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Ruiz Ibán MÁ, García Navlet M, Moros Marco S, Diaz Heredia J, Hernando Sánchez A, Ruiz Díaz R, Vaquero Comino C, Rosas Ojeda ML, Del Monte Bello G, Ávila Lafuente JL. Augmentation of a Transosseous-Equivalent Repair in Posterosuperior Nonacute Rotator Cuff Tears With a Bioinductive Collagen Implant Decreases the Retear Rate at 1 Year: A Randomized Controlled Trial. Arthroscopy 2024; 40:1760-1773. [PMID: 38158165 DOI: 10.1016/j.arthro.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/25/2023] [Accepted: 12/13/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE To determine whether the addition of a bioinductive collagen implant (BCI) over a transosseous equivalent (TOE) repair of medium-to-large posterosuperior rotator cuff tears improves the healing rate determined by magnetic resonance imaging (MRI) at 12-month follow-up. METHODS A Level I randomized controlled trial was performed in 124 subjects with isolated, symptomatic, reparable, full-thickness, medium-to-large posterosuperior nonacute rotator cuff tears, with fatty infiltration ≤2. These were randomized to 2 groups in which an arthroscopic posterosuperior rotator cuff tear TOE repair was performed alone (Control group) or with BCI applied over the TOE repair (BCI group). The primary outcome was the retear rate (defined as Sugaya 4-5) determined by MRI at 12 months of follow-up. Secondary outcomes were characteristics of the tendon (Sugaya grade and thickness of the healed tendon) and clinical outcomes (pain levels, EQ-5D-5L, American Shoulder and Elbow Surgeons, and Constant-Murley scores) at 12 months of follow-up. RESULTS Of the 124 randomized patients, 122 (60 in the BCI group and 62 in the Control group) were available for MRI evaluation 12.2 ± 1.02 months after the intervention. There were no relevant differences in preoperative characteristics. Adding the BCI reduced the retear rate (8.3% [5/60] in the BCI group vs 25.8% [16/62] in the Control group, P = .010; relative risk of retear of 0.32 [95% confidence interval 0.13-0.83]). Sugaya grade was also better in the BCI group (P = .030). There were no differences between groups in the percentage of subjects who reached the MCID for CMS (76.7% vs 81.7%, P = .654) or American Shoulder and Elbow Surgeons (75% vs 80%, P = .829), in other clinical outcomes or in complication rates at 12.4 ± 0.73 (range 11.5-17) months of follow-up. CONCLUSIONS Augmentation with a BCI of a TOE repair in a medium-to-large posterosuperior rotator cuff tear reduces the retear rate at 12-month follow-up by two-thirds, yielding similar improvements in clinical outcomes and without increased complication rates. LEVEL OF EVIDENCE Level I, randomized controlled trial.
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Affiliation(s)
- Miguel Ángel Ruiz Ibán
- Shoulder and Elbow Unit, Orthopaedic Surgery and Trauma Service, Hospital Universitario Ramón y Cajal, Madrid, Spain; Departamento de de Cirugía, Ciencias Sanitarias Y Medicosociales, Universidad de Alcalá de Henares, Alcalá de Henares, Madrid, Spain; Área De Traumatología y Ortopedia, Universidad CEU San Pablo, Madrid, Spain.
| | - Miguel García Navlet
- Shoulder and Elbow Unit, Orthopaedic Surgery and Trauma Service, Hospital Asepeyo Coslada, Madrid, Spain
| | - Santos Moros Marco
- Shoulder and Elbow Unit, Orthopaedic Surgery and Trauma Service, Hospital Maz Zaragoza, Zaragoza, Spain
| | - Jorge Diaz Heredia
- Shoulder and Elbow Unit, Orthopaedic Surgery and Trauma Service, Hospital Universitario Ramón y Cajal, Madrid, Spain; Departamento de de Cirugía, Ciencias Sanitarias Y Medicosociales, Universidad de Alcalá de Henares, Alcalá de Henares, Madrid, Spain
| | - Arántzazu Hernando Sánchez
- Shoulder and Elbow Unit, Orthopaedic Surgery and Trauma Service, Hospital Asepeyo Coslada, Madrid, Spain
| | - Raquel Ruiz Díaz
- Shoulder and Elbow Unit, Orthopaedic Surgery and Trauma Service, Hospital Universitario Ramón y Cajal, Madrid, Spain; Departamento de de Cirugía, Ciencias Sanitarias Y Medicosociales, Universidad de Alcalá de Henares, Alcalá de Henares, Madrid, Spain
| | - Carlos Vaquero Comino
- Shoulder and Elbow Unit, Orthopaedic Surgery and Trauma Service, Hospital Asepeyo Coslada, Madrid, Spain
| | - Maria Luisa Rosas Ojeda
- Shoulder and Elbow Unit, Orthopaedic Surgery and Trauma Service, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Gabriel Del Monte Bello
- Shoulder and Elbow Unit, Orthopaedic Surgery and Trauma Service, Hospital Fraternidad-Muprespa Habana, Madrid, Spain
| | - Jose Luis Ávila Lafuente
- Shoulder and Elbow Unit, Orthopaedic Surgery and Trauma Service, Hospital Maz Zaragoza, Zaragoza, Spain
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Durtschi MS, Kim S, Li J, Kim C, Chu C, Cheung E, Safran M, Abrams G, Yang YP. Optimizing Tissue Engineering for Clinical Relevance in Rotator Cuff Repair. TISSUE ENGINEERING. PART B, REVIEWS 2024. [PMID: 38411502 DOI: 10.1089/ten.teb.2023.0320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Rotator cuff tear (RCT) is the most common cause of disability in the upper extremity. It results in 4.5 million physician visits in the United States every year and is the most common etiology of shoulder conditions evaluated by orthopedic surgeons. Over 460,000 RCT repair surgeries are performed in the United States annually. Rotator cuff (RC) retear and failure to heal remain significant postoperative complications. Literature suggests that the retear rates can range from 29.5% to as high as 94%. Weakened and irregular enthesis regeneration is a crucial factor in postsurgical failure. Although commercially available RC repair grafts have been introduced to augment RC enthesis repair, they have been associated with mixed clinical outcomes. These grafts lack appropriate biological cues such as stem cells and signaling molecules at the bone-tendon interface. In addition, they do little to prevent fibrovascular scar tissue formation, which causes the RC to be susceptible to retear. Advances in tissue engineering have demonstrated that mesenchymal stem cells (MSCs) and growth factors (GFs) enhance RC enthesis regeneration in animal models. These models show that delivering MSCs and GFs to the site of RCT enhances native enthesis repair and leads to greater mechanical strength. In addition, these models demonstrate that MSCs and GFs may be delivered through a variety of methods including direct injection, saturation of repair materials, and loaded microspheres. Grafts that incorporate MSCs and GFs enhance anti-inflammation, osteogenesis, angiogenesis, and chondrogenesis in the RC repair process. It is crucial that the techniques that have shown success in animal models are incorporated into the clinical setting. A gap currently exists between the promising biological factors that have been investigated in animal models and the RC repair grafts that can be used in the clinical setting. Future RC repair grafts must allow for stable implantation and fixation, be compatible with current arthroscopic techniques, and have the capability to deliver MSCs and/or GFs.
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Affiliation(s)
| | - Sungwoo Kim
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Jiannan Li
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Carolyn Kim
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Constance Chu
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Emilie Cheung
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Marc Safran
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Geoff Abrams
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Yunzhi Peter Yang
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
- Department of Material Science and Engineering, and Stanford University, Stanford, California, USA
- Department of Bioengineering, Stanford University, Stanford, California, USA
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Retraction to: Clinical outcome of arthroscopic acromioplasty vs. arthroscopic rotator cuff repair for irreparable rotator cuff tears: A 3-year follow-up. Technol Health Care 2024:THC231589. [PMID: 38393862 DOI: 10.3233/thc-231589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
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Stern BZ, Zubizarreta N, Anthony SG, Gladstone JN, Poeran J. Variation in Utilization of Physical Therapist and Occupational Therapist Services After Rotator Cuff Repair: A Population-Based Study. Phys Ther 2024; 104:pzae015. [PMID: 38335223 DOI: 10.1093/ptj/pzae015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 10/22/2023] [Accepted: 12/20/2023] [Indexed: 02/12/2024]
Abstract
OBJECTIVE The objective of this study was to describe the utilization of physical therapist and occupational therapist services after rotator cuff repair (RCR) and examine variation in rehabilitation characteristics by profession. METHODS This retrospective cohort study used the IBM MarketScan Commercial Claims and Encounters database. Eligible patients were 18 to 64 years old and had undergone outpatient RCR between 2017 and 2020. Physical therapist and occupational therapist services were identified using evaluation and treatment codes with profession-specific modifiers ("GP" or "GO"). Factors predicting utilization of formal rehabilitation and physical therapist versus occupational therapist services were examined; and univariable and multivariable analyses of days to initiate therapy, number of visits, and episode length by profession were completed. RESULTS Among 53,497 patients with an RCR, 81.2% initiated formal rehabilitation (93.8% physical therapist, 5.2% occupational therapist, 1.0% both services). Patients in the Northeast and West (vs the South) were less likely to receive rehabilitation (odds ratio [OR] = 0.67 to 0.70) and less likely to receive occupational therapist services (OR = 0.39). Patients living in the Midwest (versus the South) were less likely to receive rehabilitation (OR = 0.79) but more likely to receive occupational therapist services (OR = 1.51). Similarly, those living in a rural (versus urban) area were less likely to utilize rehabilitation (OR = 0.89) but more likely to receive occupational therapist services (OR = 2.21). Additionally, receiving occupational therapist instead of physical therapist services was associated with decreased therapist visits (-16.89%), days to initiate therapy (-13.43%), and episode length (-13.78%). CONCLUSION Most patients in our commercially insured cohort utilized rehabilitation services, with a small percentage receiving occupational therapist services. We identified profession-specific variation in utilization characteristics that warrants further examination to understand predictors and associated outcomes. IMPACT Variation in rehabilitation utilization after RCR, including profession-specific and regional differences, may indicate opportunities to improve standardization and quality of care.
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Affiliation(s)
- Brocha Z Stern
- Leni and Peter W. May Department of Orthopaedics and Institute for Healthcare Delivery Science, Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nicole Zubizarreta
- Leni and Peter W. May Department of Orthopaedics and Institute for Healthcare Delivery Science, Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shawn G Anthony
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - James N Gladstone
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jashvant Poeran
- Leni and Peter W. May Department of Orthopaedics and Institute for Healthcare Delivery Science, Department of Population Health Science & Policy and Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Rosenberg AM, Tiao J, Kantrowitz D, Hoang T, Wang KC, Zubizarreta N, Anthony SG. Increased rate of out-of-network surgeon selection for hip arthroscopy compared to more common orthopedic sports procedures. J Orthop 2024; 50:92-98. [PMID: 38179436 PMCID: PMC10762316 DOI: 10.1016/j.jor.2023.11.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/26/2023] [Accepted: 11/28/2023] [Indexed: 01/06/2024] Open
Abstract
Background Demand for hip arthroscopy (HA) has increased, but shortfalls in HA training may create disparities in care access. This analysis aimed to (1) compare out-of-network (OON) surgeon utilization for HA with that of more common orthopedics sports procedures, including rotator cuff repair (RCR), partial meniscectomy (PM), and anterior cruciate ligament reconstruction (ACLR), (2) compare the HA OON surgeon rate with another less commonly performed procedure, meniscus allograft transplant (MAT), and (3) analyze trends and predictors of OON surgeon utilization. Methods The 2013-2017 IBM MarketScan database identified patients under 65 who underwent HA, RCR, PM, ACLR, or MAT. Demographic differences were determined using standardized differences. Cochran-Armitage tests analyzed trends in OON surgeon utilization. Multivariable logistic regression identified predictors of OON surgeon utilization. Statistical significance was set to p < 0.05 and significant standardized differences were >0.1. Results 410,487 patients were identified, of which 12,636 patients underwent HA, 87,607 RCR, 233,241 PM, 76,700 ACLR, and 303 MAT. OON surgeon utilization increased for HA, rising from 7.98 % in 2013 to 9.37 % in 2017 (p = 0.026). Compared to RCR, PM, and ACLR, HA was associated with higher likelihood of OON surgeon utilization. Usage of ambulatory surgery centers (ASCs) was predictive of higher OON surgeon rates along with procedure year, insurance plan type, and geographic region. HA performed in an ASC was 13 % less likely to have an OON surgeon (p = 0.047). Conclusion OON surgeon utilization generally declined but increased for HA. HA was a predictor of OON surgeon status, possibly because HA is a technically complicated procedure with fewer trained in-network providers. Other predictors of OON surgeon status included ASC usage, PPO/EPO plan type, and Northeast geographic region. There is a need to improve access to experienced HA providers-perhaps with prioritization of HA training in residency and fellowship programs-in order to address rising OON surgeon utilization.
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Affiliation(s)
- Ashley M. Rosenberg
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1188, New York, NY, 10029, United States
| | - Justin Tiao
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1188, New York, NY, 10029, United States
| | - David Kantrowitz
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1188, New York, NY, 10029, United States
| | - Timothy Hoang
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1188, New York, NY, 10029, United States
| | - Kevin C. Wang
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1188, New York, NY, 10029, United States
| | - Nicole Zubizarreta
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1188, New York, NY, 10029, United States
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1077, New York, NY, 10029, United States
| | - Shawn G. Anthony
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1188, New York, NY, 10029, United States
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Sandler AB, Gil LG, Scanaliato JP, Green CK, Dunn JC, Parnes N. Subacromial Balloon Placement Demonstrates No Advantage Over Debridement in the Treatment of Massive Irreparable Rotator Cuff Tears: A Dual-Armed Systematic Review and Meta-analysis of Over 1000 Patients. Am J Sports Med 2024; 52:1088-1097. [PMID: 37369101 DOI: 10.1177/03635465231168127] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
BACKGROUND In recent years, the placement of a subacromial balloon (SAB) spacer has emerged as a treatment option for massive irreparable rotator cuff tears (MIRCTs); however, there is significant controversy regarding its utility in comparison with other surgical interventions. PURPOSE To compare outcomes after SAB spacer placement versus arthroscopic debridement for MIRCTs. STUDY DESIGN Dual-armed systematic review and meta-analysis (level IV evidence). METHODS A literature search of PubMed (MEDLINE), Scopus, and CINAHL Complete databases for articles published before May 7, 2022, was conducted to identify patients with MIRCTs undergoing the 2 procedures. For the SAB arm, 14 of 449 studies were considered eligible for inclusion, while 14 of 272 studies were considered eligible for inclusion in the debridement arm. RESULTS In total, 528 patients were eligible for inclusion in the SAB arm and 479 patients in the debridement arm, and 69.9% of patients undergoing SAB placement also underwent concomitant debridement. Decreases in the visual analog scale (VAS) pain score and increases in the Constant score were found to be significantly larger after debridement (-0.7 points [P < .001] and +5.5 points [P < .001], respectively), although the Patient Acceptable Symptom State for the VAS was not achieved after either procedure. Both SAB placement and debridement significantly improved range of motion in forward flexion/forward elevation, internal and external rotation, and abduction (P < .001). Rates of general complication were higher after debridement versus SAB placement (5.2% ± 5.6% vs 3.5% ± 6.3%, respectively; P < .001); however, there were no significant differences between SAB placement and debridement in rates of persistent symptoms requiring a reintervention (3.3% ± 6.2% vs 3.8% ± 7.3%, respectively; P = .252) or reoperation rates (5.1% ± 7.6% vs 4.8% ± 8.4%, respectively; P = .552). The mean time to conversion to reverse total shoulder arthroplasty was 11.0 versus 25.4 months, respectively, for the SAB versus debridement arm. CONCLUSION While SAB placement was associated with acceptable postoperative outcomes in the treatment of MIRCTs, there was no clear benefit over debridement alone. Shorter operative times coupled with better postoperative outcomes and longer times to conversion to reverse total shoulder arthroplasty rendered debridement a more attractive option. While there may be a role for SAB placement in poor surgical candidates, there is burgeoning evidence to support debridement alone without SAB placement for the treatment of MIRCTs.
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Affiliation(s)
- Alexis B Sandler
- William Beaumont Army Medical Center/Texas Tech University Health Sciences Center, El Paso, Texas, USA
- Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Luis G Gil
- Robbins College of Health and Human Sciences, Baylor University, Waco, Texas, USA
| | - John P Scanaliato
- William Beaumont Army Medical Center/Texas Tech University Health Sciences Center, El Paso, Texas, USA
- Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Clare K Green
- School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia, USA
| | - John C Dunn
- William Beaumont Army Medical Center/Texas Tech University Health Sciences Center, El Paso, Texas, USA
- Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Nata Parnes
- Department of Orthopedics, Carthage Area Hospital, Carthage, New York, USA
- Department of Orthopedics, Claxton-Hepburn Medical Center, Ogdensburg, New York, USA
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Rosenblum J, Madi R, Lee H, Pei YA, Du S, Farooqi AS, Lee A, Kelly JD. Primary Arthroscopic Repair for Massive Rotator Cuff Tears Results in Good Shoulder Function, Low Pain, and Satisfactory Outcomes at 2-Year Minimum Follow-Up. Arthroscopy 2024:S0749-8063(24)00161-0. [PMID: 38428700 DOI: 10.1016/j.arthro.2024.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 02/03/2024] [Accepted: 02/15/2024] [Indexed: 03/03/2024]
Abstract
PURPOSE To evaluate outcomes of patients who underwent primary arthroscopic repair for massive rotator cuff tears (MRCTs). METHODS Patients with MRCTs (full-thickness tear of 2 or more tendons or full-thickness tear ≥5 cm) who underwent arthroscopic repair with a minimum follow-up of 2 years were retrospectively reviewed (n = 51). All patients had preoperative magnetic resonance imaging used to characterize pattern of tear, degree of fatty degeneration (Goutallier classification), and degree of rotator cuff arthropathy (Hamada classification). Outcomes were determined by American Shoulder and Elbow Surgeons (ASES) scores and Penn Shoulder Scores (PSS). RESULTS A total of 51 patients with a minimum 2.3-year follow-up (mean, 5.4 years; range, 2.3-9.7 years) were included in this study. Mean ASES score was 46.1 ± 7.8 (95% CI, 43.9-48.3) for pain and 39.4 ± 12.1 (95% CI, 36.0-42.8) for function. Total ASES score averaged 85.5 ± 18.4 (95% CI, 80.4-90.7). PSS had a mean pain score of 26.8 ± 4.4 (95% CI, 25.4-28.1), a mean satisfaction score of 7.9 ± 2.9 (95% CI, 7.0-8.2), and a mean function score of 48.5 ± 13.5 (95% CI, 44.7-52.3). Total PSS averaged 83.2 ± 19.6 (95% CI, 77.7-87.7). No correlation was found between Goutallier grade and ASES/PSS scores or between Hamada grade and ASES/PSS scores. Three patients underwent reoperation after primary arthroscopic repair of an MRCT (5.9%). CONCLUSIONS Patients with MRCTs who undergo primary arthroscopic repair have postoperative outcome scores indicative of good shoulder function, low pain, and high satisfaction. The rate of reoperation for individuals who underwent primary arthroscopic repair with MRCTs was low at 6%. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Jessica Rosenblum
- Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A..
| | - Rashad Madi
- Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Hannah Lee
- Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Yixuan Amy Pei
- Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Steven Du
- Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Ali S Farooqi
- Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Alexander Lee
- Department of Orthopedic Surgery, Ohio State University, Columbus, Ohio, U.S.A
| | - John D Kelly
- Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
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Stern BZ, Zubizarreta N, Anthony SG, Poeran J, Gladstone JN. Association between timing of initiating supervised physical rehabilitation after rotator cuff repair and incidence of repeat repair and capsulitis: a population-based analysis. J Shoulder Elbow Surg 2024:S1058-2746(24)00101-0. [PMID: 38378128 DOI: 10.1016/j.jse.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 12/21/2023] [Accepted: 01/01/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND There is limited consensus on the optimal time to initiate supervised physical rehabilitation after a rotator cuff repair (RCR). We examined whether timing of initiating supervised physical rehabilitation was associated with repeat RCR or development of adhesive capsulitis within 12 months postoperatively in an observational cohort of commercially insured adults. METHODS This retrospective cohort study used the IBM MarketScan Commercial Claims and Encounters Database. We included adults aged 18-64 who underwent a unilateral outpatient RCR between 2017 and 2020 and initiated supervised physical rehabilitation 1-90 days postoperatively. Multivariable logistic regression models examined the adjusted association between time of initiating supervised physical rehabilitation (1-13, 14-27, 28-41, and 42-90 days postoperatively) and each of the primary outcomes: repeat RCR and capsulitis. In a sensitivity analysis, time to rehabilitation was alternatively categorized using a data-driven approach of quartiles (1-7, 8-16, 17-30, and 31-90 days postoperatively). We report adjusted odds ratios (OR). RESULTS Among 33,841 patients (86.7% arthroscopic index RCR), the median time between index RCR and rehabilitation initiation was 16 days (interquartile range 7-30), with 39.9% initiating rehabilitation at 1-13 days. Additionally, 2.2% underwent repeat RCR within 12 months, and 12-month capsulitis was identified in 1.9% of patients. There were no significant associations between timing of initiating rehabilitation and 12-month repeat RCR (OR 0.85-0.93, P = .18-.49) or 12-month capsulitis (OR 0.83-0.94, P = .22-.63). Lack of associations between timing and outcomes was supported in sensitivity analyses. CONCLUSIONS Timing of initiating rehabilitation was not significantly associated with adverse outcomes after RCR. The finding of no increased odds of repeat RCR or capsulitis with the earliest timing may support earlier initiation of rehabilitation to accelerate return to daily activities. Findings should be replicated in another dataset of similarly-aged patients.
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Affiliation(s)
- Brocha Z Stern
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Nicole Zubizarreta
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shawn G Anthony
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jashvant Poeran
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - James N Gladstone
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Lädermann A, Cikes A, Zbinden J, Martinho T, Pernoud A, Bothorel H. Hydrotherapy after Rotator Cuff Repair Improves Short-Term Functional Results Compared with Land-Based Rehabilitation When the Immobilization Period Is Longer. J Clin Med 2024; 13:954. [PMID: 38398267 PMCID: PMC10889507 DOI: 10.3390/jcm13040954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/31/2024] [Accepted: 02/03/2024] [Indexed: 02/25/2024] Open
Abstract
Background: The evidence of hydrotherapy after rotator cuff repair (RCR) is limited as most studies either used it as an adjuvant to standard land-based therapy, or have different initiation timing. This study aimed to compare hydrotherapy and land-based therapy with varying immobilization time. Methods: Patients who underwent RCR with a 10-days or 1-month immobilization duration (early or late rehabilitation) were prospectively randomized. Results: Constant scores significantly differed at three months only, with the best score exhibited by the late hydrotherapy group (70.3 ± 8.2) followed by late land-based (61.0 ± 5.7), early hydrotherapy (55.4 ± 12.8) and early land-based (54.6 ± 13.3) groups (p < 0.001). There was a significant interaction between rehabilitation type and immobilization duration (p = 0.004). The effect of hydrotherapy compared to land-based therapy was large at three months when initiated lately only (Cohen's d, 1.3; 95%CI, 0.9-1.7). However, the relative risk (RR) of postoperative frozen shoulder or retear occurrence for late hydrotherapy was higher compared to early hydrotherapy (RR, 3.9; 95%CI, 0.5-30.0). Conclusions: Hydrotherapy was more efficient compared to land-based therapy at three months only and if initiated lately. Even though initiating hydrotherapy later brought greater constant scores at three months, it might increase the risk of frozen shoulders or retear compared to early hydrotherapy.
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Affiliation(s)
- Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, 1217 Meyrin, Switzerland
- Faculty of Medicine, University of Geneva, 1205 Geneva, Switzerland
- Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Alec Cikes
- Division of Orthopaedics and Trauma Surgery, Genolier Clinic, 1272 Genolier, Switzerland
- Synergy Medical Centre, Medbase Group, 1007 Lausanne, Switzerland
| | - Jeanni Zbinden
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, 1217 Meyrin, Switzerland
| | - Tiago Martinho
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, 1217 Meyrin, Switzerland
| | - Anthony Pernoud
- Research Department, La Tour Hospital, 1217 Meyrin, Switzerland
| | - Hugo Bothorel
- Research Department, La Tour Hospital, 1217 Meyrin, Switzerland
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10
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Rognoni C, Nherera LM, Garofalo R, Guerra E, Longo UG, Taverna E, Tarricone R. Economic Evaluation of a Bioinductive Implant for the Repair of Rotator Cuff Tears Compared with Standard Surgery in Italy. Adv Ther 2023; 40:5271-5284. [PMID: 37759150 PMCID: PMC10611596 DOI: 10.1007/s12325-023-02686-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION Rotator cuff tear (RCT) is a painful, progressive condition resulting from damage to the rotator cuff tendons and is the leading cause of shoulder-related disability. Surgical repair of rotator cuff is an established standard of care (SOC); however, failure of the procedure can occur. In this context, the use of collagen-based bioinductive implant REGENETEN showed long-term improvements in clinical scores. The aim of the study was to assess the cost-effectiveness of REGENETEN combined with SOC (SOC + REGENETEN) compared to SOC alone from both National Healthcare Service (NHS) and societal perspectives in Italy. METHODS A decision analytic model was developed to estimate the number of tears healed and costs for the two considered treatment strategies over 1 year. Clinical data were retrieved from the literature, and the clinical pathways for the management of patients with RCTs were retrieved from four key opinion leaders in Italy. RESULTS Over a 1-year time horizon, healed lesions were 90.70% and 72.90% for surgical repair of RCTs with and without REGENETEN, respectively. Considering the NHS perspective, mean costs per patient were €7828 and €4650 for the two strategies, respectively, leading to an incremental cost-effectiveness ratio (ICER) of €17,857 per healed tear. From the societal perspective, the mean costs per patient were €12,659 for SOC and €11,784 for REGENETEN, thus showing savings of €4918 per healed tear when the bioinductive implant is used. The sensitivity analyses confirmed the robustness of the model results. CONCLUSION In the context of paucity of cost-effectiveness studies, our findings provide additional evidence for clinicians and payers regarding the value of a new treatment option that supports a tailored approach for the management of patients with RCTs.
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Affiliation(s)
- Carla Rognoni
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, Via Sarfatti 10, 20136, Milan, Italy.
| | | | | | | | - Umile Giuseppe Longo
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Università Campus Bio-Medico di Roma, Rome, Italy
| | | | - Rosanna Tarricone
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, Via Sarfatti 10, 20136, Milan, Italy
- Department of Social and Political Science, Bocconi University, Milan, Italy
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11
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Balta S, Pekince O. The relationship between neuropathic pain and the outcomes of minimally invasive pain management in rotator cuff ruptures. Medicine (Baltimore) 2023; 102:e35940. [PMID: 37960795 PMCID: PMC10637454 DOI: 10.1097/md.0000000000035940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 10/12/2023] [Indexed: 11/15/2023] Open
Abstract
This study aimed to investigate how the presence of neuropathic pain related to partial rotator cuff tears affects the short-term results of subacromial injection and suprascapular nerve blockade therapy in patients with chronic shoulder pain. In this prospective observational study, shoulder pain via verbal numeric pain rating (VNPR, 0-10) and functional status through simple shoulder test (SST) were evaluated before and second week after procedure. After dividing as neuropathic pain and non-neuropathic pain groups, pre-procedural and follow-up scores concerning pain intensity, functional status, and whether there were those of patients with minimal clinically important change (MCIC) in areas of pain and function were evaluated. Between the groups including 140 patients, while there was no statistical difference in baseline pain intensity and functional status (P = .14,.11, respectively), outcomes of those without neuropathic pain were favored at the follow-up (P = .02,.01, respectively). Given baseline pain scores, the reduction (%) was significantly lower in neuropathic pain group (P = .03). There was no significant difference in patients with MCIC in pain intensity and functional status between the groups (P = .08,.59, respectively). An improvement was determined in pain intensity and functional status at the follow-up in both groups (P < .001). The improvement in pain intensity and functional status is poorer in patients with partial rotator cuff rupture-related neuropathic pain than in those without neuropathic pain. However neuropathic pain has no negative effect on the response to treatment.
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Affiliation(s)
- Selin Balta
- Department of Pain Medicine, University of Health Sciences Turkey, Konya City Hospital, Karatay/Konya, Türkiye
| | - Oguzhan Pekince
- Department of Orthopaedic and Trauma Surgery, Konya City Hospital, Karatay/Konya, Türkiye
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12
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Dratsch T, Siedek F, Zäske C, Sonnabend K, Rauen P, Terzis R, Hahnfeldt R, Maintz D, Persigehl T, Bratke G, Iuga A. Reconstruction of shoulder MRI using deep learning and compressed sensing: a validation study on healthy volunteers. Eur Radiol Exp 2023; 7:66. [PMID: 37880546 PMCID: PMC10600091 DOI: 10.1186/s41747-023-00377-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 08/10/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND To investigate the potential of combining compressed sensing (CS) and deep learning (DL) for accelerated two-dimensional (2D) and three-dimensional (3D) magnetic resonance imaging (MRI) of the shoulder. METHODS Twenty healthy volunteers were examined using at 3-T scanner with a fat-saturated, coronal, 2D proton density-weighted sequence with four acceleration levels (2.3, 4, 6, and 8) and a 3D sequence with three acceleration levels (8, 10, and 13), all accelerated with CS and reconstructed using the conventional algorithm and a new DL-based algorithm (CS-AI). Subjective image quality was evaluated by two blinded readers using 6 criteria on a 5-point Likert scale (overall impression, artifacts, and delineation of the subscapularis tendon, bone, acromioclavicular joint, and glenoid labrum). Objective image quality was measured by calculating signal-to-noise-ratio, contrast-to-noise-ratio, and a structural similarity index measure. All reconstructions were compared to the clinical standard (CS 2D acceleration factor 2.3; CS 3D acceleration factor 8). Additionally, subjective and objective image quality were compared between CS and CS-AI with the same acceleration levels. RESULTS Both 2D and 3D sequences reconstructed with CS-AI achieved on average significantly better subjective and objective image quality compared to sequences reconstructed with CS with the same acceleration factor (p ≤ 0.011). Comparing CS-AI to the reference sequences showed that 4-fold acceleration for 2D sequences and 13-fold acceleration for 3D sequences without significant loss of quality (p ≥ 0.058). CONCLUSIONS For MRI of the shoulder at 3 T, a DL-based algorithm allowed additional acceleration of acquisition times compared to the conventional approach. RELEVANCE STATEMENT The combination of deep-learning and compressed sensing hold the potential for further scan time reduction in 2D and 3D imaging of the shoulder while providing overall better objective and subjective image quality compared to the conventional approach. TRIAL REGISTRATION DRKS00024156. KEY POINTS • Combination of compressed sensing and deep learning improved image quality and allows for significant acceleration of shoulder MRI. • Deep learning-based algorithm achieved better subjective and objective image quality than conventional compressed sensing. • For shoulder MRI at 3 T, 40% faster image acquisition for 2D sequences and 38% faster image acquisition for 3D sequences may be possible.
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Affiliation(s)
- Thomas Dratsch
- Department of Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
| | - Florian Siedek
- Department of Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Charlotte Zäske
- Department of Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Kristina Sonnabend
- Philips GmbH Market DACH, Hamburg, Röntgenstrasse 22, 22335, Hamburg, Germany
| | - Philip Rauen
- Department of Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Robert Terzis
- Department of Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Robert Hahnfeldt
- Department of Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - David Maintz
- Department of Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Thorsten Persigehl
- Department of Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Grischa Bratke
- Department of Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Andra Iuga
- Department of Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
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13
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Saavedra JP, Droppelmann G, García N, Jorquera C, Feijoo F. High-accuracy detection of supraspinatus fatty infiltration in shoulder MRI using convolutional neural network algorithms. Front Med (Lausanne) 2023; 10:1070499. [PMID: 37305126 PMCID: PMC10248442 DOI: 10.3389/fmed.2023.1070499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
Background The supraspinatus muscle fatty infiltration (SMFI) is a crucial MRI shoulder finding to determine the patient's prognosis. Clinicians have used the Goutallier classification to diagnose it. Deep learning algorithms have been demonstrated to have higher accuracy than traditional methods. Aim To train convolutional neural network models to categorize the SMFI as a binary diagnosis based on Goutallier's classification using shoulder MRIs. Methods A retrospective study was performed. MRI and medical records from patients with SMFI diagnosis from January 1st, 2019, to September 20th, 2020, were selected. 900 T2-weighted, Y-view shoulder MRIs were evaluated. The supraspinatus fossa was automatically cropped using segmentation masks. A balancing technique was implemented. Five binary classification classes were developed into two as follows, A: 0, 1 v/s 3, 4; B: 0, 1 v/s 2, 3, 4; C: 0, 1 v/s 2; D: 0, 1, 2, v/s 3, 4; E: 2 v/s 3, 4. The VGG-19, ResNet-50, and Inception-v3 architectures were trained as backbone classifiers. An average of three 10-fold cross-validation processes were developed to evaluate model performance. AU-ROC, sensitivity, and specificity with 95% confidence intervals were used. Results Overall, 606 shoulders MRIs were analyzed. The Goutallier distribution was presented as follows: 0 = 403; 1 = 114; 2 = 51; 3 = 24; 4 = 14. Case A, VGG-19 model demonstrated an AU-ROC of 0.991 ± 0.003 (accuracy, 0.973 ± 0.006; sensitivity, 0.947 ± 0.039; specificity, 0.975 ± 0.006). B, VGG-19, 0.961 ± 0.013 (0.925 ± 0.010; 0.847 ± 0.041; 0.939 ± 0.011). C, VGG-19, 0.935 ± 0.022 (0.900 ± 0.015; 0.750 ± 0.078; 0.914 ± 0.014). D, VGG-19, 0.977 ± 0.007 (0.942 ± 0.012; 0.925 ± 0.056; 0.942 ± 0.013). E, VGG-19, 0.861 ± 0.050 (0.779 ± 0.054; 0.706 ± 0.088; 0.831 ± 0.061). Conclusion Convolutional neural network models demonstrated high accuracy in MRIs SMFI diagnosis.
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Affiliation(s)
- Juan Pablo Saavedra
- School of Industrial Engineering, Pontificia Universidad Católica de Valparaíso, Valparaíso, Chile
| | - Guillermo Droppelmann
- Research Center on Medicine, Exercise, Sport and Health, MEDS Clinic, Santiago, Chile
- Health Sciences PhD Program, Universidad Católica de Murcia UCAM, Murcia, Spain
- Principles and Practice of Clinical Research (PPCR), Harvard T. H. Chan School of Public Health, Boston, MA, United States
| | - Nicolás García
- Research Center on Medicine, Exercise, Sport and Health, MEDS Clinic, Santiago, Chile
| | - Carlos Jorquera
- Facultad de Ciencias, Escuela de Nutrición y Dietética, Universidad Mayor, Santiago, Chile
| | - Felipe Feijoo
- School of Industrial Engineering, Pontificia Universidad Católica de Valparaíso, Valparaíso, Chile
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14
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Resorbable Bioinductive Collagen Implant Is Cost Effective in the Treatment of Rotator Cuff Tears. Arthrosc Sports Med Rehabil 2023; 5:e367-e374. [PMID: 37101868 PMCID: PMC10123441 DOI: 10.1016/j.asmr.2023.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 01/04/2023] [Indexed: 02/13/2023] Open
Abstract
Purpose This study was conducted to investigate whether the use of resorbable bioinductive collagen implant (RBI) in addition to conventional rotator cuff repair (conventional RCR) is cost-effective when compared to conventional RCR alone, in the treatment of full-thickness rotator cuff tears (FT RCT). Methods We developed a decision analytic model to compare the expected incremental cost and clinical consequences for a cohort of patients with FT RCT. The probabilities for healing or failure to heal (retear) were estimated from the published literature. Implant and healthcare costs were estimated from a payor's perspective in 2021 U.S. prices. An additional analysis included indirect cost estimations (e.g., productivity losses). Sensitivity analyses explored the effect of tear size, as well as the impact of risk factors. Results The base case analysis demonstrated that resorbable bioinductive collagen implant + conventional rotator cuff repair results in incremental costs of $232,468 and an additional 18 healed RCTs per 100 treated patients over 1 year. The estimated incremental cost-effectiveness ratio (ICER) is $13,061/healed RCT compared to conventional RCR alone. When return to work was included in the model, RBI + conventional RCR was found to be cost saving. Cost-effectiveness improved with tear size with the largest benefit seen in massive tears compared to large tears, as well as patients at higher risk of retearing. Conclusions This economic analysis demonstrated that RBI + conventional RCR delivered improved healing rates at a marginal increase in costs when compared to conventional RCR alone and is, therefore, cost-effective in this patient population. Considering indirect costs, RBI + conventional RCR resulted in lower costs compared to conventional RCR alone and is, therefore, deemed to be cost saving. Level of Evidence Level IV, economic analysis.
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15
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Johnson AJ, Bradsell H, Frank RM. Use of Injections and Biologics for the Nonoperative Treatment of Rotator Cuff Pathology. Clin Sports Med 2023; 42:53-68. [DOI: 10.1016/j.csm.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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16
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Bushnell BD, Connor PM, Harris HW, Ho CP, Trenhaile SW, Abrams JS. Two-year outcomes with a bioinductive collagen implant used in augmentation of arthroscopic repair of full-thickness rotator cuff tears: final results of a prospective multicenter study. J Shoulder Elbow Surg 2022; 31:2532-2541. [PMID: 35788057 DOI: 10.1016/j.jse.2022.05.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 05/19/2022] [Accepted: 05/30/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Full-thickness rotator cuff tears (FTRCTs) represent a common shoulder injury that, if untreated, can progress in size, become increasingly painful, and inhibit function. These lesions are often surgically repaired, with double-row arthroscopic repair often preferred for larger tears. Biological augmentation technologies have been developed to improve rates of postoperative radiographic retear and enhance patient-reported outcomes after surgical FTRCT repair. This study sought to confirm that augmented repair with a bioinductive bovine collagen implant results in favorable retear rates and patient outcomes with follow-up to 2 years. METHODS A prospective multicenter cohort study was undertaken to determine the efficacy and safety of augmenting single- or double-row arthroscopic repair of FTRCTs with a bioinductive bovine collagen implant. Of 115 adult patients participating, 66 (57.4%) had medium (1-3-cm) tears and 49 (42.6%) had large (3-5-cm) tears. Magnetic resonance imaging and patient-reported outcomes (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES] and Constant-Murley Score [CMS]) were performed and recorded at baseline, 3 months, 1 year, and 2 years. RESULTS Mean duration of follow-up was 2.1 years (range, 1.5-2.9 years). Between baseline and 2-year follow-up, mean total thickness of the supraspinatus tendon increased by 12.5% for medium tears and by 17.1% for large tears. Radiographic retear was noted in 7 of 61 available patients (11.5%) with medium tears, and in 14 of 40 patients (35.0%) with large tears. In both groups, these tears primarily occurred before the 3-month follow-up visit (13 of 21 [61.9%]). Radiographic retear with the supplemented double-row (DR) repair technique was 13.2% overall (12 of 91 DR patients; 11.3% for medium tears and 15.8% for large tears). The minimal clinically important difference was achieved by >90% of patients with both medium and large tears for both ASES and CMS. There were 2 serious adverse events classified by the treating surgeon as being possibly related to the device and/or procedure (1 case of swelling/drainage and 1 case of intermittent pain). Nine patients (7.8%; 4 medium tears and 5 large tears) required reoperation of the index rotator cuff surgery. CONCLUSION Final 2-year data from this study confirm that using this implant in augmentation of arthroscopic double-row repair of FTRCTs provides favorable rates of radiographic retear and substantial functional recovery. The relative safety of the device is also further supported.
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Affiliation(s)
| | | | | | - Charles P Ho
- The Steadman Philippon Research Institute, Vail, CO, USA
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17
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Quigley R, Verma N, Evuarherhe A, Cole BJ. Rotator Cuff Repair with Graft Augmentation Improves Function, Decreases Revisions, and Is Cost-Effective. Arthroscopy 2022; 38:2166-2174. [PMID: 35066111 DOI: 10.1016/j.arthro.2022.01.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 01/07/2022] [Accepted: 01/08/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study is to evaluate the cost effectiveness of the use of extracellular matrix (ECM) augment at the time of primary rotator cuff repair utilizing a decision tree analysis. METHODS A decision tree model was created utilizing the existing literature for retear rates with and without dermal graft augmentation. Costs for rotator cuff repair (hospital and surgeon fees) were based on published studies and the cost for graft augmentation was based on institutional data. Utility measures were based upon EQ-5D (European Quality of Life 5 Dimension) scores to assess for improvement in quality adjusted life years (QALY) over a 10-year postoperative period with and without graft augmentation. Cost effectiveness was assessed using the incremental cost effectiveness ratio (ICER), or the incremental cost for per QALY with graft augmentation. Cost effectiveness is based on previous literature whereby an intervention is considered cost effective if the ICER is less than $50,000/QALY. RESULTS On the basis of our decision tree analysis, total cost for rotator cuff tear without augmentation was $12,763, while the cost increased to $16,039 with ECM augmentation. With graft augmentation there was an improvement in 2.29 QALY, while there was an improvement of 2.05 without graft augmentation. The ICER of graft augmentation is $14,000/QALY, well below the cost effectiveness cut-off of $50,000/QALY. Sensitivity analysis showed the maximum cost of the ECM augment to be cost effective is $11,921. CONCLUSION Graft augmentation does come with a significant upfront cost; however, on the basis of our decision-tree analysis, it may represent a cost-effective procedure. There is evidence to potentially consider more routine use in rotator cuff repairs, while being cost effective. LEVEL OF EVIDENCE Economic: Level IV: computer simulation model (Monte Carlo simulation, Markov model) with inputs derived from Level IV studies.
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Affiliation(s)
- Ryan Quigley
- Kaiser Permanente, Sacramento, California, U.S.A
| | - Nikhil Verma
- Midwest Orthopaedics at Rush, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Aghogho Evuarherhe
- Midwest Orthopaedics at Rush, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Brian J Cole
- Midwest Orthopaedics at Rush, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A..
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Metcalfe A, Parsons H, Parsons N, Brown J, Fox J, Gemperlé Mannion E, Haque A, Hutchinson C, Kearney R, Khan I, Lawrence T, Mason J, Stallard N, Underwood M, Drew S. Subacromial balloon spacer for irreparable rotator cuff tears of the shoulder (START:REACTS): a group-sequential, double-blind, multicentre randomised controlled trial. Lancet 2022; 399:1954-1963. [PMID: 35461618 DOI: 10.1016/s0140-6736(22)00652-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND New surgical procedures can expose patients to harm and should be carefully evaluated before widespread use. The InSpace balloon (Stryker, USA) is an innovative surgical device used to treat people with rotator cuff tears that cannot be repaired. We aimed to determine the effectiveness of the InSpace balloon for people with irreparable rotator cuff tears. METHODS We conducted a double-blind, group-sequential, adaptive randomised controlled trial in 24 hospitals in the UK, comparing arthroscopic debridement of the subacromial space with biceps tenotomy (debridement only group) with the same procedure but including insertion of the InSpace balloon (debridement with device group). Participants had an irreparable rotator cuff tear, which had not resolved with conservative treatment, and they had symptoms warranting surgery. Eligibility was confirmed intraoperatively before randomly assigning (1:1) participants to a treatment group using a remote computer system. Participants and assessors were masked to group assignment. Masking was achieved by using identical incisions for both procedures, blinding the operation note, and a consistent rehabilitation programme was offered regardless of group allocation. The primary outcome was the Oxford Shoulder Score at 12 months. Pre-trial simulations using data from early and late timepoints informed stopping boundaries for two interim analyses. The primary analysis was on a modified intention-to-treat basis, adjusted for the planned interim analysis. The trial was registered with ISRCTN, ISRCTN17825590. FINDINGS Between June 1, 2018, and July 30, 2020, we assessed 385 people for eligibility, of which 317 were eligible. 249 (79%) people consented for inclusion in the study. 117 participants were randomly allocated to a treatment group, 61 participants to the debridement only group and 56 to the debridement with device group. A predefined stopping boundary was met at the first interim analysis and recruitment stopped with 117 participants randomised. 43% of participants were female, 57% were male. We obtained primary outcome data for 114 (97%) participants. The mean Oxford Shoulder Score at 12 months was 34·3 (SD 11·1) in the debridement only group and 30·3 (10·9) in the debridement with device group (mean difference adjusted for adaptive design -4·2 [95% CI -8·2 to -0·26];p=0·037) favouring control. There was no difference in adverse events between the two groups. INTERPRETATION In an efficient, adaptive trial design, our results favoured the debridement only group. We do not recommend the InSpace balloon for the treatment of irreparable rotator cuff tears. FUNDING Efficacy and Mechanism Evaluation Programme, a Medical Research Council and National Institute for Health and Care Research partnership.
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Affiliation(s)
- Andrew Metcalfe
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK; Warwick Medical School, University of Warwick, Coventry, UK.
| | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Jaclyn Brown
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | | | - Aminul Haque
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Charles Hutchinson
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Rebecca Kearney
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Iftekhar Khan
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Tom Lawrence
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - James Mason
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Nigel Stallard
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Martin Underwood
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Stephen Drew
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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