Faculty Bibliography

BACKGROUND:This study compares the outcomes of Latarjet-Patte procedures (LPs) performed for primary glenohumeral instability in the setting of critical bone loss (LP-BL) versus salvage surgery performed after a failed arthroscopic Bankart repair (LP-FB). METHODS:LP's performed by senior author from 2017 to 2021 were separated into cohorts by LP indication. Data abstracted from electronic medical records included demographic information, preoperative clinical scores, radiological imaging, and complications. Postoperative clinical outcome scores collected after a 2-year minimum follow-up included: patient-reported outcomes measurement information system (PROMIS) upper extremity (UE), PROMIS pain interference, PROMIS pain intensity, American Shoulder and Elbow Surgeons (ASES), and visual analog scale pain scores. RESULTS:A total of 47 patients (LP-BL: n=29, LP-FB: n=18) with a mean age of 29 years (range, 15-58 years) were included in this study. Both cohorts achieved good upper extremity functionality without significant differences as indicated by mean PROMIS UE (LP-BL: 52.6±10.0 vs. LP-FB: 54.6±7.6, P=0.442) and ASES score (LP-BL: 89.9±15.7 vs. LP-FB: 91.5±14.4, P=0.712). However, the LP-FB cohort reported lower levels of pain (LP-FB: 0.5±1.1 vs. LP-BL: 1.9±2.7, P=0.020) at their latest follow-up. There were no significant differences in complication rates including re-dislocation between cohorts (LP-BL: 2/29 [6.9%] vs. LP-FB: 2/18 [11.1%], P=0.629). CONCLUSIONS:When performed after failed Bankart repair, the LP results in similar postoperative functional outcomes and similar rates of complications and re-dislocations when compared to the primary indication of recurrent glenohumeral instability in the setting of critical bone loss. Level of evidence: III.

OBJECTIVE:To determine the cost-effectiveness of rotator cuff hydroxyapatite deposition disease (HADD) treatments. METHOD/METHODS:A 1-year time horizon decision analytic model was created from the US healthcare system perspective for a 52-year-old female with shoulder HADD failing conservative management. The model evaluated the incremental cost-effectiveness ratio (ICER) and net monetary benefit (NMB) of standard strategies, including conservative management, ultrasound-guided barbotage (UGB), high- and low-energy extracorporeal shock wave therapy (ECSW), and surgery. The primary effectiveness outcome was quality-adjusted life years (QALY). Costs were estimated in 2022 US dollars. The willingness-to-pay (WTP) threshold was $100,000. RESULTS:For the base case, UGB was the preferred strategy (0.9725 QALY, total cost, $2199.35, NMB, $95,048.45, and ICER, $33,992.99), with conservative management (0.9670 QALY, NMB $94,688.83) a reasonable alternative. High-energy ECSW (0.9837 QALY, NMB $94,805.72), though most effective, had an ICER of $121, 558.90, surpassing the WTP threshold. Surgery (0.9532 QALY, NMB $92,092.46) and low-energy ECSW (0.9287 QALY, NMB $87,881.20) were each dominated. Sensitivity analysis demonstrated that high-energy ECSW would become the favored strategy when its cost was < $2905.66, and conservative management was favored when the cost was < $990.34. Probabilistic sensitivity analysis supported the base case results, with UGB preferred in 43% of simulations, high-energy ECSW in 36%, conservative management in 20%, and low-energy ECSW and surgery in < 1%. CONCLUSION/CONCLUSIONS:UGB appears to be the most cost-effective strategy for patients with HADD, while surgery and low-energy ECSW are the least cost-effective. Conservative management may be considered a reasonable alternative treatment strategy in the appropriate clinical setting.

PURPOSE/UNASSIGNED:Arthroscopic Bankart repair (ABR) may be more effective than nonoperative management for patients with anterior shoulder instability following first-time dislocation. The purpose of the study was to determine the most cost-effective treatment strategy by evaluating the incremental cost-effectiveness ratio (ICER) for ABR versus nonoperative treatment. METHODS/UNASSIGNED:This cost-effectiveness study utilized a Markov decision chain and Monte Carlo simulation. Probabilities, health utility values, and outcome data regarding ABR and nonoperative management of first-time shoulder instability derived from level I/II evidence. Costs were tabulated from Centers for Medicaid & Medicare Services. Probabilistic sensitivity analysis was performed using >100,000 repetitions of the Monte Carlo simulation. A willingness-to-pay (WTP) threshold was set at $50,000. RESULTS/UNASSIGNED:The expected cost for operative management higher than nonoperative management ($32,765 vs $29,343). However, ABR (5.48 quality-adjusted life years (QALYs)) was the more effective treatment strategy compared to nonoperative management (4.61 QALYs). The ICER for ABR was $3943. Probabilistic sensitivity analysis showed that ABR was the most cost-effective strategy in 100% of simulations. DISCUSSION/UNASSIGNED:ABR is more cost-effective than nonoperative management for first-time anterior shoulder dislocation. The threshold analysis demonstrated that when accounting for WTP, ABR was found to be the more cost-effective strategy.

OBJECTIVE:To evaluate the efficacy of a multimodal intervention in reducing CT pulmonary angiography (CTPA) overutilization in the evaluation of suspected pulmonary embolism in the emergency department (ED). METHODS:Previous mixed-methods analysis of barriers to guideline-concordant CTPA ordering results was used to develop a provider-focused behavioral intervention consisting of a clinical decision support tool and an audit and feedback system at a multisite, tertiary academic network. The primary outcome (guideline concordance) and secondary outcomes (yield and CTPA and D-dimer order rates) were compared using a pre- and postintervention design. ED encounters for adult patients from July 5, 2017, to January 3, 2019, were included. Fisher's exact tests and statistical process control charts were used to compare the pre- and postintervention groups for each outcome. RESULTS:Of the 201,912 ED patient visits evaluated, 3,587 included CTPA. Guideline concordance increased significantly after the intervention, from 66.9% to 77.5% (P < .001). CTPA order rate and D-dimer order rate also increased significantly, from 17.1 to 18.4 per 1,000 patients (P = .035) and 30.6 to 37.3 per 1,000 patients (P < .001), respectively. Percent yield showed no significant change (12.3% pre- versus 10.8% postintervention; P = .173). Statistical process control analysis showed sustained special-cause variation in the postintervention period for guideline concordance and D-dimer order rates, temporary special-cause variation for CTPA order rates, and no special-cause variation for percent yield. CONCLUSION/CONCLUSIONS:Our success in increasing guideline concordance demonstrates the efficacy of a mixed-methods, human-centered approach to behavior change. Given that neither of the secondary outcomes improved, our results may demonstrate potential limitations to the guidelines directing the ordering of CTPA studies and D-dimer ordering.

PURPOSE/OBJECTIVE:The purpose of this systematic review is to evaluate the current literature on the use of image-guided corticosteroid injections in the treatment of patients with knee and hip OA. EVIDENCE ACQUISITION/METHODS:We conducted a comprehensive literature search through June 30, 2022. Publication type, study design, imaging guidance modality, osteoarthritis severity, number of injections, steroid type and dose, anesthetic type and dose, the total number of patients, follow-up intervals, and measured outcomes were extracted from the included studies. EVIDENCE SYNTHESIS/RESULTS:There were 23 included studies (10 hips, 12 knees, 1 both hip and knee). Hip injections were found to be effective in treating short- and long-term pain and more effective than hyaluronic acid, Mepivacaine, NSAIDs, and normal saline in terms of improvement in pain and/or function. There was less impact on QoL. Knee injections were found either to have little or no impact or were similar or inferior to comparison injections (intra-articular hyaluronic acid, PRP, NSAIDs, normal saline, adductor canal blocks). Study data could not be aggregated because the corticosteroid types and doses, methods of outcome assessment, and follow-up time points varied widely. CONCLUSION/CONCLUSIONS:Our systematic review found generally positive outcomes for the hip, but overall negative outcomes for the knee, although hip injections may carry a risk of serious adverse outcomes. A larger trial with uniform methodology is warranted. Specific studies on the adverse effects of corticosteroid injections are also warranted.

PURPOSE/OBJECTIVE:The current investigation evaluated the relationship between the synovial fluid cytokine microenvironment at the time of isolated anterior cruciate ligament (ACL) reconstruction and the presence of subsequent chondral wear and radiologic evidence of osteoarthritis (OA) on cartilage-specific MRI sequences at a minimum of 5-year follow-up. METHODS:Patients who underwent primary ACL reconstruction with no baseline concomitant cartilage or meniscal defects and had synovial fluid samples obtained at the time of surgery were retrospectively identified. Patients with a minimum of 5 years of postoperative follow-up were contacted and asked to complete patient-reported outcome (PRO) measures including Visual Analog Scale (VAS) for pain, Lysholm Scale, Knee Injury and Osteoarthritis Outcome Score (KOOS), and Tegner Activity Scale, along with postoperative magnetic resonance imaging (MRI). The concentration of ten biomarkers that have previously been suggested to play a role in cartilage degradation and inflammation in the joint space was measured. Linear regression controlling for age, sex, and body mass index (BMI) was performed to create a model using the synovial fluid concentrations at the time of surgery to predict postoperative semiquantitative cartilage lesion size and depth on MRI at a minimum of 5 years follow up. RESULTS:The patients were comprised of eight males (44.4%) and ten females (55.6%) with a mean age at the time of surgery of 30.8 ± 8.7 years (range 18.2-44.5 years). The mean follow-up time was 7.8 ± 1.5 years post-operatively (range 5.7-9.7 years). MCP-1, VEGF, and IL-1Ra were found to have significant associations with the presence of postoperative cartilage wear (p < 0.05). No correlations were demonstrated among the biomarker concentrations at the time of injury with PRO scores at final follow-up (NS). CONCLUSION/CONCLUSIONS:Synovial fluid inflammatory biomarker concentrations at the time of injury can predict progression of early-stage post-traumatic osteoarthritis at a mean of almost 8 years post-operatively. Findings from this study may help identify treatment targets to alter the natural history of cartilage loss following anterior cruciate ligament injury. LEVEL OF EVIDENCE/METHODS:Level III, retrospective cohort study.