Sunday, January 22, 2017

Risk adjustment - is this the best way to save money in shoulder arthroplasty?

Perioperative Risk Adjustment for Total Shoulder Arthroplasty: Are Simple Clinically Driven Models Sufficient?

The first sentence in this article is "There is growing interest in value-based health care in the United States."

CORR Insights1: Perioperative Risk Adjustment for Total Shoulder Arthroplasty: Are Simple Clinically Driven Models Sufficient?

The first two sentences in this discussion of the paper are "With increasing pressure on healthcare budgets around the globe, it is vital for healthcare providers to demonstrate that their procedures deliver value. If we want to improve the value of healthcare, we will need to institute substantial cost-saving measures."

Comment: The assessment of preoperative risk is important, not so much because it holds promise for improving the value of health care, but because it enhances clinical decision making and informed consent and because it enables providers to anticipate and attempt to prevent adverse outcomes.

If we were serious about improving the value of total shoulder arthroplasty, we would study the value to the patient of the many new technologies featured in every orthopedic journal as suggested here:

Recently the Congressional Budget Office published a report on Technological Change and the Growth of Health Care Spending.

This publication points to the rising costs of health care as the nation's central long-term fiscal challenge. We have summarized some of the important statements in this document here.

Over the past four decades, health care spending has roughly tripled as a share of the economy - from about 5 percent of GDP in 1960 to more than 15 percent today. Health care costs per person are rising faster than income.There has been a sharp increase in health care costs as a share of GDP-from 12.5 percent in 1999 to 14.5 percent in 2005. Most analysts agree that the most important factor has been the emergence, adoption, and widespread diffusion of new medical technologies and services: approximately half of all long-term growth in health care spending has been associated with technological advances.
Under CBO's projections, health care spending will double by 2035, reaching 31 percent of GDP. Thereafter, health care costs will continue to account for a steadily growing share of GDP, reaching 41 percent by 2060 and 49 percent by the end of the 75-year projection period.
Net federal spending on Medicare and Medicaid now accounts for about 4 percent of GDP. That rises to 12 percent by 2050 and 19 percent by 2082.
Most of that increase is due to excess cost growth, not to an aging population.
The rise in health care spending is the largest contributor to the growth projected for federal spending over the long term.
All of these projections raise fundamental questions of economic sustainability.

The report notes that costly technologies known to be highly effective in some types of patients are often provided to other patients for whom clinical benefits have not been rigorously demonstrated.

We surely see this in the practice of orthopaedics - CT scans and MRI's are used when plain films are sufficient, more complex prostheses are used when simpler and less expensive ones yield similar results, complex surgeries are used when simpler ones or non operative management work equally well, and complex preoperative planning and patient specific instrumentation systems are proposed for routine use.

The point is that each of us can help assure that expensive technologies are used only when expensive technologies are necessary.

If we really want to improve value, we should take a hard look at how the money is being spent.


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Reverse total shoulder in young patients, why is it done and what are the results?

Reverse shoulder arthroplasty in patients younger than 55 years: 2- to 12-year follow-up

These authors reviewed sixty-seven patients (average age, 47.9 years; range, 21-54 years) having reverse total shoulders (RSA) at an average 62.3 months of follow-up (24-144 months). There were 35 patients (group 1) who had RSA for a failed arthroplasty and 32 patients (group 2) who had primary RSA.

Of note is that many of the patients in either group had had prior surgery.



While both groups showed significant improvements in ASES and SST scores, these improvements were modest. In group 1, ASES score improved from 24.4 to 40.8 (P = .003), and SST score improved from 1.3 to 3.2 (P = .043). In group 2, ASES score improved from 28.1 to 58.6 (P < .001), and SST score improved from 1.3 to 4.5 (P = .004). 

The total complication rate was 22.4%. 
The total reoperation rate was 13.4%.
The revision rate was 8.9%. 
Infection was the cause of all revisions. We are not informed of which types of bacteria caused the infection.

Group 1 had 2 patients with humeral lucency (1 treated conservatively), 2 with glenoid screw lucency (treated conservatively), 2 with periprosthetic fractures (1 treated conservatively), 1 with humeral dissociation, 1 with infection, and 1 with recurrent instability (treated conservatively).

Group 2 had 1 patient with scapular fracture (healed conservatively), 1 patient with symptomatic hardware after fixation for an os acromiale at the time of index surgery, and 4 patients with periprosthetic infections.

The total reoperation rate was 13.4% (11.4% in group 1 and 15.6% in group 2). The revision rate was 8.9% (5.7% in group 1 and 12.5% in group 2).

Group 1 had 1 reoperation for open reduction and internal fixation of a periprosthetic humerus fracture. One patient underwent a resection arthroplasty for a persistent periprosthetic infection. Two patients were revised in group 1 (1 for dissociation of humeral modular component and 1 for resorption of humeral allograft and humeral loosening).

Group 2 had 1 reoperation for removal of symptomatic hardware after open reduction and internal fixation of an os acromiale at the time of index surgery. Four patients required revision in group 2 (all were revised because of infection).

Comment: These results at the hands of high volume reverse arthroplasty surgeons can inform our decision making and discussions with young patients considering arthroplasty. While the authors present the results from two groups based on whether the patient had a prior arthroplasty, we can assume that essentially all of the patients had prior surgery. Mindful of the information in a prior post, "The risk of shoulder joint replacement infection is doubled by prior surgery on the shoulder", it is not surprising that infection was the most common reason for revision surgery. In patients having RSA after prior surgery, the surgeon may consider obtaining preemptive cultures at the time of the RSA and recognize that any deviation from the expected course may be due to the stealth presentation of an infection.

The risk of shoulder joint replacement infection is doubled by prior surgery on the shoulder

Is previous nonarthroplasty surgery a risk factor for periprosthetic infection in primary shoulder arthroplasty?

These authors reviewed 4577 patients including 2890 with total shoulder arthroplasties, 1233 with hemiarthroplasties, and 454 with reverse total shoulders 813 (18%).

Medical records and the surgeon’s clinical notes and operative reports were reviewed to determine the type of prior surgery. These were categorized as rotator cuff repair (353), open reduction and internal fixation (185), d├ębridement for nonseptic reasons (235), acromioplasty (111), capsular repair (131), hardware removal (35), and other surgeries (152).

Deep postoperative infection of the shoulder was diagnosed in 68 patients (1.49%). An infected arthroplasty was diagnosed by the presence of 1 or both of the following: (1) positive joint fluid culture from needle aspiration, arthroscopic procedure, fluid obtained at surgery, or fluid draining from a wound communicating  with the humerus or (2) positive synovial or bone tissue culture. In those patients without a positive joint fluid culture, the presence of a clinical infection was determined when the treating orthopedic surgeon believed an infection was present on the basis of clinical presentation (history and physical examination), documentation in the surgeon’s note, and one or both of the following: (1) operative findings including purulent joint fluid, thick serosanguineous joint fluid, or the presence of necrotic synovial tissue or (2) a positive blood culture. The criteria for diagnosing 'infection' obviously affect the rate with which it is diagnosed. On one hand the authors recognize the possibility of 'culture negative' infection. On the other hand, it is recognized that cultures of joint fluid aspirates may be negative in the presence of positive deep cultures of tissue and explants as is emphasized in this link. The authors do not provide the data on the type of organisms cultured.

Of the 813 patients who had undergone previous surgery, 20 (2.46%) developed a deep postoperative infection. 

Of the 3764 patients who did not have previous shoulder surgery, 48 patients (1.28%) sustained deep shoulder infection. This difference was significant in both the univariate (P = .0094) and multivariate analyses (P = .0390). A higher number of previous surgeries was significantly associated with an increased risk of deep postoperative infection (P = .0272).

Younger age and male gender were significantly associated with a higher risk of deep postoperative infection (P = .0150 and P = .0074, respectively).  Patients undergoing SA for cuff tear arthropathy (HR, 3.49; 95% CI, 1.60-7.27; P = .0020) or in the setting of acute trauma (HR, 4.49; 95% CI, 1.33- 10.61; P = .0117) had a significantly increased risk of deep postoperative infection in the multivariable analysis.

Comment: The messages are clear: (1) surgeons need to be aware that even 'minor' surgeries (such as joint debridement) can increase the risk of infection in a subsequent joint replacement and (2) surgeons and patients need to discuss the fact that a shoulder arthroplasty on a previously operated shoulder has almost twice the risk of becoming infected. Surgeons need to consider obtaining 'preemptive' cultures at the time of arthroplasty in such cases and to be aware that a deviation from the expected postoperative course may represent the stealth presentation of a periprosthetic infection.

These authors are not the first to point out the relationship between prior surgery and shoulder arthroplasty infection. Their findings are similar to those of a prior article, our post on which is reproduced here:
Infection after primary anatomic versus primary reverse total shoulder arthroplasty.

These authors reviewed 814 primary total shoulder arthroplasties and found deep periprosthetic infections in 16: 6 anatomic total shoulders (aTSA)  and 10 reverse total shoulders (rTSA).

The surgical technique included the use of surgical hoods, limitation of operating room traffic, 
antibiotic prophylaxis with intravenous cefazolin (or clindamycin in cases of b-lactam allergy) at
least 30 minutes before the incision, followed by 3 additional postoperative doses. Preparation of the surgical site was with chlorhexidine.

The infections were determined by retrospective chart review. An infection was diagnosed by joint fluid culture or tissue/bone culture. Infections occurred in 7 women (44%) and in 9 men (56%).
The isolated causative organisms were Staphylococcus  spp in 7 patients (43.8%), Propionibacterium
acnes  in 7 (43.8%), Escherichia coli  in 1 (6.3%), and both Staphylococcus  spp and P acnes  in 1 (6.3%). The prior surgeries included rotator cuff repair in 5, Bankart repair in 1, ORIF for fracture in 1, and arthroscopic debridement/biceps tenotomy in 1. The patient with the E coli infection had no prior surgery.

Shoulders with previous nonarthroplasty operations undergoing primary TSA exhibited a significantly higher (P = .016) infection rate compared with shoulders with no operative history. 

Both aTSA and rTSA performed in previously operated-on shoulders demonstrated higher infection rates compared with shoulders with no prior operative intervention. 

Comment: We prepared this chart to make the data from this study a bit easier to grasp.




These data indicate that patients with prior surgery have an increased risk of sustaining an infection after shoulder arthroplasty - information that should be shared with candidates for this procedure.

It is likely that these numbers underestimate the number of infections in that we recognize that Propionibacterium infections may present as pain, stiffness and component loosening many years after the index procedure as described in this post.

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Rotator cuff failure is part of getting older

Are degenerative rotator cuff disorders a cause of shoulder pain? Comparison of prevalence of degenerative rotator cuff disease to prevalence of nontraumatic shoulder pain through three systematic and critical reviews


These authors attempted to determine the prevalence estimates for rotator cuff partial or complete tears and to relate this prevalence to the prevalence of self-reported nontraumatic shoulder pain.

Their results remind us that the prevalence of rotators cuff lesions increases gradually after 50 years, whether on correlates clinical clinical findings with person age in the general population (see this link).


or whether one correlates cadaver findings with cadaver age


These data suggest that about 50% of 70 year old people have a partial or complete rotator cuff defect. Because degenerative cuff defects usually progress slowly with time the shoulder and the patient have time to successfully accommodate to the loss of cuff integrity(see this link).

This article prompted us to resurface some of the content of a previous post that emphasizes the clinical importance of recognizing the degenerative nature of cuff failue (see this link).

 Rotator cuff tear and rotator cuff wear.
 "The rotator cuff is the only tendon structure situated between two bones. Compressed between the acromion and the humerus by every motion of the shoulder, it succumbs to the ravages of attrition long before most other tendons. In youth, it is thick, strong, and elastic and can be disrupted only by great force; after middle age, it has worn thin and often becomes so weak and brittle that it ruptures with ease." McLaughlin 1962

Detachment of the rotator cuff tendons from the greater tuberosity is often described as a rotator cuff tear. The word 'tear' suggests an acute process, such as tear in otherwise great blue jeans that can be easily repaired.



On the other hand, most cuff defects arise in tendons of suboptimal quality without an acute traumatic episode and may be better referred to as cuff wear, similar to defects in worn jeans that defy repair.


We emphasize the distinction in an article on rotator cuff failure in the New England Journal as well as in the text, The Shoulder, where we quote McLauhglin's admonition regarding 'rotten cloth to sew' in an Instructional Course Lecture: "The wise surgeon, realizing that he may find little but rotten cloth to sew, will operate only by necessity and make a carefully guarded prognosis. [There was complete agreement of the Panel on this point.]" See these links to his work
Lesions of the musculotendinous cuff of the shoulder. The exposure and treatment of tears with retraction. 1944.

Saturday, January 21, 2017

Economics and shoulder surgery - how much will the sea change?

Medicaid payer status is linked to increased rates of complications after treatment of proximal humerus fractures

These authors note that low socioeconomic status and Medicaid insurance as a primary payer have been associated with major disparities in resource utilization and risk-adjusted outcomes for patients undergoing totaljoint arthroplasty.

Using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database they identified patients who were treated for proximal humeral fractures (PHFs) from 2002 to 2012.

In an effort to minimize confounding variables, each Medicaid patient was matched to a privately insured patient on the basis of gender, race, year of procedure, and age (but notably not to fracture type or type of treatment):



Of the 678,831 patients treated with PHF, 4.9% (33,263) had Medicaid as the primary payer during the 10-year period. Medicaid patients were found to have a significantly higher risk (P < .05) of postoperative in-hospital complications, including postoperative infection (odds ratio [OR], 2.00 [1.37-2.93]), wound complications (OR, 1.69 [1.04-2.75]), and acute respiratory distress syndrome (OR, 1.34 [1.15-1.59]).

They concluded that Medicaid patients have a significantly higher risk for certain postoperative hospital complications and consume more resources after treatment for PHFs.

Comment: It is apparent that our health care system is on the cusp of change with the new administration. Under most any system, however, the observation that Medicaid insurance (which provides relatively low reimbursement) can be a risk factor for an increased rate of complications and for increased per-case expense will continue to create an ethical, social and economic challenge for the providers. This is especially the case if there are penalties for the increased readmission rates that are likely to be necessary to manage the increased rate of complications. Our hope is that broad-based discussion will lead to a well-informed approach so that our patients can get the care they need.



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What happens if a rotator cuff tear is not repaired?


The natural course of nonoperatively treated rotator cuff tears: an 8.8-year follow-up of tear anatomy and clinical outcome in 49 patients

From May 2001 through November 2006, 1 orthopedic surgeon referred to physiotherapy 89 consecutive patients who were diagnosed sonographically and by MRI with an isolated full-thickness tear of the rotator cuff with a tear size of no more than 3 cm, no involvement of the subscapularis tendon, a negative tangent sign for muscle atrophy and a fatty degeneration of no more than stage 2 according to Goutallier.

It is unclear why surgery was not performed on these shoulders and what percent of similar tears were operated on by this surgeon during the same time period? Were these patients too ill (of note 11 could not participate in followup because of serious medical conditions unrelated to the shoulder and 4 had died)? Were they poor candidates for surgery for other reasons? Did they decline surgery because of minimal symptomatology? Or was this surgeon very conservative with the indications for surgery?

Twenty-three had surgical treatment later on but we do not know if this surgery improved the function of these shoulders.  The remaining 49 still unrepaired tears were re- examined after 8.8 (8.2-11.0) years with sonography.

The mean tear size increased by 8.3 mm in the anterior-posterior plane (P = .001) and by 4.5 mm in the medial-lateral plane (P = .001). Increase of tear size was −5 to +9.9 mm in 33 patients, 10 to 19.9 mm in 8 patients, and ≥20 mm in 8 patients. The Constant Score was 81 points for tear increases <20 mm and 58.5 points for increases ≥20 mm (P = .008). Muscle atrophy and fatty degeneration progressed in 18 and 15 of the 37 patients, respectively. In tears with no progression of atrophy, the CS was 82 points compared with 75.5 points in tears with progression (P = .04). 

Comment: This study again demonstrates the uncertain indictions for the different types of management for the different types of cuff tears. 

It is surely of interest that the average Constant scores improved with non operative management

A key question is the relationship of cuff integrity to shoulder function. In that light, it would have been interesting to see a plot of the final Constant score as a function of final tear size and to see a plot of the change in Constant score as a function of change in tear size.

While it may be tempting to use these results as justification for surgical intervention in an attempt to prevent tear enlargement, we do not have evidence that the anatomic or functional outcomes would have been better had these shoulders been operated on.

The bottom line is that, even in spite of some tear enlargement with time, the shoulder comfort and function for these shoulders as reflected by the Constant Score improved over 9 years with non operative management (p<.0001).

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Positive cultures at revision arthroplasty, expecting the unexpected


Future surgery after revision shoulder arthroplasty: the impact of unexpected positive cultures

These authors studied 117 patients having revision shoulder arthroplasty without obvious evidence of infection. The average time from the initial surgery to revision was 4.3 years. 28 of 117 (23.9%) had what they referred to as 'unexpected positive cultures ( UPCs).

The diagnoses at time of revision surgery were rotator cuff dysfunction (32/117; 27.3%), glenoid wear after shoulder hemiarthroplasty/painful shoulder hemiarthroplasty (23/117; 19.7%), glenoid loosening (17/117; 14.5%), dislocation (11/117; 9.4%), malunion/nonunion (11/117; 9.4%), instabil- ity (10/117; 8.6%), arthrofibrosis (7/117; 6.0%), and humeral loosening (6/117; 5.1%). It is not clear from the manuscript what type of revision surgeries were performed for these shoulders, specifically how many had complete single stage exchange of the prosthesis. 

Interestingly, these authors appear to routinely administer at least 2 weeks of empirical oral antibiotics after each revision surgery, so each patient received some antibiotic treatment for a possibly positive culture. The antibiotics used are not described. 18 of 28 (64.3%) patients received antibiotics for 6 weeks postoperatively without complications compared with 10 of 28 (35.7%) who received the routine 2-week empirical antibiotic regimen. The decision to continue antibiotics beyond the 2-week threshold was based on culture results, clinical presentation, and intraoperative findings. Patients with positive cultures for Propionibacterium were variably treated with no antibiotics in 8 cases, with 6 weeks of IV Vancomycin in 5 cases, and with IV Penicillin in two cases.

28 of 117 (23.9%) had what they referred to as 'unexpected positive cultures ( UPCs). 15 (57.1%) of these cultures grew Propionibacterium acnes. However, review of the data (Table II) indicate that three cases had only one specimen submitted for culture and 10 had only two cultures submitted. Over half of the cases had four or fewer cultures sent. It is recognized that the presence of Propionibacterium may be overlooked if a small number of specimens are submitted. The number of specimens submitted for culture in the 89 cases without positive cultures is not presented.

2 of 28 (7.1%) patients with UPCs required future surgery, and only 1 (3.6%) had a recurrent infection. This reinfection was in a patient who grew 1 of 6 cultures positive for P. acnes, and this reinfection was 2.2 years after the index revision. This patient did not receive a course of postoperative antibiotics (outside of the routine 2-week empirical antibiotic regimen). In addition, there were 3 patients without UPCs (3.4%; P = .959) who presented with reinfection. These 3 patients did not receive a course of postoperative antibiotics outside of the routine 2 weeks of empirical postoperative antibiotics.
18 of 89 (20.2%) patients without UPCs required 25 additional surgeries. The difference in reoperation rate between those shoulders with and without UPCs was not statistically significant.

Comment: It is critical to recognize that the need for re-revision after a shoulder arthroplasty revision may be prompted by a wide variety of mechanical factors, so that the overall re-revision rate is not a useful indicator of the importance of culture results. It is also import to recognize that the 28 cases with positive cultures presented years after the index procedure without obvious evidence of infection. This observation makes it impossible to know when a revision surgery with positive cultures has successfully eliminated bacteria from the shoulders.

In cases where these authors performed a single stage revision followed by two weeks of antibiotics, they may have adequately treated the presence of Propionibacterium as pointed out in this article,  Failed shoulder joint replacement: single stage revision when cultures are positive for Propionibacterium. The key in managing Propionibacterium appears to be the removal the implant carrying the infected biofilm.

Shoulder arthroplasty failure may or may not be associated with positive cultures. The role of bacteria in the failure remains unclear, as emphasized in this article, Glenoid loosening - is it predictive of positive cultures? and in this article,  How do revised shoulders that are culture positive for Propionibacterium differ from those that are not? In the latter article the authors reviewed records of 132 shoulders that underwent surgical revision of a shoulder arthroplasty, 66 of which became culture positive for Propionibacterium and 66 did not. The authors found that Propionibacterium-positive and Propionibacterium-negative shoulders were similar with respect to many characteristics; however, Propionibacterium-negative shoulders were revised sooner after the index procedure and were significantly more likely to be female, to have sustained a fall, to have instability, and to have rotator cuff deficiency. Intraoperatively, Propionibacterium-positive shoulders demonstrated more glenoid erosions, glenoid osteolysis, glenoid loosening, and a higher incidence of a soft tissue mem- brane between the humeral component and humeral endosteum. Shoulders culture positive for Propionibacterium were more likely to be culture positive for another bacteria. 
These authors concluded that although Propionibacterium-positive and Propionibacterium-negative shoulders have many similarities, factors such as male gender, delayed presentation, glenoid osteolysis and loosening, humeral membrane, and the absence of instability or cuff failure should arouse suspicion of Propionibacterium and suggest the need for deep cultures and consideration of aggressive surgical and medical treatment.

We conclude that this article demonstrates the need for a standardized approach to culturing and reporting quantitative culture results in cases of revision arthroplasty as emphasized in this article,  Considering the Load of Propionibacterium in Revision Shoulder Arthroplasty. Correlating the standardize quantitative culture results obtained with the management strategy and clinical outcome will inform our future understanding and management of failed shoulder arthroplasty.


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