuff Tears

BACKGROUND AND OBJECTIVES

Currently, management of patients presenting with chronic rotator cuff tears in Alberta is in need of quality improvements. This article explores the potential impact of a proposed care pathway whereby all patients presenting with chronic rotator cuff tears in Alberta would adopt an early, conservative management plan as the first stage of care; ultrasound investigation would be the preferred tool for diagnosing a rotator cuff tear; and only patients are referred for surgery once conservative measures have been exhausted.

METHODS

We evaluate evidence in support of surgery and conservative management, compare care in the current state with the proposed care pathway, and identify potential solutions in moving toward optimal care.

RESULTS

A literature search resulted in an absence of indications for either surgical or conservative management. Conservative management has the potential to reduce utilization of public health care resources and may be preferable to surgery. The proposed care pathway has the potential to avoid nearly Can $87 000 in public health care costs in the current system for every 100 patients treated successfully with conservative management.

CONCLUSION

The proposed care pathway is a low-cost, first-stage treatment that is cost-effective and has the potential to reduce unnecessary, costly surgical procedures.

The primary cost drivers of arthroscopic rotator cuff repair surgery: a cost-minimization analysis of 40,618 cases

BACKGROUND

An estimated 250,000 rotator cuff repair (RCR) surgical procedures are performed every year in the United States. Although arthroscopic RCR has been shown to be a cost-effective operation, little is known about what specific factors affect the overall cost of surgery. This study examines the primary cost drivers of RCR surgery in the United States.

METHODS

Univariate analysis was performed to determine the patient- and surgeon-specific variables for a multiple linear regression model investigating the cost of RCR surgery. The 2014 State Ambulatory Surgery and Services Databases were used, yielding 40,618 cases with Current Procedural Terminology code 29827 ("arthroscopic shoulder rotator cuff repair").

RESULTS

The average cost of RCR surgery was $25,353. Patient-specific cost drivers that were significant under multiple linear regression included black race (P < .001), presence of at least 1 comorbidity (P < .001), income quartile (P < .001), male sex (P = .012), and Medicare insurance (P = .035). Surgical factors included operative time (P < .001), use of regional anesthesia (P < .001), quarter of the year (January to March, April to June, July to September, and October to December) (P < .001), concomitant subacromial decompression or distal clavicle excision (P < .001), and number of suture anchors used (P < .001). The largest cost driver was subacromial decompression, adding $4992 when performed alongside the RCR.

CONCLUSION

There are several patient-specific variables that can affect the cost of RCR surgery. There are also surgeon-controllable factors that significantly increase cost, most notably subacromial decompression, distal clavicle excision, use of regional anesthesia, and number of suture anchors. Surgeons must consider these factors in an effort to minimize cost, particularly as bundled payments become more common.

A Novel, Fast, Safe, and Effective All-Inside Arthroscopic Rotator Cuff Repair Technique: Results of 1000 Consecutive Cases

Background:

Arthroscopic rotator cuff repair is a common but technically difficult surgical technique. This study describes a novel arthroscopic rotator cuff repair technique where the repair was performed while visualized entirely from the glenohumeral joint. A single-row knotless tension band inverted mattress suture technique was utilized with fixation obtained via suture anchors. The technique was relatively easy to perform and demonstrated good repair strength and footprint compression in an ex vivo ovine model.

Purpose:

To evaluate the safety and efficacy of this technique in 1000 consecutive patients.

Study Design:

Case series; Level of evidence, 4.

Methods:

This study was a retrospective analysis of prospectively collected data in 1000 consecutive patients. Included patients underwent primary arthroscopic rotator cuff repair by a single surgeon performing the undersurface repair technique and attended 6-month follow-up with ultrasound evaluation to determine repair integrity. Exclusion criteria were irreparable tears, incomplete repairs, tendon reconstruction with a synthetic patch, and revision cases.

Results:

The only complication was retear. The overall retear rate at 6 months following repair with the undersurface technique was 8.5%. The mean ± SEM operative time for the technique was 16 ± 0.3 minutes (range, 4-75 minutes). There were no infections. Smaller tears were repaired faster and had better healing rates.

Conclusion:

The novel all-inside arthroscopic rotator cuff repair technique was safe and significantly faster and provided better healing rates than other repair techniques. The retear rate of 8.5% is, to the authors’ knowledge, the lowest reported rotator cuff retear rate in a large cohort of patients based on a single technique.

Disparities in Cost and Access by Caseload for Arthroscopic Rotator Cuff Repair: An Analysis of 18,616 Cases

Background

Surgeon caseload has been shown to affect both health and economic outcomes in arthroscopic rotator cuff repair. Although previous studies have investigated disparities in access to care, little is known about disparities between low- and high-volume surgeons and facilities.

Purpose

To identify where disparities may exist regarding access to high-volume surgeons and facilities.

Study Design

Cross-sectional study.

Methods

Univariate analysis was performed to analyze differences in the caseload between low- and high-volume surgeons and facilities. Cutoff values were set at 50 cases per year for high-volume surgeons and 125 cases annually for high-volume facilities. Multiple linear regression was then used to develop a cost model incorporating all variables significant under univariate analysis. We collected 18,616 cases with Current Procedural Terminology code 29827 ("arthroscopic rotator cuff repair") from the 2014 Florida State Ambulatory Surgery and Services Databases.

Results

A greater proportion of the caseload for low-volume surgeons and facilities was composed of patients who were of lower socioeconomic status, had government-subsidized insurance, or lived in areas with low-income ZIP codes. Low-volume surgeons and facilities also had higher total charges, higher postoperative admission rates, and lower distal clavicle excision rates (P < .001). In our cost model, a low facility volume significantly increased costs. Subacromial decompression, postoperative admission, distal clavicle excision, male sex, and government-subsidized insurance were all significant factors for increased costs in multivariate cost analysis.

Conclusion

There are disparities in access to high-volume surgeons and facilities for patients undergoing arthroscopic rotator cuff repair in Florida. Patients with a lower socioeconomic status, government-subsidized insurance, and low income all faced decreased access to these high-volume groups. High-volume surgeons and facilities were associated with lower total charges, higher rates of distal clavicle excision, and lower readmission rates. Low-volume facilities added a significant amount of cost, even when controlling for all other significant variables. It is important for providers to be aware of these disparities and work to address them in their own practices.

Do elderly patients gain as much benefit from arthroscopic rotator cuff repair as their younger peers?

BACKGROUND

This study was conducted to ascertain whether patients aged older than 75 years achieve outcomes after arthroscopic rotator cuff repair comparable to younger patients.

METHODS

Arthroscopic cuff repair was performed in 60 shoulders of 59 patients aged older than 75 years. A control group of 60 younger patients, matched for sex, tear size, and American Society of Anesthesiology Functional Classification grade were included. Surgery occurred from 2006 to 2016. Prospective outcomes were the Constant score (CS), Subjective Shoulder Value, pain, satisfaction, and operative complications. Mean follow-up was 29 months.

RESULTS

The elderly group was a mean age of 78 years compared with 59 years for controls. Tear sizes were 25 massive, 20 large, 12 medium, and 3 small. The CS improved by 25.1 points in elderly patients compared with 23.7 points for controls (P = .742). Pain improved by 7.5 of 15 in elderly patients vs. 6.2 of 15 in controls (P = .055). Fifty-five of 59 older patients were satisfied compared with 52 of 60 controls (P = .378). The overall complication rate did not differ between the groups (P = .509). Both groups had 1 infection and 1 stiffness. An acromioclavicular joint cyst developed in 1 younger patient, and a traumatic retear occurred in 1 patient. Subsequent reverse total shoulder arthroplasty was performed in 4 elderly patients at a mean of 28 months after cuff repair. Massive tears had higher risk for subsequent reverse total shoulder arthroplasty (P = .026).

CONCLUSION

Elderly patients benefit as much from arthroscopic rotator cuff repair as their younger counterparts. Similar improvements in CS, Subjective Shoulder Value, pain, and satisfaction occurred for both elderly and control patients. Arthroscopic repair was safe and effective in both groups. Even elderly patients with massive tears showed clinically significant improvements. Arthroscopic rotator cuff repair should be considered as a valuable treatment irrespective of age.

Long-term results after arthroscopic transosseous rotator cuff repair

BACKGROUND

The purpose of this study was to evaluate the long-term clinical and radiologic results after arthroscopic transosseous rotator cuff repair (TORCR).

METHODS

A total of 69 patients with full-thickness supraspinatus tendon tears with or without infraspinatus tendon tears treated with arthroscopic TORCR by a single surgeon between 1998 and 2003 were included. Among them, 56 patients (81%) with a mean age of 58 ± 5 years (range, 42-70 years) were available for final follow-up examination after an average of 15 ± 2 years (range, 12-18 years). The Subjective Shoulder Value, Constant score (CS), University of California at Los Angeles score, and American Shoulder and Elbow Surgeons score were recorded. Magnetic resonance imaging (MRI) was performed to visualize tendon integrity in 66% of patients.

RESULTS

At final follow-up, the mean CS was 84 ± 8 points; mean University of California at Los Angeles score, 33 ± 2 points; mean American Shoulder and Elbow Surgeons score, 92 ± 10 points; and mean Subjective Shoulder Value, 89% ± 17%. MRI revealed asymptomatic repair failure in 9 patients (27%). Moreover, 4 patients (7%) underwent revision surgery because of a symptomatic rerupture, resulting in an overall retear rate of 33%. Patients with intact repairs at final follow-up showed a significantly higher CS (P = .019) and abduction strength (P = .016) than patients with retears.

CONCLUSION

Arthroscopic TORCR for the treatment of full-thickness rotator cuff tears provided good clinical results 12 to 18 years after surgery. Cuff integrity on follow-up MRI scans had a positive effect on the clinical outcome.

EFFECT OF SUBSCAPULARIS TEARS ON FUNCTIONAL SCORES OF PATIENTS UNDERGOING ROTATOR CUFF REPAIR

OBJECTIVE

To evaluate the influence of partial- and full-thickness upper third subscapularis tendon tears on the functional scores of patients undergoing arthroscopic rotator cuff repair.

METHODS

Patients who underwent arthroscopic rotator cuff repair were divided into three groups according to the subscapularis tendon condition: intact, partial-thickness tear, or full-thickness upper third tear. Functional scores were compared among groups. Second, the influence of biceps and infraspinatus tears on the scores was tested using multivariate regression analysis.

RESULTS

We evaluated 307 shoulders in 297 patients. Full-thickness upper third subscapularis tears presented significantly worse scores than intact tendons. Partial-thickness tears had scores that did not differ significantly from those of the other groups. Patients with full-thickness upper third tears presented a greater rate of injured and unstable biceps tendons. The multivariate analysis showed that biceps and infraspinatus tendon tears did not influence the scores or the intergroup comparison.

CONCLUSION

Full-thickness upper third subscapularis tendon tears presented worse functional scores than intact subscapularis tendons among patients undergoing posterosuperior rotator cuff repair. Patients with full-thickness subscapularis tears were more likely to suffer biceps tears, but this fact did not influence functional scores. Level of Evidence I; Clinical randomized trial.

Tear characteristics and surgeon influence repair technique and suture anchor use in repair of superior-posterior rotator cuff tendon tears

BACKGROUND

The factors that associate with surgical decisions about repair technique and the number of suture anchors used in rotator cuff repair have not been previously investigated. This study investigated the extent to which patient, surgeon, and surgical factors associate with performing single-row vs. double-row repair technique and ultimately with the number of suture anchors used.

METHODS

Our institution's prospective surgical cohort was queried for patients undergoing suture anchor repair of superior-posterior rotator cuff tendon tears between February 2015 and August 2017. Exclusion criteria were patients with isolated subscapularis tears, tears that were not repaired, repairs without suture anchors, repairs involving graft augmentation, and repairs by surgeons with fewer than 10 cases. Multivariable statistical modeling was used to investigate associations between patient and surgical factors and the choice of repair technique and number of suture anchors used.

RESULTS

A total of 925 cases performed by 13 surgeons met inclusion criteria. Tear type (full thickness), tear size (medium, large, and massive), a greater number of torn tendons, repair type (arthroscopic), and surgeon were significantly associated with performing a double-row over a single-row repair. Tear size, a greater number of torn tendons, double-row repair technique, and surgeon were significantly associated with a greater number of anchors used for repair.

CONCLUSIONS

Our findings suggest that in the absence of data to conclusively support a clinical benefit of one repair technique over another, surgeons' training, experience, and inherent practice patterns become the primary factors that define their surgical methods.

Evaluation of long-term postoperative outcomes between mini-open and arthroscopic repair for isolated supraspinatus tears: a retrospective analysis

BACKGROUND

Despite arthroscopic repair of the rotator cuff is an increasingly popular procedure, the mini-open (MO) repair still remains a viable and appreciated technique. The purpose of the study was to analyze the long-term clinical outcomes of patients with isolated supraspinatus tear undergoing MO or arthroscopic surgery (AS) repair.

PATIENTS AND METHODS

Forty-six patients underwent supraspinatus repair with anchors: 24 with MO technique and 22 with AS procedure. They were evaluated postoperatively at 3, 6, 12 months and 2 years.

RESULTS

The mean surgery time, the mean hospital stay and the average costs were shorter in the MO patients respect to the AS group. Despite an initial better Disabilities of Arm, Shoulder and Hand and Constant Murley Score in the first 6 months of follow-up in the AS group, no differences were detected at 24 months.

CONCLUSION

This study suggests that isolated supraspinatus tears can be treated with a MO or arthroscopic repair procedure with similar clinical outcome in the long-term postoperative period. The mean surgery time and the average costs are less in the MO group respect to the AS group.

Practicing Cost-Conscious Shoulder Surgery

Second only to the knee, the shoulder is the most commonly reported area of chronic joint pain. By practicing evidence-based methods for improved outcomes at lower costs, providers can increase both efficiency and margin, while patients experience better care and higher satisfaction. Current cost studies on shoulder care provide a base for improving evidence-based care and improving value.

Editorial Commentary: Don't Throw Away the Retractors: Complications of Open Versus Arthroscopic Rotator Cuff Repair Could Be Influenced by Indications

Shoulder surgeons must carefully interpret literature that compares outcomes and complications of open and arthroscopic rotator cuff repair techniques. It is important for shoulder surgeons to be facile with both techniques.

Cost-effectiveness of magnetic resonance imaging versus ultrasound for the detection of symptomatic full-thickness supraspinatus tendon tears

BACKGROUND

The purpose of this study was to determine the value of magnetic resonance imaging (MRI) and ultrasound-based imaging strategies in the evaluation of a hypothetical population with a symptomatic full-thickness supraspinatus tendon (FTST) tear using formal cost-effectiveness analysis.

METHODS

A decision analytic model from the health care system perspective for 60-year-old patients with symptoms secondary to a suspected FTST tear was used to evaluate the incremental cost-effectiveness of 3 imaging strategies during a 2-year time horizon: MRI, ultrasound, and ultrasound followed by MRI. Comprehensive literature search and expert opinion provided data on cost, probability, and quality of life estimates. The primary effectiveness outcome was quality-adjusted life-years (QALYs) through 2 years, with a willingness-to-pay threshold set to $100,000/QALY gained (2016 U.S. dollars). Costs and health benefits were discounted at 3%.

RESULTS

Ultrasound was the least costly strategy ($1385). MRI was the most effective (1.332 QALYs). Ultrasound was the most cost-effective strategy but was not dominant. The incremental cost-effectiveness ratio for MRI was $22,756/QALY gained, below the willingness-to-pay threshold. Two-way sensitivity analysis demonstrated that MRI was favored over the other imaging strategies over a wide range of reasonable costs. In probabilistic sensitivity analysis, MRI was the preferred imaging strategy in 78% of the simulations.

CONCLUSION

MRI and ultrasound represent cost-effective imaging options for evaluation of the patient thought to have a symptomatic FTST tear. The results indicate that MRI is the preferred strategy based on cost-effectiveness criteria, although the decision between MRI and ultrasound for an imaging center is likely to be dependent on additional factors, such as available resources and workflow.

A Review of a Workers' Compensation Database 2003 to 2013: Patient Factors Influencing Return to Work and Cumulative Financial Claims After Rotator Cuff Repair in Geriatric Workers' Compensation Cases

Background

Workers' compensation status is associated with poor outcomes after rotator cuff repair surgery. The purpose of this study was to analyze a database of geriatric workers' compensation patients after surgical repair of the rotator cuff and identify both medical and nonmedical patient factors that influence the time it takes for them to return to work at full duty, including a comparison of arthroscopic and open techniques.

Methods

An all workers' compensation database was queried for rotator cuff claims that were surgically managed using arthroscopic, open, or both approaches from 2003 to 2013 in patients aged ≥60. Primary outcomes were the number of days for return to full work (RTW) following surgery and the total reimbursement for health care. Multivariate analysis was performed, and data are presented as average ± standard deviation.

Results

The database yielded 1903 claims for surgically treated rotator cuff conditions (arthroscopic n = 935; open n = 926; both n = 42). In multivariate RTW analyses, we did not find a significant difference between groups (RTW in days was 153 ± 134 for arthroscopy [P = .81], 160 ± 160 for open [Ref], and 140 ± 82 days for both [P = .75]). However, multivariate analysis of reimbursement claims found arthroscopic surgery claims to be 13% higher compared to claims for open surgery only (US $29 986 ± 16 259 for arthroscopy vs US $26 495 ± 13 186 for open, P < .001). Patients aged ≥65 had more medical expenses than patients aged 60 to 64 (P = .03). Potentially modifiable variables that significantly prolonged RTW timing and higher health-care claims included need for vocational rehabilitation services and filing of a legal suit.

Conclusions

Return to full-duty work in geriatric workers' compensation patients after rotator cuff repair takes about 5 months regardless of surgical approach and costs significantly more in patients aged ≥65. Arthroscopic repairs generated 13% more cumulative health-care costs than open surgery alone. More efficient vocational rehabilitation services and minimizing legal suits may help get patients back to work sooner and reduce overall costs.

Evaluation of the Trends, Concomitant Procedures, and Complications With Open and Arthroscopic Rotator Cuff Repairs in the Medicare Population

Background:

Medicare insures the largest population of patients at risk for rotator cuff tears in the United States.

Purpose:

To evaluate the trends in incidence, concomitant procedures, and complications with open and arthroscopic rotator cuff repairs in Medicare patients.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

All Medicare patients who had undergone open or arthroscopic rotator cuff repair from 2005 through 2011 were identified with a claims database. Annual incidence, concomitant procedures, and postoperative complications were compared between these 2 groups.

Results:

In total, 372,109 rotator cuff repairs were analyzed. The incidence of open repairs decreased (from 6.0 to 4.3 per 10,000 patients, P < .001) while the incidence of arthroscopic repairs increased (from 4.5 to 7.8 per 10,000 patients, P < .001) during the study period. Patients in the arthroscopic group were more likely to have undergone concomitant subacromial decompression than those in the open group (87% vs 35%, P < .001), and the annual incidence of concomitant biceps tenodesis increased for both groups (from 3.8% to 11% for open and 2.2% to 16% for arthroscopic, P < .001). While postoperative complications were infrequent, patients in the open group were more likely to be diagnosed with infection within 6 months (0.86% vs 0.37%, P < .001) but no more likely to undergo operative debridement (0.43% vs 0.26%, P = .08). Additionally, patients in the open group were more likely to undergo intervention for shoulder stiffness within 1 year (1.4% vs 1.1%, P = .01).

Conclusion:

In the Medicare population, arthroscopic rotator cuff repairs have increased in incidence and now represent the majority of rotator cuff repair surgery. Among concomitant procedures, subacromial decompression was most commonly performed despite evidence suggesting a lack of efficacy. Infections and stiffness were rare complications that were slightly but significantly more frequent in open rotator cuff repairs.

Arthroscopic Versus Open Rotator Cuff Repair: Which Has a Better Complication and 30-Day Readmission Profile?

PURPOSE

To provide a comparative 30-day postoperative analysis of complications and unplanned readmission rates, using the National Surgical Quality Improvement Program database, after open or arthroscopic rotator cuff repair (RCR).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for postoperative complications after open or arthroscopic RCR over an 8-year period, from 2007 through 2014. Patients were identified by use of Current Procedural Terminology codes. The open group contained 3,590 cases (21.8%) and the arthroscopic group had 12,882 cases (78.2%), for a total of 16,472 patients undergoing RCR. The risk of complications was compared between the 2 groups, along with patient demographic characteristics, operative time, length of stay, and unplanned readmission within 30 days. We compared dichotomous variables using the Fisher exact test and continuous variables with 1-way analysis of variance. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated when appropriate.

RESULTS

The open RCR group had a higher prevalence of patients aged 65 years or older and comorbidities such as hypertension, diabetes, chronic obstructive pulmonary disease, smoking, and alcoholism (P < .05). Patients undergoing open RCR had a higher risk of any adverse event when compared with arthroscopic RCR patients (1.48% vs 0.84%; RR, 1.17; 95% CI, 1.05-1.30; P = .0010). They were also at higher risk of return to the operating room within 30 days (0.70% vs 0.26%; RR, 1.36; 95% CI, 1.09-1.69; P = .0004). Open RCR was associated with a longer average hospital stay (0.48 ± 2.7 days vs 0.23 ± 4.2 days, P = .0007), whereas arthroscopic RCR had a longer average operative time (90 ± 45 minutes vs 79 ± 45 minutes, P < .0001).

CONCLUSIONS

Although both open and arthroscopic approaches to RCR had low morbidity, arthroscopy was associated with lower risks of any adverse event and return to the operating room during the initial 30-day postoperative period.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Arthroscopic, open and mini-open approach for rotator cuff repair: no difference in pain or function at 24 months

BACKGROUND

The New Zealand Rotator Cuff Registry was established in 2009 to collect prospective functional, pain and outcome data on patients undergoing rotator cuff repair (RCR).

METHODS

Information collected included an operation day technical questionnaire completed by the surgeon and Flex Shoulder Function (SF) functional and pain scores preoperatively, immediately post-operatively and at 6, 12 and 24 months. A multivariate analysis was performed analysing the three surgical approaches to determine if there was a difference in pain or functional outcome scores.

RESULTS

A total of 2418 RCRs were included in this paper. There were 418 (17.3%) arthroscopic, 956 (39.5%) mini-open and 1044 (43.2%) open procedures. Twenty-four-month follow-up data were obtained for pain and Flex SF in 71% of patients. At 24 months, there was no difference in the average Flex SF score for the arthroscopic, mini-open and open groups. There was no difference in improvement in Flex SF score at 24 months. At 24 months, there was no difference in mean pain scores. There was no difference in improvement in pain score from preoperation to 24 months. Most patients returned to work within 3 months of surgery, with no difference between the three surgical approaches.

CONCLUSION

RCR has good to excellent outcomes in terms of improvement in pain and function at 2-year follow-up. We found no difference in pain or functional outcome at 24 months between arthroscopic, open and mini-open approaches for RCR.

Satisfaction, function and repair integrity after arthroscopic versus mini-open rotator cuff repair

AIMS

Advances in arthroscopic techniques for rotator cuff repair have made the mini-open approach less popular. However, the mini-open approach remains an important technique for repair for many surgeons. The aims of this study were to compare the integrity of the repair, the function of the shoulder and satisfaction post-operatively using these two techniques in patients aged > 50 years.

PATIENTS AND METHODS

We identified 22 patients treated with mini-open and 128 patients treated with arthroscopic rotator cuff repair of July 2007 and June 2011. The mean follow-up was two years (1 to 5). Outcome was assessed using the American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test (SST) scores, and satisfaction. The integrity of the repair was assessed using ultrasonography. A power analysis ensured sufficient enrolment.

RESULTS

There was no statistically significant difference between the age, function, satisfaction, or pain scores (p > 0.05) of the two groups. The integrity of the repair and the mean SST scores were significantly better in the mini-open group (91% of mini-open repairs were intact versus 60% of arthroscopic repairs, p = 0.023; mean SST score 10.9 (standard deviation (sd) 1.3) in the mini-open group; 8.9 (sd 3.5) in arthroscopic group; p = 0.003). The ASES scores were also higher in the mini-open group (mean ASES score 91.0 (sd 10.5) in mini-open group; mean 82.70 (sd 19.8) in the arthroscopic group; p = 0.048).

CONCLUSION

The integrity of the repair and function of the shoulder were better after a mini-open repair than after arthroscopic repair of a rotator cuff tear in these patients. The functional difference did not translate into a difference in satisfaction. Mini-open rotator cuff repair remains a useful technique despite advances in arthroscopy. Cite this article: Bone Joint J 2017;99-B:245-9.

Immediate costs of mini-open versus arthroscopic rotator cuff repair in an Asian population

OBJECTIVE

While there has been increasing interest in minimally invasive surgery, the expenses incurred by patients undergoing this form of surgery have not been comprehensively studied. The authors compared the costs borne by patients undergoing arthroscopic rotator cuff repair with the standard mini-open repair at a tertiary hospital in an Asian population.

PATIENTS AND METHODS

This was a retrospective cohort study. The authors studied the inpatient hospital bills of patients following rotator cuff tear repair between January 2010 and October 2014 via the hospital electronic medical records system. 148 patients had arthroscopic repair and 78 had mini-open repair. The cost of implants, consumables, and the total cost of hospitalization were analyzed. Operative times and length of stay for both procedures were also studied. Constant scores and American Shoulder Elbow Scores (ASES) were recorded preoperatively and at 1 year postoperatively.

RESULTS

Three fellowship-trained surgeons performed arthroscopic repairs and one performed the mini-open repair. The cost of implants and consumables was significantly higher with arthroscopic repair. The duration of surgery was also significantly longer with that technique. There was no difference in length of stay between the two techniques. There was also no difference in Constant scores or ASES scores, both preoperatively and at 1 year postoperatively.

CONCLUSIONS

The immediate costs of mini-open repair of rotator cuff tears are significantly less than that of arthroscopic repair. Most of the difference arises from the cost of implants and consumables. Equivalent functional outcomes from both techniques suggest that mini-open repair may be more cost-effective.

Surgeon-Directed Cost Variation in Isolated Rotator Cuff Repair

Background:

As value becomes a larger component of heath care decision making, cost data can be evaluated for regional and physician variation. Value is determined by outcome divided by cost, and reducing cost increases value for patients. “Third-party spend” items are individual selections by surgeons used to perform procedures. Cost data for third-party spend items provide surgeons and hospitals with important information regarding care value, potential cost-saving opportunities, and the total cost of ownership of specific clinical decisions.

Purpose:

To perform a cost review of isolated rotator cuff repair within a regional 7-hospital system and to document procedure cost variation among operating surgeons.

Study Design:

Economic and decision analysis; Level of evidence, 4.

Methods:

Current Procedural Terminology (CPT) codes were used to retrospectively identify subjects who received an isolated rotator cuff repair within a 7-hospital system. Cost data were collected for clinically sensitive third-party spend items and divided into 4 cost groups: (1) suture anchors, (2) suture-passing devices and needles, (3) sutures used for cuff repair, and (4) disposable tools or instruments.

Results:

A total of 62 isolated rotator cuff repairs were performed by 17 surgeons over a 13-month period. The total cost per case for clinically sensitive third-party spend items (in 2015 US dollars) ranged from $293 to $3752 (mean, $1826). Four surgeons had a mean procedure cost that was higher than the data set mean procedure cost. The cost of an individual suture anchor ranged from $75 to $1775 (mean, $403). One disposable suture passer was used, which cost $140. The cost of passing needles ranged from $140 to $995 (mean, $468). The cost per repair suture (used to repair cuff tears) varied from $18 to $298 (mean, $61). The mean suture (used to close wounds) cost per case was $81 (range, $0-$454). A total of 316 tools or disposable instruments were used, costing $1 to $1573 per case (mean, $624).

Conclusion:

This study demonstrates significant cost variation with respect to cost per case and cost of individual items used during isolated rotator cuff repair. Suture anchors represent the most expensive and variable surgeon-directed cost. The wide cost variation seen in all cost categories illustrates both the effect of surgeon choice in procedure cost and the opportunity for significant cost savings in cases of isolated rotator cuff repair. Engaging surgeons in discussion on cost can positively influence the value of care provided to patients if costs can be reduced without affecting the quality of patient outcomes.

[Controversies in the therapy of rotator cuff tears. Operative or nonoperative treatment, open or arthroscopic repair?]

Rotator cuff tears are a common cause of shoulder pain that may lead to severe impairment of shoulder function with significant limitation of the quality of life. Furthermore, they are associated with high direct and indirect costs.Conservative therapy and various surgical procedures for rotator cuff repair are all possible treatment options. Therefore, the correct treatment for a symptomatic rotator cuff tear is important.The conservative therapy may be considered as an alternative treatment option for a symptomatic rotator cuff tear in patients with small or incomplete tears with no fatty atrophy or tendon retraction, with only slight pain, and in older patients with few functional demands. Surgical treatment is recommended after failed conservative treatment lasting 3-6 months, with the corresponding psychological strain. Moreover, surgical treatment should be considered as a primary treatment option for a symptomatic rotator cuff tear in young patients with high functional demands, patients with a high level of physical strain in their jobs, large tears, and tears where there is already significant muscle atrophy or tendon retraction.Arthroscopic treatment is considered to be the gold standard because of the better cosmetic results and treatment of concomitant pathological conditions, the lower levels of postoperative pain, the potentially lower risk of shoulder stiffness, and more focused adhesiolysis. However, arthroscopy does not improve clinical results. Because of the current financial situation, however, open rotator cuff repair is still a viable alternative.

Cost Savings From Utilization of an Ambulatory Surgery Center for Orthopaedic Day Surgery

INTRODUCTION

Healthcare providers are increasingly searching for ways to provide cost-efficient, high-quality care. Previous studies on evaluating cost used estimated cost-to-charge ratios, which are inherently inaccurate. The purpose of this study was to quantify actual direct cost savings from performing pediatric orthopaedic sports day surgery at an ambulatory surgery center (ASC) compared with a university-based children's hospital (UH).

METHODS

Custom-scripted accounting software was queried for line-item costs for a period of 3 fiscal years (fiscal year 2012 to fiscal year 2014) for eight day surgery procedures at both a UH and a hospital-owned ASC. Hospital-experienced direct costs were compared while controlling for surgeon, concomitant procedures, age, sex, and body mass index.

RESULTS

One thousand twenty-one procedures were analyzed. Using multiple linear regression analysis, direct cost savings at the ASC ranged from 17% to 43% for seven of eight procedures. Eighty percent of the cost savings was attributed to time (mean, 64 minutes/case; P < 0.001) and 20% was attributed to supply utilization (P < 0.001). Of the time savings in the operating room, 73% (mean, 47 minutes; P < 0.001) was attributed to the surgical factors whereas 27% (17 minutes; P < 0.001) was attributed to anesthesia factors.

CONCLUSIONS

Performing day surgery at an ASC, compared with a UH, saves 17% to 43% from the hospital's perspective, which was largely driven by surgical and anesthesia-related time expenditures in the operating room.

LEVEL OF EVIDENCE

Level II.

Direct Cost Analysis of Outpatient Arthroscopic Rotator Cuff Repair in Medicare and Non-Medicare Populations

Background:

Providing high-quality care while also containing cost is a paramount goal in orthopaedic surgery. Increasingly, insurance providers in the United States, including government payers, are requiring financial and performance accountability for episodes of care, including a push toward bundled payments.

Hypothesis:

The direct cost of outpatient arthroscopic rotator cuff repair was assessed to determine whether, due to an older population, rotator cuff surgery was more costly in Medicare-insured patients than in patients covered by other insurers. We hypothesized that operative time, implant cost, and overall higher cost would be observed in Medicare patients.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Billing and operative reports from 184 outpatient arthroscopic rotator cuff repairs performed by 5 fellowship-trained arthroscopic surgeons were reviewed. Operative time, number and cost of implants, hospital reimbursement, surgeon reimbursement, and insurance type were determined from billing records and operative reports. Patients were stratified by payer (Medicare vs non-Medicare), and these variables were compared.

Results:

There were no statistically significant differences in the number of suture anchors used, implant cost, surgical duration, or overall cost of arthroscopic rotator cuff repair between Medicare and other insurers. Reimbursement was significantly higher for other payers when compared with Medicare, resulting in a mean per case deficit of $263.54 between billing and reimbursement for Medicare patients.

Conclusion:

Operating room time, implant cost, and total procedural cost was the same for Medicare patients as for patients with private payers. Further research needs to be conducted to understand the patient-specific factors that affect the cost of an episode of care for rotator cuff surgery.

Cost-Effectiveness of Reverse Total Shoulder Arthroplasty Versus Arthroscopic Rotator Cuff Repair for Symptomatic Large and Massive Rotator Cuff Tears

PURPOSE

To compare the cost-effectiveness within the United States health care system of arthroscopic rotator cuff repair versus reverse total shoulder arthroplasty in patients with symptomatic large and massive rotator cuff tears without cuff-tear arthropathy.

METHODS

An expected-value decision analysis was constructed comparing the costs and outcomes of patients undergoing arthroscopic rotator cuff repair and reverse total shoulder arthroplasty for large and massive rotator cuff tears (and excluding cases of cuff-tear arthropathy). Comprehensive literature search provided input data to extrapolate costs and health utility states for these outcomes. The primary outcome assessed was that of incremental cost-effectiveness ratio (ICER) of reverse total shoulder arthroplasty versus rotator cuff repair.

RESULTS

For the base case, both arthroscopic rotator cuff repair and reverse total shoulder were superior to nonoperative care, with an ICER of $15,500/quality-adjusted life year (QALY) and $37,400/QALY, respectively. Arthroscopic rotator cuff repair was dominant over primary reverse total shoulder arthroplasty, with lower costs and slightly improved clinical outcomes. Arthroscopic rotator cuff repair was the preferred strategy as long as the lifetime progression rate from retear to end-stage cuff-tear arthropathy was less than 89%. However, when the model was modified to account for worse outcomes when reverse shoulder arthroplasty was performed after a failed attempted rotator cuff repair, primary reverse total shoulder had superior outcomes with an ICER of $90,000/QALY.

CONCLUSIONS

Arthroscopic rotator cuff repair-despite high rates of tendon retearing-for patients with large and massive rotator cuff tears may be a more cost-effective initial treatment strategy when compared with primary reverse total shoulder arthroplasty and when assuming no detrimental impact of previous surgery on outcomes after arthroplasty. Clinical judgment should still be prioritized when formulating treatment plans for these patients. LEVEL OF EVIDENCE: Level II, economic decision analysis.

Risk Factors for Infection After Rotator Cuff Repair

PURPOSE

To identify risk factors for infection after rotator cuff repair. We hypothesized that patient characteristics and surgical technique would affect the rate of infection.

METHODS

The records of 1,824 rotator cuff repairs performed by a single surgeon from 1995 to 2010 were reviewed retrospectively. Fourteen patients had an early deep postoperative wound infection that was treated with surgical irrigation and debridement. One hundred eighty-five control patients who were treated with rotator cuff repair and did not develop an infection were selected randomly for comparison and statistical analysis. Data regarding preoperative and intraoperative risk factors for infection were recorded, and a multiple logistic regression was conducted to investigate predictors of infection.

RESULTS

The infection rate was 0.77% (14/1,822). On average 2.1 (range 1 to 4) surgical debridements were performed in addition to treatment with intravenous antibiotics. Patients who had open or miniopen rotator cuff repair had a significantly greater risk of acute postoperative infection (odds ratio [OR] = 8.63, P = .002). Seventy-nine percent of the patients in the infection group had an open or miniopen repair, whereas only 28% of the control group had an open or miniopen repair. Male patients also had a significantly greater risk of acute postoperative infection (OR = 9.52, P = .042). A total of 92% of the infection patients were male compared with 58% of the control group. In addition, as body mass index increased there was a reduction in the odds of infection (OR = 0.81, P = .023).

CONCLUSIONS

The results of this case control study demonstrate that open or miniopen surgical technique and male sex are significant risk factors for infection after rotator cuff repair. In our study, arthroscopic rotator cuff repair reduced the risk of infection compared with open techniques.

LEVEL OF EVIDENCE

Level IV.

Utilization and Costs of Postoperative Physical Therapy After Rotator Cuff Repair: A Comparison of Privately Insured and Medicare Patients

PURPOSE

To evaluate the utilization and charges related to physical therapy (PT) after rotator cuff repair in privately insured and Medicare patients and between arthroscopic and open/mini-open repair techniques.

METHODS

The PearlDiver insurance database was queried for patients receiving postoperative PT using Current Procedural Terminology codes. Data were available from 2007 to 2011 for United Healthcare and from 2005 to 2011 for Medicare patients. Patients undergoing arthroscopic (CPT 29827) or open/mini-open approaches (CPT 23410, 23412, 23420) were identified in both populations. Utilization was determined by both the percentage of patients with at least one postoperative PT-related code and the average number of encounters per patient. Per-patient average charge was determined by dividing total charges within the billing period by the patient total.

RESULTS

A total of 365,891 patients undergoing rotator cuff repair were identified. There was an increase in the number of arthroscopic repairs (+29.1%, P = .027, United Healthcare; +78.9%, P < .001, Medicare) and a decrease in the number of open/mini-open repairs (-18.2%, P = .038, United Healthcare; -18.2%, P < .001, Medicare) across the study period. At 6 months postoperatively, PT utilization was greater in the United Healthcare groups (82.9% arthroscopic, 81.0% open/mini-open) than in the Medicare groups (41.8% arthroscopic, 43.2% open/mini-open). Utilization-weighted per-patient average charge was comparable among all 4 groups, with slightly higher charges in the United Healthcare groups ($3,376 arthroscopic, $3,251 open/mini-open) compared with the Medicare groups ($2,940 arthroscopic, $2,807 open/mini-open). The United Healthcare groups had a greater number of utilization-weighted billed encounters (36.1 for open/mini-open, 9.5 for arthroscopic) than their Medicare counterparts (12.8 open/mini-open, 16.7 arthroscopic).

CONCLUSIONS

Utilization of PT after rotator cuff repair is substantially higher in privately insured than in Medicare patients. Utilization rates appear to be comparable between surgical approaches. Per-patient costs were comparable irrespective of surgical approach and insurance modality.

LEVEL OF EVIDENCE

Level IV, economic.

Arthroscopic Rotator Cuff Repair Using the Undersurface Technique: A 2-Year Comparative Study in 257 Patients

Background:

Arthroscopic rotator cuff repair has traditionally been performed in the subacromial space from the bursal side of the tendon. The undersurface rotator cuff repair technique involves the arthroscope remaining in the glenohumeral joint, thus viewing the tendon from its undersurface during repair without a bursectomy or acromioplasty.

Purpose:

To compare the clinical and structural outcomes of undersurface rotator cuff repair with bursal-side repair.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective analysis of prospectively collected data was conducted on 2 cohorts of patients who had undergone arthroscopic rotator cuff repair with knotless suture anchors configured in a single-row formation using inverted mattress–style sutures from either the bursal side (n = 100) or undersurface (n = 165) of the supraspinatus tendon. Data were collected preoperatively, intraoperatively, and at 1 week, 6 weeks, 3 months, 6 months, and 2 years postoperatively. At each time point, patients completed a modified L’Insalata questionnaire to assess patient-ranked pain scores and were clinically examined using standardized tests. Ultrasound examination was performed at 6 months and 2 years to assess the integrity of the repair.

Results:

At 2 years postoperatively, patients in both cohorts had significantly less pain and less difficulty with overhead activities compared with preoperative levels (P < .001). The type of repair performed (bursal or undersurface) did not affect the ability to perform overhead activities at 2 years. At 2 years, both groups also had similar retear rates (21% for bursal side, 23% for undersurface). The mean operative time for the arthroscopic rotator cuff repair was 32 minutes when performed from the bursal side and 20 minutes when performed from the undersurface (P < .001).

Conclusion:

Arthroscopic rotator cuff repair, whether performed from the subacromial space or glenohumeral joint, resulted in decreased levels of pain and difficulty with overhead activities at 2 years. The major difference between the 2 techniques was operative time, with the undersurface technique being performed significantly faster than the bursal-side repair technique.