Faculty Bibliography

OBJECTIVE:To retrospectively validate the diagnostic power of attenuation values on chest and abdomen/pelvis CECTs, together and separately, compared with dual-energy X-ray absorptiometry (DEXA)-determined osteoporosis diagnoses, and to determine thresholds for accurate osteoporosis diagnosis. MATERIALS AND METHODS/METHODS:Subjects were identified using the electronic health record. Included patients received DEXA and CECT scans within 60 days of each other. Patients were excluded if taking osteoporosis medication, undergoing dialysis, receiving hormone or cancer therapy, had a history of cancer, osseous metastases, fractures, or compressions. Minimum, mean, and maximum CECT attenuation values of L1 trabecular bone axial cross-sections were measured by a non-physician in Hounsfield units (HUs) using an elliptical region of interest (ROI) tool. DEXA diagnoses were dichotomized as positive (osteoporosis) or negative (osteopenia/normal). The area under the receiver-operator characteristic curves (AUCs) were compared to identify ideal CECT attenuation thresholds. RESULTS:Two hundred nineteen subjects (mean age 66 ± 0.6 [range 35-92]; 196 (89%) females and 23 (11%) males) were included for analysis. Thirty-one (14%) subjects were positive and 188 (86%) were negative for osteoporosis. Minimum, mean, and maximum combined chest and abdomen/pelvis attenuation values demonstrated AUCs of 0.75 (95% CI 0.67-0.84), 0.931 (95% CI 0.88-0.99), and 0.82 (95% CI 0.73-0.90). The optimal mean attenuation threshold for osteoporosis diagnosis was 120 HU (84% sensitive, 90% specific). There was no statistical difference in diagnostic power between mean attenuation values of chest and abdomen/pelvis CECTs. CONCLUSION/CONCLUSIONS:CECT mean attenuation values of either chest or abdomen/pelvis CECTs could be used as appropriate thresholds in screening for osteoporosis.

RATIONALE AND OBJECTIVES/OBJECTIVE:Multiple modalities exist for diagnosing ulnar neuropathy at the elbow (UNE), including electrodiagnostic testing (EDX), ultrasound (US), and magnetic resonance imaging (MRI), with no consensus on the optimal strategy. This study's objective was to determine the most cost-effective diagnostic strategy in patients with suspected UNE. MATERIALS AND METHODS/METHODS:We developed a decision analytic model from the U.S. healthcare perspective over a 1-year time horizon. Our hypothetical population comprised 56-year-old males with medial elbow pain and/or paresthesias radiating to the hand, without weakness. We compared incremental cost-effectiveness and total net monetary benefit (NMB) of single-modality strategies (EDX, US, MRI) and multimodality strategies (combinations of US/MRI, EDX/US, EDX/MRI). Input probabilities and utility values were obtained from the literature, and costs from Centers for Medicaid & Medicare Services and institutional data. The primary outcome was quality-adjusted life years (QALYs). Willingness-to-pay threshold was $100,000. RESULTS:The diagnostic strategy utilizing US first, followed by MRI, was favored with the highest total QALYs, .935, and total NMB, $92,667. EDX and US single-modality strategies were less favorable, with lower total QALYs, .894 and .906, respectively, and lower total NMB, $88,866 and $90,022. Other diagnostic strategies were excluded by absolute or extended dominance. One-way sensitivity analyses found model results sensitive to the utility of UNE recovery, but otherwise robust over a range of costs/probabilities. CONCLUSION/CONCLUSIONS:Our cost-effectiveness analysis suggests an initial US, then MRI is the most cost-effective strategy in the workup of patients with suspected UNE.

OBJECTIVE:To determine the cost-effectiveness of different imaging modalities for initial detection of multiple myeloma (MM)-defining bone lesions. METHODS:A Markov model from the health care system perspective for patients with MGUS was used to evaluate the incremental cost-effectiveness of five imaging techniques: skeletal survey (SS), low-dose computed tomography (LDCT), positron emission computed tomography (PETCT), and whole-body magnetic resonance imaging (WBMRI) with and without diffusion (DIFF). Model inputs, including probabilities, utilities, and costs were obtained from comprehensive literature review. Costs were estimated in 2024 U.S. dollars, effectiveness was measured in quality adjusted life years (QALYs), willingness-to-pay (WTP) threshold was set to $100,000/QALY, and timeframe of the simulation was 20 years. Model analyses included Monte Carlo microsimulation and probabilistic sensitivity analysis (PSA). RESULTS:The most cost-effective imaging strategy was dependent on the number of patient risk factors for progression from MGUS to myeloma. At a WTP threshold of $100,000, for patients with no risk factors for progression, LDCT amassed the greatest net monetary benefit (NMB) ($1,030,913.57) while incurring the second lowest costs ($44,870.73). For patients with 1 or 2 risk factors for progression, WBMRI + DIFF amassed the greatest NMB (1 risk factor: $802,637.30, 2 risk factors: $664,430.36). WBMRI and PETCT were absolutely dominated in all cases. PSA also found that the most cost-effective strategy was dependent on the WTP threshold. CONCLUSION/CONCLUSIONS:Our model suggests that LDCT and WBMRI + DIFF can be the most cost-effective imaging strategies for the initial diagnosis of MM in patients, depending on the number of risk factors for progression.

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.

PURPOSE/OBJECTIVE:The aim of this study was to use the National Ambulatory Medical Care Survey database to assess MRI utilization in patients 50 years and older with atraumatic hip or knee pain. METHODS:National Ambulatory Medical Care Survey weighted survey data (2007-2019) were obtained for ambulatory visits in patients 50 years and older with atraumatic hip or knee pain. The outcome variable was MRI ordering status, and analyzed characteristics included patient age, race/ethnicity, payer, physician specialty, metropolitan statistical area, and a coexistent radiography order. Multivariable logistic regressions were conducted to assess the association between MRI ordering status and the analyzed patient characteristics. All tests were two sided, and P values ≤.05 were considered to indicate statistical significance. RESULTS:In total, 88,978,804 knee pain and 28,675,725 hip pain patient visits (survey weighted) were analyzed, with 4,690,943 (5.3%) and 2,023,226 (7.1%) having knee or hip MRI orders, respectively. Overall, 2,454,433 knee pain visits (2.8%) and 575,155 hip pain visits (2.0%) had orders for both MRI and radiographs. Black patients (P = .03) and patients 80 years and older (P = .04) were less likely to have knee MRI ordered, whereas uninsured patients were less likely to have hip MRI ordered (P = .01). Patients with hip pain were more likely to have hip MRI ordered if seen by a surgical subspecialist (P = .01). CONCLUSIONS:A low proportion of MRI examinations were ordered for visits in patients 50 years and older with atraumatic hip or knee pain. Groups with lower health care access were less likely to have an MRI order, highlighting known disparities in health care equity.

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.

PURPOSE/OBJECTIVE:To report osteoporosis screening utilization rates among Asian American (AsA) populations in the USA. METHODS:We retrospectively assessed the use of dual-energy X-ray absorptiometry (DXA) screening using the Medicare 5% Research Identifiable Files. Using Current Procedural Terminology (CPT) codes indicative of a DXA scan, we identified patients recommended for DXA screening according to the ACR-SPR-SSR Practice Parameters (females ≥ 65 years, males ≥ 70 years). Sociodemographic factors and their association with screening were evaluated using chi-square tests. RESULTS:There were 80,439 eligible AsA beneficiaries, and 12,102 (15.1%) received osteoporosis screening. DXA rate for women was approximately four times greater than the rate for men (19.8% vs. 5.0%; p < 0.001). AsA beneficiaries in zip codes with higher mean household income (MHI) were more likely to have DXA than those in lower MHI areas (17.6% vs. 14.3%, p < 0.001). AsA beneficiaries aged < 80 were more likely to receive DXA (15.5%) than those aged ≥ 80 (14.1%, p < 0.001). There were 2,979,801 eligible non-AsA beneficiaries, and 496,957 (16.7%) received osteoporosis screening during the study period. Non-Hispanic white beneficiaries had the highest overall screening rate (17.5%), followed by North American Native (13.0%), Black (11.8%), and Hispanic (11.1%) beneficiaries. Comparing AsA to non-AsA populations, there were significantly lower DXA rates among AsA beneficiaries when controlling for years of Medicare eligibility, patient age, sex, location, and mean income (p < 0.001). CONCLUSION/CONCLUSIONS:We found lower than expected DXA screening rates for AsA patients. A better understanding of the barriers and facilitators to AsA osteoporosis screening is needed to improve patient care.

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.