Daniel Badin

Background: There is limited evidence evaluating the cost-effectiveness of adding subacromial decompression (SAD) to rotator cuff repair (RCR) in the treatment of full-thickness rotator cuff tears. Purpose: The purpose of this study was to perform (1) a systematic review and (2) cost-utility analysis comparing isolated RCR versus RCR with SAD in patients with full-thickness rotator cuff tears. Study design: This was an economic and decision-analysis study; Level II. Methods: A systematic review was conducted per Preferred Reporting Items for Systemactic reviews and Meta-Analyses (PRISMA) 2020 guidelines to identify Level I-II studies comparing RCR and RCR with SAD at ≥5-year follow-up. A decision tree model evaluated cost-effectiveness over a 5-year time horizon. Costs, revision rates, and utility values (EQ-5D–based) were derived from the literature. Health utility was expressed in quality-adjusted life years (QALYs). Cost-effectiveness was assessed using incremental cost-effectiveness ratios and net monetary benefit (NMB), with a $50,000/QALY willingness-to-pay threshold. Monte Carlo and one-way sensitivity analyses were done to account for parameter uncertainty. Results: Over 5 years, RCR with SAD had a lower mean cost ($33,448) compared with isolated RCR ($34,593) and yielded slightly higher QALYs (1.465 vs 1.454). RCR + SAD demonstrated a positive incremental NMB ($1,695) and a negative incremental cost-effectiveness ratio, emerging as the dominant strategy. Probabilistic sensitivity analysis favored RCR + SAD in 99.28% of 1,000 simulations. On one-way analysis, RCR + SAD remained cost-effective with burr costs up to $1,721, additional surgical time up to 43.6 minutes, and revision probabilities up to 10%. Conclusion: Despite higher upfront costs, SAD during RCR remains cost-effective at mid-term follow-up. By reducing revision rates, SAD provides greater QALYs at a lower overall cost compared with isolated RCR.

Case: A 34-year-old man presented with bilateral locked posterior shoulder dislocations associated with proximal humerus fractures secondary to a tonic-clonic seizure. The patient underwent open reduction and internal fixation of both shoulders. At 1 year postoperatively, the patient exhibited near-complete recovery of shoulder function with no pain, excellent radiographic outcomes, and no evidence of early avascular necrosis (AVN) or hardware complications. Conclusion: While this injury's sequelae can be devastating, an interdisciplinary approach may help optimize outcomes, and a prompt reduction with stable fixation may facilitate earlier fracture healing and rehabilitation progression, potentially contributing to a lower likelihood of AVN.

Background: Lenke curve types can vary in their response to treatment. We explored potential differences in reoperation rates, causes, and risk factors among patients with different Lenke types who underwent posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Methods: We studied a multicenter database of patients with AIS who underwent index PSF at ≤21 years of age and had a minimum 2-year follow-up. Baseline and surgical characteristics were collected. Reoperation rates, causes, and risk factors were analyzed by Lenke type. Results: A total of 3,165 patients were included. The mean age was 14.6 years, and most patients were female (81%) and Caucasian (68%). The mean follow-up period was 4.4 years. A total of 138 patients (4.4%) underwent reoperation. The reoperation rate varied by Lenke type (p = 0.02): patients with type-5 curves had the highest reoperation rate (7.2%), and those with type-1 curves had the lowest (3.0%). The most common cause of reoperation was an instrumentation complication. The rate of reoperation due to an instrumentation complication varied by Lenke type (p < 0.01). Compared with patients with type-1 curves, those with type-5 curves had significantly higher rates of reoperation due to implant prominence (odds ratio [OR], 11.7; p = 0.03), loss of fixation (OR, 3.9; p = 0.01), or a broken rod (OR, 7.8; p = 0.02) and those with type-3 curves had a significantly higher rate of reoperation due to loss of fixation (OR, 4.37; p = 0.01). Independent risk factors for reoperation were a major curve magnitude of ≥60° in patients with type-5 curves (adjusted OR [aOR], 4.18; p = 0.04), a major curve correction of ≥40° in patients with type-5 curves (aOR, 3.6; p = 0.04), and a lowest instrumented vertebra (LIV) at or above L1 in patients with type-1 curves (aOR, 2.8; p = 0.02). Conclusions: The reoperation rate for patients with AIS who underwent PSF varied by Lenke type. Patients with type-5 curves had the highest reoperation rate, whereas patients with type-1 curves had the lowest. Patients with Lenke type-5 curves had a higher rate of reoperation due to instrumentation complications. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Orthopaedic surgery residency programs have traditionally had less representation of underrepresented minority (URM) and female trainees compared with other medical specialties. Widespread efforts have been implemented to increase the diversity of orthopaedic surgery residency programs; however, it is not known whether URM and female applicants are increasingly likely to match as a result. Thus, we aimed to study the independent association between URM and female applicants and matching into orthopaedic surgery over the past decade. Methods: Applicant-level data from the Electronic Residency Application Service were reviewed from 2011 to 2021 with variables including demographic variables, URM status, and matriculation to an orthopaedic surgery residency program. Multivariate logistic regression was used to identify the likelihood of matriculating into orthopaedic surgery when controlling for number of applications, top 40 medical school status, AOA status, and MD/other degree. Results: Twelve thousand one hundred eleven applicants were identified from 2011 to 2021 with a match rate of 70% overall. Two thousand fifty-six applicants (17%) were female and 1,926 (16%) classified as URM. The total number of applications increased from 1,074 in 2011 to 1,229 in 2021. The adjusted odds ratio (OR) associated with matching among all applicants decreased from 0.75 in 2011 to 0.64 in 2021, p < 0.001, and the OR of non-URM male and female applicants also decreased (female: 0.79-0.69, p < 0.001; male: 0.78-0.65, p < 0.001). The OR of URM male applicants did not change significantly (0.57-0.55, p = 0.60). The OR for URM female applicants, however, increased significantly from 0.46 to 0.61, p < 0.001. Over the entire time frame, the odds of matching were significantly lower for URM applicants compared with non-URM applicants (both male and female). Conclusions: Overall, the adjusted odds ratio of matching into orthopaedic surgery among female URM applicants has increased over the past decade, indicating successful efforts to improve the diversity of orthopaedic surgery training programs. The odds of URM male applicants have remained relatively constant, and the odds of URM male and female applicants were significantly lower than all non-URM applicants. Level of Evidence: III.

Background: There is limited literature on the outcomes in patients with osteogenesis imperfecta (OI) undergoing growth-friendly instrumentation (GFI). The purpose of this study was to report the outcomes of GFI in patients with early-onset scoliosis (EOS) and OI. We hypothesized that similar trunk elongation could be obtained in OI patients, but with higher complication rates. Methods: A multicenter database was studied for patients with EOS and OI etiology who had GFI from 2005 to 2020, with a minimum 2-year follow-up. Demographic, radiographic, clinical, and patient-reported outcomes data were collected and compared with an idiopathic EOS cohort matched 2:1 for age, follow-up duration, and curve magnitude. Results: Fifteen OI patients underwent GFI at a mean age of 7.3±3.0 years, with an average follow-up of 7.3±3.9 years. OI patients had a mean preoperative coronal curve of 78.1±14.5 and achieved 35% correction after index surgery. There were no differences in major coronal curves and coronal percent correction between the OI and idiopathic groups at all time points. T1-S1 length (cm) was lower for the OI group at baseline (23.3±4.6 vs. 27.7±7.0; P=0.028) but both groups had similar growth (mm) per month (1.0±0.6 vs. 1.2±1.1; P=0.491). OI patients had a significantly increased risk of proximal anchor failure, which occurred in 8 OI patients (53%) versus 6 idiopathic patients (20%) (P=0.039). OI patients who underwent preoperative halo-traction (N=4) had greater T1-S1 length gain (11.8±3.2 vs. 7.3±2.8; P=0.022) and greater percent major coronal curve correction (45±11 vs. 23±17; P=0.042) at final follow-up versus patients with no halo-traction (N=11). Staged foundation fusion was performed in 2 cases. Conclusion: Compared with matched idiopathic EOS patients, OI patients undergoing GFI achieved similar radiographic outcomes but sustained greater rates of anchor failures, likely due to weakened bone. Preoperative halo-traction was a useful adjunct and may improve final correction. Staged foundation fusion is an idea to consider for difficult cases. Level of Evidence: Therapeutic—III

Current literature on pin migration is inconsistent and its significance is not understood. We aimed to investigate the incidence, magnitude, predictors, and consequences of radiographic pin migration after pediatric supracondylar humeral fractures (SCHF). We retrospectively reviewed pediatric patients treated with reduction and pinning of SCHF at our institution. Baseline and clinical data were collected. Pin migration was assessed by measuring the change in distance between pin tip and humeral cortex on sequential radiographs. Factors associated with pin migration and loss of reduction (LOR) were assessed. Six hundred forty-eight patients and 1506 pins were included; 21%, 5%, and 1% of patients had pin migration ≥5 mm, ≥10 mm, and ≥20 mm respectively. Mean migration in symptomatic patients was 20 mm compared to a migration of 5 mm in all patients with non-negligible migration (P < 0.001). Pin migration > 10 mm was strongly associated with LOR [odds ratio (OR) = 6.91; confidence interval (CI), 2.70–17.68]. Factors associated with increased migration included increased days to pin removal (β = 0.022; CI, 0.002–0.043), migration outwards versus inwards ( = 1.02; CI, 0.21–1.80), and BMI > 95th percentile (OR = 1.63; [1.06–2.50]). Factors not associated with migration included cross-pinning, number of pins, and fracture grade. In summary, we identified a 5% incidence of radiographic pin migration ≥ 10 mm and determined the factors associated with it. Pin migration became radiographically significant at >10 mm where it was strongly associated with LOR. Our findings contribute to the understanding of pin migration and suggest that interventions targeting pin migration may decrease the risk of LOR. Level of Evidence: Level III – Retrospective Cohort Study