Camp, Christopher L.

Background: Charge and reimbursement trends for arthroscopic partial meniscectomies among orthopaedic surgeons, anesthesiologists, and hospital/surgery centers have not been formally analyzed, even though meniscectomies are the most commonly performed orthopaedic surgery. Purpose: To analyze Medicare charge and reimbursement trends for surgeons, anesthesiologists, and hospital/surgery centers for outpatient arthroscopic partial meniscectomies performed in the United States. Study Design: Economic and decision analysis; Level of evidence, 4. Methods: We analyzed trends in surgeon, anesthesiologist, and hospital charges and reimbursements for outpatient isolated arthroscopic partial meniscectomies from 2005 to 2014. Current Procedural Terminology codes were used to capture charge and reimbursement information using the nationally representative 5% Medicare sample. National and regional trends for charge, reimbursement, and Charlson Comorbidity Index (CCI) were evaluated using linear regression analysis. Results: A total of 31,717 patients were analyzed in this study. Charges across all groups increased significantly ( P < .001) during the 10-year study period, with an increase of 18.4% ($2754-$3262) for surgeons, 85.5% ($802-$1480) for anesthesiologists, and 116.8% ($2743-$5947) for hospitals. Surgeon reimbursements declined by 15.5% ($504-$426; P = .072) during this period. Anesthesiologist and hospital reimbursements increased significantly during by 36.5% ($133-$182; P < .001) and 28.9% ($1540-$1984; P < .001) during the 10-year study period, respectively. The annual incidence of partial meniscectomies per 10,000 database patients decreased significantly from 18.3 to 15.6 over the course of the study (14.8% decrease; P = .009), while the CCI did not change significantly ( P = .798). Conclusion: Hospital and anesthesiologist Medicare reimbursements for outpatient arthroscopic partial meniscectomies increased significantly, while surgeon reimbursements decreased. In 2005, hospitals were reimbursed 205% more ($1540 vs $504) than surgeons, and by 2014, they were reimbursed 365% more ($1984 vs $426), indicating that the gap between hospital and surgeon reimbursement is rising. Improved understanding of charge and reimbursement trends represents an opportunity for key stakeholders to improve financial alignment across the field of orthopaedics.

Purpose To evaluate the effect of the Nonoperative Instability Severity Index Score (NISIS) criteria on an established US‐geographic population‐based cohort of patients with anterior shoulder instability. Methods An established geographically based medical record system was used to identify patients <40 years of age with anterior shoulder instability between 1994 and 2016. Medical records were reviewed to obtain patient demographics and instability characteristics. Patient‐specific risk factors were individually incorporated into the 10‐point NISIS criteria: age (>15 years), bone loss, type of instability (dislocation vs subluxation), type of sport (collision vs noncollision), male sex, and dominant arm involvement. High risk was considered a score of ≥7 points and low risk as <7 points. Failure was defined as either progression to surgery or recurrent instability diagnosed by a consulting physician at any point after initial consultation. Results The study population consisted of 405 patients with a mean follow‐up time of 9.6 ± 5.9 years. Failure was defined as recurrent instability or progression to surgery, and the overall failure rate was 52.8% (214/405). The rate of recurrent instability after initial consultation was 34.6% (140/405), and the rate of conversion to surgery was 37.8% (153/405). A total of 264 (65.2%) patients were considered low risk (NISIS < 7), and 141 (34.8%) patients were considered high risk (NISIS ≥ 7). Patients in the high‐risk group were more likely to fail nonoperative management than those in the low‐risk group (60.3% vs 48.9%; P = .028). Conclusions The NISIS has been proposed as a potentially useful tool in clinical decision‐making regarding the appropriate use of nonoperative treatment in scholastic athletes. When applied to an established US‐geographic population‐based cohort consisting of competitive and recreational athletes under the age of 40 with longer‐term follow‐up, the NISIS high‐risk cutoff was able to predict overall failure with 60.3% accuracy. Level of Evidence III, retrospective observation trial

Objective: To report the injury characteristics, radiographic findings, and long-term outcomes of nonoperative management for posterior shoulder instability (PSI). Design: A retrospective review of 143 patients with PSI using a large geographic database. Setting: Single county between January 1994 and July 2012. Patients: A clinical history and diagnosis of PSI, one confirmatory imaging study to support the diagnosis, and a minimum of 5 years follow-up were required for inclusion. Patients with seizure disorders, anterior-only instability, multidirectional instability, and superior labrum from anterior to posterior diagnosis were excluded. Interventions: Patients with PSI were managed nonoperatively or operatively. Main Outcome Measures: Pain, recurrent instability, and progression into glenohumeral osteoarthritis at long-term follow-up. Results: One hundred fifteen patients were identified. Thirty-seven (32%) underwent nonoperative management. Twenty (54%) patients were diagnosed with posterior subluxation, 3 (8%) with a single dislocation, and 7 (19%) with multiple dislocations. Symptomatic progression of glenohumeral arthritis was observed in 8% (3) of patients. Pain improved in 46% (17) of patients and worsened in 19% (7). Recurrent instability and progression to osteoarthritis occurred in 15% (3/20) of patients with a traumatic instability event compared with 0% of atraumatic patients after nonoperative management ( P = 0.234). Pain at follow-up was more common in nonoperative than operative patients ( P = 0.017). Conclusions: Nonoperative management is a viable option for many patients with posterior shoulder instability; however, many may continue to have posterior shoulder pain.

Purpose To define the success rate of initial nonoperative treatment for traumatic anterior shoulder instability in a defined U.S. geographic population, describe factors that predict conversion to surgery after initial nonoperative management, and describe the long‐term outcomes of nonoperative treatment after the index traumatic anterior instability event. Methods The Rochester Epidemiology Project database was used to identify patients aged 14 to 39 years treated for anterior shoulder instability between 1994 and 2016. Patient demographic characteristics, comorbidities, injury characteristics, and imaging were evaluated. Patients treated nonoperatively for the first 6 months after the index instability event were analyzed to determine long‐term outcomes (recurrence rate, pain at last follow‐up, radiographic outcomes), the success rate of continued nonoperative treatment (no conversion to surgery), and factors associated with conversion to surgery (patient and injury characteristics). Survivorship free of surgery was reported with a Kaplan‐Meier survival curve, and Cox proportional hazards models were used to evaluate association of variables with conversion to surgery. Results A total of 379 patients met the study criteria, with an average follow‐up period of 10.2 years (range, 0.53‐25.00 years). The average age was 23.9 years, the mean body mass index was 26.2, and 100% of instability events were due to trauma. Of the shoulders, 79 (20.1%) ultimately failed initial nonoperative treatment and progressed to surgery. At final follow‐up, the rate of recurrent instability was 52.3% in the group treated definitively without surgery, and the recurrence rate decreased from 92.4% to 10.1% in patients who underwent conversion to surgical treatment. Factors associated with conversion to surgery included 2 or more subluxations prior to the first evaluation (hazard ratio [HR], 1.82; P = .002), 2 or more dislocations prior to the first evaluation (HR, 1.76; P = .006), and recurrent instability at follow‐up (HR, 4.21; P < .001). Conclusions Most patients younger than 40 years with shoulder instability who were initially treated nonoperatively for 6 months were definitively treated without surgery. Ultimately, 35% of these patients experienced recurrent dislocations after 6 months of conservative treatment and 20% underwent surgical treatment. In most patients who underwent conversion to surgical treatment, surgery was performed within 12.5 years of their first instability event. Patients who experienced multiple instability events before or after consultation were more likely to undergo conversion to surgery after initial nonoperative management. Level of Evidence Level III, retrospective database review.

Purpose To evaluate both the potential causes and resultant outcomes in patients in whom subchondral insufficiency fracture of the knee (SIFK) develops after arthroscopy. Methods We performed a retrospective review of all patients with a magnetic resonance imaging diagnosis of SIFK after arthroscopic meniscectomy and chondroplasty over a 12‐year period. Results A total of 28 patients were included, with a mean age of 61 years and mean follow‐up period of 5.7 years. SIFK showed a predilection for the medial compartment (n = 25, 89%), specifically the medial femoral condyle (n = 21, 75%). In 7 patients (25%), SIFK developed in both the femoral condyle and tibial plateau in the ipsilateral compartment. Fifteen patients (54%) went on to conversion to arthroplasty at a mean of 0.72 years. The rate of survival free of conversion to arthroplasty was 57%, 45%, and 40% at 1 year, 2 years, and 5 years, respectively. Furthermore, 63% of patients with a meniscal tear and SIFK in the same compartment went on to arthroplasty ( P = .04). There was an increased risk of conversion to arthroplasty if SIFK was present in both the femur and tibia in the same compartment ( P = .04). A higher Kellgren‐Lawrence grade at the time of the SIFK diagnosis increased the likelihood of eventual arthroplasty ( P = .03). The presence of SIFK in both the femur and tibia in the ipsilateral compartment, an increased Kellgren‐Lawrence grade, and a meniscal tear or prior meniscectomy in the same compartment as SIFK were associated with an increased risk of eventual arthroplasty. Conclusions Post‐arthroscopic SIFK most commonly occurs in the medial compartment, particularly in patients who underwent a prior meniscectomy. The presence of meniscal root and radial tears in these patients is notable (75%). Ultimately, there is a high rate of progression of arthrosis (33%) and eventual conversion to arthroplasty. Level of Evidence Level IV, case series.

Purpose To analyze the available literature pertaining to the indications, outcomes, and complications of both microfracture (MFX) and simple debridement for capitellar osteochondritis dissecans (OCD). Methods A comprehensive literature review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA) criteria. Studies were included if they evaluated OCD of the capitellum that underwent either arthroscopic debridement (AD) or MFX. The risk of bias was assessed using the Methodological Index for Non‐randomized Studies (MINORS) scale. Patient demographic characteristics, imaging findings, return‐to‐sport rates, patient‐reported outcomes, range of motion (ROM), complications, failures, and reoperations were recorded. Results Eleven studies with 327 patients (332 elbows) met the inclusion criteria. Methodological Index for Non‐randomized Studies (MINORS) scores ranged from 63% to 75% and showed considerable heterogeneity. Both AD and MFX showed improvement in patient outcome scores, ROM, and return to play, although the data precluded relative conclusions. Improvement in motion after MFX ranged from 4.9° to 5° of flexion, 5° to 22.6° of extension, 1° to 2° of pronation, and 0.5° to 2° of supination, whereas after AD, it ranged from –4° to 6° of flexion and –0.4° to 14° of extension, with prono‐supination noted in only 1 study. The rate of return to play at a similar level of preinjury athletic competition ranged from 55% to 75% after MFX and from 40% to 100% after AD. Lesion location was discussed in only 1 study. Postoperative imaging trended toward early degenerative changes, most commonly of the radial head. Complications were only reported in 1 MFX study; in all cases, the complication was transient ulnar nerve neurapraxia. Reoperation rates ranged from 0% to 10%, and reoperation was most commonly performed to address radial head enlargement. Five studies reported no reoperations. Conclusions Both AD and MFX for capitellar OCD appear to yield excellent improvements in pain, ROM, patient outcome scores, and return to sport. Given that comparable mid‐term outcomes can be achieved with debridement alone, without the use of MFX, similarly to recent prospective studies in the knee, AD alone may be a reasonable approach to relatively small OCD defects. Level of Evidence Level IV, systematic review of studies, all Level IV evidence.

Background: The medial ulnar collateral ligament (MUCL) is the primary restraint to valgus force on the elbow. Since the first description of MUCL reconstruction by Jobe et al in 1986, many technical advancements have been implemented to improve outcomes and reduce complications. The docking technique has emerged as one of the most commonly used techniques. Indications: Following repetitive stress on the elbow during the overhead throwing motion, the MUCL may become attenuated, insufficient, or rupture completely. Although nonoperative treatment with rest and therapy is often the initial treatment of choice, individuals who fail conservative measures may require MUCL reconstruction. Technique Description: The major steps of the procedure are (1) harvesting of palmaris longus autograft, (2) incision and exposure, (3) preparation of ulnar tunnel, (4) preparation of docking site on medial epicondyle, (5) graft passage, (6) graft tensioning and length determination, (7) final fixation, and (8) closure. Results: This procedure allows for reconstruction of the MUCL, restoration of valgus stability to the elbow, and return to play rates of 80% to 95%. The docking technique has advantages over previously described MUCL reconstruction techniques in that it minimizes injury to the flexor pronator mass, avoids the ulnar nerve, allows for robust graft tensioning, and reduces the amount of bone removed from the medial epicondyle. Discussion/Conclusion: The docking technique, as described in this video demonstration, is the most common MUCL reconstruction technique used today. When precise surgical steps are followed, complication rates are low and patient outcomes are favorable.

Background: Wrestlers are highly active, young athletes prone to meniscal injuries that often require surgery. However, there is a lack of data evaluating the results of meniscal repair or partial meniscectomy in this cohort. Purpose: To describe the outcomes (subjective function, return to play, complications, reoperation rates, and progression of osteoarthritis) for treatment (meniscectomy or repair) of meniscal injuries in a cohort of competitive wrestlers. Study Design: Case series; Level of evidence, 4. Methods: All competitive wrestlers (high school, collegiate, or professional leagues) with a history of a meniscal injury and isolated meniscal surgery at a single institution between 2001 and 2017 were retrospectively identified. Failure was defined as a reinjury of the operative meniscus by clinical or advanced imaging examination, reoperation, or any additional surgical treatment of the meniscus after the index procedure. All patients were contacted for determination of reinjury rates, current sport status, and International Knee Documentation Committee and Tegner activity scores. Results: Of 85 male wrestlers with isolated meniscal tears, 34% underwent a meniscal repair, and 66% received a partial meniscectomy. Index surgery failed for 9.4% of the cohort. Among wrestlers treated with initial meniscal repair, 21% required a subsequent partial meniscectomy at a mean 2.2 years, and of those treated with partial meniscectomy, 3% underwent a second operation ( P < .001). All secondary operations were revision partial meniscectomies occurring at a mean 3.2 years (95% CI, 0.01-6.4 years) after the index procedure. At final follow-up, 89% of patients were able to return to sport, with 65% returning to wrestling competition. There was significant improvement in the Tegner score from a mean 6.5 (95% CI, 5.9-7.2) preoperatively to 8.3 (95% CI 8.0-8.6) postoperatively ( P < .001). Conclusion: The reoperation rate after meniscal surgery in wrestlers was quite low, but only 65% returned to competitive wrestling. Meniscal repair and partial meniscectomy improved patient-reported outcomes and activity levels at short-term follow-up. However, 21% of wrestlers treated with initial meniscal repair required a subsequent partial meniscectomy at a mean 2.2 years.

Purpose To compare the differences in preoperative pathology, surgical technique, and overall outcomes between patients treated surgically after a single anterior glenohumeral joint dislocation and those undergoing surgery after multiple dislocations. Methods An epidemiologic database was used to identify all patients younger than 40 years undergoing surgery for anterior shoulder instability between January 1, 1994, and July 31, 2016, in a defined geographic area. Patient medical records were reviewed to obtain demographic information, patient history, physical examination findings, imaging findings, clinical progression, surgical details, and outcomes. Comparative analysis was performed between patients who underwent surgery after a single dislocation and those who underwent surgery after multiple preoperative dislocations. Results The study population consisted of 187 patients who had a single anterior shoulder dislocation (n = 55) or multiple anterior shoulder dislocations (n = 132) prior to surgery. The mean follow‐up period was 103.3 months (range, 0.3‐328.4 months). Demographic characteristics were not significantly different between groups. Although the presence of Hill‐Sachs lesions on radiographs was more common in the multiple‐dislocation group (42.1%) than in the single‐dislocation group (18.8%, P = .005), there were no other significant differences in concomitant pathology between groups. Latarjet procedures were more commonly performed in the multiple‐dislocation group (12.5% vs 2.1% in the single‐dislocation group, P = .04). There were no other significant differences in surgical techniques and characteristics between groups. Rates of survival free from recurrent instability ( P = .790), revision surgery ( P = .726), and progression to symptomatic osteoarthritis ( P = .588) were not significantly different between groups. Conclusions Although patients with multiple dislocations prior to surgery were more likely to show radiographic evidence of Hill‐Sachs lesions and undergo the Latarjet procedure than those who received surgery after a single dislocation, no significant differences in outcomes with respect to recurrent instability, revision surgery, or progression to symptomatic osteoarthritis were found between these 2 groups at long‐term follow‐up. Level of Evidence Level III, retrospective comparative study.

Purpose To report the annual incidence of anterior shoulder instability (ASI) diagnosis, injury severity, and surgical stabilization in a U.S. population. Methods An established U.S. geographic database was used to identify patients < 40 years old with diagnoses of ASI from 1994‐2016. Medical records were reviewed to obtain patient demographics, histories, imaging results, and surgical details. Age‐ and sex‐specific incidence rates were calculated and adjusted to the 2010 U.S. population. Poisson regression was performed to examine trends by timeline, sex and age. Results The study population consisted of 652 patients with ASI and a mean age of 21.5 years (range, 3.6‐39.5). Comparing 2015‐2016 to 1994‐1999, we found an increase in the number of dislocations (from 1.0‐1.9; P = 0.016) and total instability events (from 2.3‐3.4; P = 0.041) per patient prior to presentation to a physician. There was a trend in increased diagnosis of bony Bankart and/or Hill‐Sachs on MRI over time, with these lesions documented in 96% of patients undergoing MRI in 2015‐2018 compared to 52.9% in 1994‐1999 ( P < .001). The use of arthroscopic procedures increased and peaked in 2005‐2009 (90% of surgical cases performed). The proportion of open Latarjet procedures increased from 2010‐2014 (14%) and 2015‐2018 (31%). Conclusions The age‐ and sex‐ adjusted incidence of ASI diagnosis in a U.S. population from 1994‐2016 is comparable to that demonstrated in Canadian and European populations. This study demonstrates an increasing number of instability events prior to surgical evaluation, which may correlate with patients’ more commonly presenting with bone loss and requiring more aggressive surgical treatment or that ASI is being more frequently cared for and documented by present‐day orthopedic surgeons. Level of Evidence Level III, cross‐sectional study.