Outpatient Arthroscopic Rotator Cuff Repair Research Articles

Do web-based follow-up surveys have a better response rate than traditional paper-based questionnaires following outpatient arthroscopic rotator cuff repair? A randomized controlled trial

IntroductionConsidering the extensive use of smartphones in current societies, web-based applications could be considered as a new option for patient follow-up in surgery. By means of such tool, automated and periodic questionnaires could improve the rigor, accuracy and the comprehensiveness of postoperative monitoring, as well as early detection of complications, especially in the current context of evolving ambulatory surgery. HypothesisThe web-based surveys would improve the quality of immediate postoperative monitoring. Material and methodsFor 7 months, we included all patients who underwent outpatient arthroscopic rotator cuff repair. After preoperative randomization, each patient was asked postoperatively to complete either paper-based forms or digital questionnaires via a website (Orthense.com®, Digikare Inc. Blagnac, France). Both media (i.e. paper and digital) followed the same postoperative agenda (i.e., D+3, D+14, D+28, D+45, D+90) and had the same content, including pain and discomfort assessments, functional scores (i.e. Shoulder subjective value, simple shoulder test and auto-constant scores). The main objective was to investigate the quality of postoperative follow-up after outpatient arthroscopic rotator cuff surgery, using either printed questionnaires or web-based surveys. The hypothesis was that using a web-based survey would result in greater response rates and increased patient satisfaction regarding follow-up. Primary outcomes were questionnaire response rates at D+45 and D+90, while secondary outcomes were overall response rates, patient recommendation for the monitoring medium and overall patient satisfaction regarding their follow-up using the net promoter score (NPS). ResultsAmong the 59 consecutive patients who were included, there were 27 females and 26 males with a mean age of 57±10.2 years; 27 patients completed the web-based survey (Group A) and 26 patients answered paper-based questionnaires (Group B). Regarding the D+45 questionnaire, response rates were 85.2% (n=23) in group A and 42.3% (n=11) in group B (p=.005); a similar significant difference was observed regarding the D+90 questionnaire, with response rates of 70.4% and 34.6%, respectively (p=.027). The mean NPS for the survey was 10 in Group A and 8.29 in Group B (p=.016). Overall, satisfaction regarding postoperative care did not differ between the two groups. DiscussionCompared to traditional paper-based forms, web-based surveys appear to increase patient adherence to short-term postoperative monitoring. If these findings were to be confirmed in long-term follow-up, such straightforward and cost-effective tool could be of great use in clinical care and research. Level of evidenceI; Randomized controlled clinical trial.

Single-Shot Liposomal Bupivacaine Reduces Postoperative Narcotic Use Following Outpatient Rotator Cuff Repair: A Prospective, Double-Blinded, Randomized Controlled Trial.

Liposomal bupivacaine (LB) theoretically is longer-acting compared with conventional bupivacaine. The purpose of this study was to compare conventional bupivacaine combined with dexamethasone (control group), LB combined with conventional bupivacaine (LB group), and LB combined with dexamethasone and conventional bupivacaine (LBD group) in a perineural interscalene nerve block during ambulatory arthroscopic rotator cuff repair to determine if LB decreased postoperative narcotic consumption and pain. The effect of supplemental dexamethasone on prolonging the analgesic effect of LB was also assessed. This was a prospective, double-blinded, randomized controlled trial of 76 consecutive patients who underwent outpatient arthroscopic rotator cuff repair. Patients were randomized into the 3 interscalene-block treatment groups: control group (n = 26), LB group (n = 24), and LBD group (n = 26). Outcome measures included pain measured with a visual analog scale (VAS; 0 to 10) and narcotic consumption measured in oral morphine milligram equivalents (MME). Both were measured daily on postoperative day 0 through postoperative day 4. Generalized estimating equation modeling revealed that narcotic consumption across all time points (postoperative days 0 to 4) was significantly lower in the LB group compared with the control group (mean difference, -8.5 MME; 95% confidence interval, -15.4 to -1.6; p = 0.015). Narcotic consumption was significantly higher in the control group on postoperative days 2 and 3 compared with the LB group (p = 0.004 and p = 0.02, respectively) and the LBD group (p = 0.01 and p = 0.003, respectively). There was no difference in narcotic consumption between the LBD and LB groups on any postoperative day. VAS pain scores in all groups were similar across all postoperative days. Among patients undergoing outpatient arthroscopic rotator cuff repair, the addition of LB to conventional bupivacaine in interscalene nerve blocks appeared to be effective in controlling postoperative pain. Because LB with and without dexamethasone decreased postoperative narcotic use, LB should be considered for use in preoperative interscalene nerve blocks to reduce the reliance on narcotics for pain management. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Comparison of Subacromial Injection and Interscalene Block for Immediate Pain Management After Arthroscopic Rotator Cuff Repair

To compare the efficacy of a subacromial injection (SAI) with a single-shot interscalene block (ISB) for immediate postoperative pain relief after outpatient arthroscopic rotator cuff repair (ARCR). We performed a retrospective chart review of consecutive patients who underwent ARCR. Patients received either an ISB before the procedure or an SAI after the procedure. Preoperative baseline patient characteristics were collected and compared. Visual analog scale (VAS) pain scores were recorded preoperatively, at 15-minute intervals over a 120-minute period in the postanesthesia care unit (PACU), and at discharge. Differences in VAS scores between groups were compared with known values of the minimal clinically important difference, and the percentage of patients with VAS scores below the patient acceptable symptom state was tabulated. Differences between preoperative characteristics were assessed using the Mann-Whitney U, Fisher exact, or χ2 test. The Mann-Whitney U test was also used to evaluate VAS scores and total time spent in the PACU between groups. The median VAS score was significantly lower in the ISB group at PACU admission, at all intervals throughout the PACU stay, and at discharge (P < .0001). The median total time in the PACU was 107 minutes (25th percentile-75th percentile, 90-120 minutes) and 210 minutes (25th percentile-75th percentile, 175-274 minutes) in the ISB and SAI groups, respectively (P < .0001). Between-group differences in VAS scores were greater than the values of the minimal clinically important difference at each measured interval. A total of 98% and 67% of patients in the ISB and SAI groups, respectively, were discharged with VAS scores below the patient acceptable symptom state of3. Patients receiving an ISB experience significantly less pain than those receiving an SAI. In addition, they are discharged home from the PACU in half the time as patients receiving an SAI. On the basis of the comparative efficacy, an SAI cannot replace an ISB after ARCR. The ISB should therefore remain the standard of care as an adjunct to postoperative analgesia for patients who undergo outpatient ARCR. Level III, retrospective, comparative therapeutic trial.

Unanticipated Admission Following Outpatient Rotator Cuff Repair: An Analysis of 18,061 Cases.

The objective of this investigation was to examine the characteristics that place patients at risk for unanticipated inpatient admission after outpatient arthroscopic rotator cuff repair. This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program data sets from years 2012 to 2015. Patients were included in the study based on the presence of a primary Current Procedural Terminology code for rotator cuff repair (23410, 23412, 23420, and 29827). Only outpatient, nonemergent, and elective procedures performed on patients with American Society of Anesthesiologists classification of 4 or less were considered. The primary outcome variable was admission after outpatient surgery (defined as length of initial hospital stay >0). This study examined risk factors for unanticipated admission following rotator cuff repair, finding that age of 65 years or older, female sex, hypertension, body mass index of 35 kg/m2 or greater, American Society of Anesthesiologists classification of 2 or greater, and open surgical technique were significant predictors of admission, whereas monitored anesthesia care and regional anesthesia were associated with decreased odds of admission. Identifying patients with these characteristics will be critical in risk adjusting the anticipated cost of the episode of care in outpatient rotator cuff repair. [Orthopedics. 2018; 41(3):164-168.].

Factors influencing direct clinical costs of outpatient arthroscopic rotator cuff repair surgery

Very limited information exists about factors affecting direct clinical costs of rotator cuff repair surgery. The purpose of this study was to determine the direct cost of outpatient arthroscopic rotator cuff repair surgery using a unique value-driven outcomes tool and to identify patient- and treatment-related variables affecting cost. Cost data were derived for arthroscopic rotator cuff repairs performed by 3 surgeons from March 2014 to June 2015 using the value-driven outcomes tool. Costs included overall total direct cost, which included facility utilization costs, medication costs, supply costs, and other ancillary costs. Univariate and multivariate regressions were performed to determine the effect of various patient-related and surgical-related factors on costs. There were 170 arthroscopic rotator cuff repairs performed during the study period. Multivariate analysis showed significant correlations between higher total direct cost and the presence of a subscapularis repair being performed (P = .015) and total number of anchors used (P < .0001). Higher body mass index, severe systemic illness, 1 of the 3 surgeons, biceps tenodesis using an anchor, and total sum of anchors were correlated with higher facility utilization costs (P < .04). Severe systemic illness, addition of a subscapularis repair, 1 of the 3 surgeons, and additional subacromial decompression were correlated with higher pharmacy costs (P < .006). The addition of a subscapularis repair, total sum of anchors, and severe muscle changes to the supraspinatus were correlated with higher supply costs (P < .015). From a direct cost perspective, implementation of strategies to reduce overall costs should focus on reducing overall anchor quantity or price.

Paper #24 - Factors influencing direct clinical costs of outpatient arthroscopic rotator cuff repair surgery

Background: Understanding the cost of healthcare delivered is critical to understanding the overall value provided. Billing charges are often confused with the cost of delivering care and are often inaccurate estimates of the actual costs incurred. Overall, there is limited information on the “true cost” of care delivered or direct clinical care costs. Very limited information exists as to what variables affect the direct clinical care costs of rotator cuff repair surgery. The purpose of this study was to determine the direct clinical care cost of outpatient arthroscopic rotator cuff repair surgery utilizing a unique Value-Driven Outcomes (VDO) tool which was designed to identify and track direct costs of all aspects of clinical care; and to identify various patient and treatment-related variables affecting cost. Methods: Arthroscopic rotator cuff repairs performed at an outpatient academic medical center by three surgeons were included in the analysis from 3/2014 to 6/2015. Cost data was derived for all cases during this period using the VDO tool developed and validated at our institution. Cost data included overall total cost, and was further broken down to identify facility utilization costs, indirect costs, medication costs, supply costs and other ancillary costs. Patient and surgical data collected included attending surgeon, smoking status, BMI, ASA health status, tear severity (partial thickness versus full thickness), repair construct (single row versus double row), if a subscapularis repair was performed, if a subacromial decompression was performed, if a distal clavicle excision was performed, if a biceps tenodesis was performed, the overall numbers of anchors utilized per case, anteroposterior size of the tear (mm), tear retraction (mm) and supraspinatus and infraspinatus muscle quality (Goutallier grade). Univariate and multivariate regressions were performed to determine the affect of various factors on cost. P < .05 was considered statistically significant. Results: 170 arthroscopic rotator cuff repairs were performed during the study period. There were 17 active smokers. 31 patients were considered to have severe systemic disease based upon their ASA classification. 138 full thickness tears and 32 partial thickness tears were repaired. A single row repair was performed on 128 patients and double-row repair on 42 patients. The average total number of anchors used per case overall was 3. The average tear size was 21 mm. The average tear retraction was 18 mm.The average Goutallier grade for the supraspinatus and infraspinatus were 0.9 and 0.4 respectively. Subscapularis repair and subacromial decompression were performed in 37 cases and 106 cases respectively. Distal clavicle excision was performed in 19 cases. A biceps tenodesis was performed in 66 cases and a tenotomy in 26 cases. In the univariate analysis, higher overall total cost was correlated with the presence of subscapularis repair being performed (P < .0001), a bicep tenodesis being performed (P = .043) and a greater total number of anchors used per case (P < .0001). Multivariate analysis results showed continued significant correlations between higher total cost and the presence of a subscapularis repair being performed (P = .015) and total number of anchors utilized (P < .0001). Smoking status, attending surgeon, BMI, ASA classifications, partial versus full-thickness tear, single row vs double row construct, the addition of a subacromial decompression or distal clavicle excision, tear size and retraction and muscle quality were not significantly associated with total cost. (P > .05) Discussion: Direct clinical care costs associated with arthroscopic rotator cuff repair are related to the overall number of suture anchors utilized and the addition of concomitant procedures (biceps tenodesis, subscapularis repair). Implementation of strategies to reduce overall costs should focus on reducing overall anchor quantity and/or potentially using alternative surgical techniques that may result in equivalent clinical results (biceps tenotomy vs. tenodesis; debridement of partial thickness upper border subscapularis tears vs. repair).

Direct Cost Analysis of Outpatient Arthroscopic Rotator Cuff Repair in Medicare and Non-Medicare Populations.

Background:Providing high-quality care while also containing cost is a paramount goal in orthopaedic surgery. Increasingly, insurance providers in the United States, including government payers, are requiring financial and performance accountability for episodes of care, including a push toward bundled payments.Hypothesis:The direct cost of outpatient arthroscopic rotator cuff repair was assessed to determine whether, due to an older population, rotator cuff surgery was more costly in Medicare-insured patients than in patients covered by other insurers. We hypothesized that operative time, implant cost, and overall higher cost would be observed in Medicare patients.Study Design:Cohort study; Level of evidence, 3.Methods:Billing and operative reports from 184 outpatient arthroscopic rotator cuff repairs performed by 5 fellowship-trained arthroscopic surgeons were reviewed. Operative time, number and cost of implants, hospital reimbursement, surgeon reimbursement, and insurance type were determined from billing records and operative reports. Patients were stratified by payer (Medicare vs non-Medicare), and these variables were compared.Results:There were no statistically significant differences in the number of suture anchors used, implant cost, surgical duration, or overall cost of arthroscopic rotator cuff repair between Medicare and other insurers. Reimbursement was significantly higher for other payers when compared with Medicare, resulting in a mean per case deficit of $263.54 between billing and reimbursement for Medicare patients.Conclusion:Operating room time, implant cost, and total procedural cost was the same for Medicare patients as for patients with private payers. Further research needs to be conducted to understand the patient-specific factors that affect the cost of an episode of care for rotator cuff surgery.

The Incidence of Subsequent Surgery After Outpatient Arthroscopic Rotator Cuff Repair

To quantify the incidence and risk factors associated with subsequent shoulder procedures in individuals undergoing outpatient arthroscopic rotator cuff repair (ARCR). We examined the New York Statewide Planning and Research Cooperative Systems outpatient database from 2003 through 2014 to identify patients undergoing isolated ARCR with or without concomitant acromioplasty. Patients were longitudinally followed up for a minimum of 2 years to determine the incidence of subsequent ipsilateral shoulder surgery. The impact of age, sex, insurance, concomitant acromioplasty, and tobacco use on reoperation was explored. Between 2003 and 2012, 30,430 patients underwent isolated ARCR. The mean age was 56.6 ± 11.5 years, and 55.1% were male patients. A total of 1,826 patients (6.0%) underwent subsequent ipsilateral outpatient shoulder surgery a mean of 24.3 ± 27.1 months after the initial ARCR. Of patients who underwent repeat surgery, 57.3% underwent a revision cuff repair. Patients who underwent additional outpatient shoulder surgery were significantly younger (53.7 ± 10.9 years v 56.8 ± 11.5years, P < .001). Tobacco use was associated with an increased rate of subsequent surgery (7.3% v 5.9%, P= .044) and accelerated time to reoperation (16.9 months v 24.7 months, P < .001). Independent risk factors for subsequent ipsilateral surgery after initialARCR were presence of a Workers' Compensation claim (odds ratio, 2.11; 95% confidence interval, 1.89-2.36; P<.001) and initial ARCR without acromioplasty (odds ratio, 1.20; 95% confidence interval, 1.09-1.34; P < .001). We identified a 6.0% incidence of repeat ipsilateral surgery after isolated ARCR. Although reasons for reoperation are likely multifactorial, younger age, Workers' Compensation claim, and absence of acromioplasty at the time of initial ARCR remained independent predictors of subsequent outpatient procedures, whereas a history of tobacco use was associated with accelerated time to subsequent surgery. Level III, retrospective comparative study.

Continuous Interscalene Block in Patients Having Outpatient Rotator Cuff Repair Surgery

We performed this randomized trial to compare the recovery profile of patients receiving single injection (SISB) and continuous interscalene brachial plexus block (CISB) or general anesthesia (GA) for arthroscopic rotator cuff repair surgery through the first postoperative week. Our primary hypothesis was that the highest pain numeric rating scale (NRS) (worst pain score) at the end of the study week would be lower for patients in the CISB group than for patients in the SISB or GA groups. Seventy-one patients scheduled for elective outpatient arthroscopic rotator cuff repair were enrolled. CISB patients received 20 mL of 0.5% ropivacaine as a bolus through a catheter, whereas SISB patients received the same injection volume through a needle. CISB patients received an infusion of 0.2% ropivacaine at 5 mL/h with a patient-controlled bolus of 5 mL hourly for 48 hours. GA-only patients received a standardized general anesthetic. Postoperative highest NRS pain scores through the first postoperative week, time-to-first pain, analgesic consumption, fast-tracked postoperative anesthesia care unit (PACU) bypass rate, length of PACU stay, time-to-discharge home, total hours of sleep, and related adverse effects were recorded in the PACU and at home on postoperative days 1, 2, 3, and 7. No patient in the CISB or SISB groups reported a NRS ≥1 or required analgesics while in the PACU. While most patients in the CISB and SISB groups were fast-tracked to PACU discharge, no patient in the GA group was fast-tracked (Χ P = 0.003). Length of stay in the PACU was significantly shorter for the CISB and SISB groups than for the GA group (20 ± 31, 30 ± 42, and 165 ± 118 minutes, respectively (CISB vs GA, P < 0.001; SISB vs GA, P <0.001), and time-to-discharge home was significantly shorter when compared with the GA group. Time to first pain report was longer in the CISB group. Mean NRS scores were lower for patients in the CISB group than in the SISB and GA groups on postoperative days 1 and 2, and use of narcotics (doses ≥1) was lower until postoperative day 3. Patients who received CISB slept significantly longer than patients who received SISB or GA (P < 0.01) during the first 48 hours postoperatively. By the end of the study week, 26% of patients in the CISB group, 83% in the SISB group, and 58% of GA patients reported NRS ≥4 (both P-values ≤ 0.05). The analgesic benefits of CISB found in the PACU and immediately after discharge extend through the intermediate recovery period ending on postoperative day 7.

Diaphragm function after interscalene brachial plexus block: a double-blind, randomized comparison of 0.25% and 0.125% bupivacaine

Interscalene brachial plexus block (ISBPB) provides excellent analgesia after rotator cuff surgery but is associated with diaphragm dysfunction. In this study, ISBPB with 20 mL of 0.125% or 0.25% bupivacaine were compared to assess the effect on diaphragm function, oxygen saturation, pain control, opioid requirements, and patient satisfaction. In this prospective, randomized, double-blind study, 30 adults undergoing outpatient arthroscopic rotator cuff repair were enrolled to receive ultrasound-guided interscalene brachial plexus catheter placement with 20 mL of 0.125% (n = 15) or 0.25% bupivacaine (n = 15). Diaphragm function and oxygen saturation were assessed before ISBPB placement and on discharge from the postanesthesia care unit. Postoperative pain scores, opioid requirements, and patient satisfaction were compared. Diaphragm function and oxygen saturation were superior in the low concentration group. Absent or paradoxic motion of the diaphragm was present in 78% of the 0.25% group compared with 21% of patients in the 0.125% group (P = .008). Oxygen saturation decreased 4.3% in the 0.25% group compared with a decrease of 2.6% in the 0.125% group (P = .04). Pain scores averaged 1 of 10 in the 0.25% group and 0 of 10 in the 0.125% group (P = .02). Opioid requirements and patient satisfaction were not different between the two groups. In this randomized, double-blind comparison of ISBPB performed with 20 mL of 0.125% or 0.25% bupivacaine, diaphragm function and oxygen saturation were superior in patients treated with more dilute bupivacaine. Furthermore, there were no clinically significant differences in pain scores, and no statistically significant differences in opioid requirements and patient satisfaction.

Randomized Controlled Trial Comparing Interscalene Nerve Block versus Continuous Infusion Local Anesthetic Pump for Outpatient Arthroscopic Rotator Cuff Repair (SS-34)

PurposePostoperative analgesia is vital for outpatient shoulder arthroscopy patients. Interscalene nerve block (ISB) is a well accepted method of shoulder surgery pain control but has reported disadvantages of significant complications and compromise of postoperative neurological evaluation. Continuous infusion local anesthetic pump (LAP) is a new technology for pain management. The purpose of this study is to compare ISB to LAP in patients having outpatient shoulder arthroscopy. Our hypothesis is that there is no difference between modalities.MethodsAfter a statistical power analysis, 55 consecutive patients, having outpatient arthroscopic shoulder surgery by a single surgeon were prospectively randomized to ISB or LAP. Included were patients having arthroscopic rotator cuff repair regardless of associated procedures. ISB was administered preoperatively, while subacromial LAP was placed intraoperatively and maintained for 48 hours. VAS pain scores were recorded twice daily for 2 days, then daily for 5 additional days. Quantity of Ibuprofen and Percocet use were also recorded as were total hospital costs (hospital charges multiplied by hospital cost to charges ratio).ResultsNo significant differences were found between groups with respect to pain at any time interval (p-value range 0.23 to 0.95), medication use (p-value range 0.55 to 0.98), or total hospital costs (p=0.72). There were no complications in the ISB group, while one LAP catheter was inadvertently removed at 24 hours.ConclusionsOur results demonstrate no differences between ISB and LAP. These results are clinically relevant because incidence of outpatient shoulder arthroscopy is increasing as are societal expectations with regard to surgical pain management. PurposePostoperative analgesia is vital for outpatient shoulder arthroscopy patients. Interscalene nerve block (ISB) is a well accepted method of shoulder surgery pain control but has reported disadvantages of significant complications and compromise of postoperative neurological evaluation. Continuous infusion local anesthetic pump (LAP) is a new technology for pain management. The purpose of this study is to compare ISB to LAP in patients having outpatient shoulder arthroscopy. Our hypothesis is that there is no difference between modalities. Postoperative analgesia is vital for outpatient shoulder arthroscopy patients. Interscalene nerve block (ISB) is a well accepted method of shoulder surgery pain control but has reported disadvantages of significant complications and compromise of postoperative neurological evaluation. Continuous infusion local anesthetic pump (LAP) is a new technology for pain management. The purpose of this study is to compare ISB to LAP in patients having outpatient shoulder arthroscopy. Our hypothesis is that there is no difference between modalities. MethodsAfter a statistical power analysis, 55 consecutive patients, having outpatient arthroscopic shoulder surgery by a single surgeon were prospectively randomized to ISB or LAP. Included were patients having arthroscopic rotator cuff repair regardless of associated procedures. ISB was administered preoperatively, while subacromial LAP was placed intraoperatively and maintained for 48 hours. VAS pain scores were recorded twice daily for 2 days, then daily for 5 additional days. Quantity of Ibuprofen and Percocet use were also recorded as were total hospital costs (hospital charges multiplied by hospital cost to charges ratio). After a statistical power analysis, 55 consecutive patients, having outpatient arthroscopic shoulder surgery by a single surgeon were prospectively randomized to ISB or LAP. Included were patients having arthroscopic rotator cuff repair regardless of associated procedures. ISB was administered preoperatively, while subacromial LAP was placed intraoperatively and maintained for 48 hours. VAS pain scores were recorded twice daily for 2 days, then daily for 5 additional days. Quantity of Ibuprofen and Percocet use were also recorded as were total hospital costs (hospital charges multiplied by hospital cost to charges ratio). ResultsNo significant differences were found between groups with respect to pain at any time interval (p-value range 0.23 to 0.95), medication use (p-value range 0.55 to 0.98), or total hospital costs (p=0.72). There were no complications in the ISB group, while one LAP catheter was inadvertently removed at 24 hours. No significant differences were found between groups with respect to pain at any time interval (p-value range 0.23 to 0.95), medication use (p-value range 0.55 to 0.98), or total hospital costs (p=0.72). There were no complications in the ISB group, while one LAP catheter was inadvertently removed at 24 hours. ConclusionsOur results demonstrate no differences between ISB and LAP. These results are clinically relevant because incidence of outpatient shoulder arthroscopy is increasing as are societal expectations with regard to surgical pain management. Our results demonstrate no differences between ISB and LAP. These results are clinically relevant because incidence of outpatient shoulder arthroscopy is increasing as are societal expectations with regard to surgical pain management.