Orthopedics

ANSWER
The radiograph shows a fracture dislocation of the ankle. The distal tibia is dislocated medially relative to the talus, as evidenced by the widened joint space. There is also an oblique fracture of the distal fibula.

Since the patient was experiencing neurovascular compromise, the dislocation was promptly reduced in the emergency department. Subsequently, he was taken to the operating room for open reduction and internal fixation of his fibula fracture.   

ANSWER
The radiograph shows a fracture dislocation of the ankle. The distal tibia is dislocated medially relative to the talus, as evidenced by the widened joint space. There is also an oblique fracture of the distal fibula.

Since the patient was experiencing neurovascular compromise, the dislocation was promptly reduced in the emergency department. Subsequently, he was taken to the operating room for open reduction and internal fixation of his fibula fracture.   

ANSWER
The radiograph shows a fracture dislocation of the ankle. The distal tibia is dislocated medially relative to the talus, as evidenced by the widened joint space. There is also an oblique fracture of the distal fibula.

Since the patient was experiencing neurovascular compromise, the dislocation was promptly reduced in the emergency department. Subsequently, he was taken to the operating room for open reduction and internal fixation of his fibula fracture.   

Participating in a short series of phone conversations with trained counselors can substantially boost recovery and reduce pain in patients after spinal surgery, according to a study published online ahead of print March 28 in Archives of Physical Medicine and Rehabilitation.

The phone calls were designed to enhance standard pre- and post-operative care by reinforcing the value of continuing with physical therapy and back-strengthening exercise regimens.

“Phone counseling appears to be an easy, low-cost strategy that yields meaningful results by improving patient engagement in physical therapy and at-home exercise programs that are so vital for their recovery,” said lead study author Richard Skolasky Jr., ScD, Associate Professor of Orthopedic Surgery at the Johns Hopkins University School of Medicine in Baltimore.

The study included 122 patients ages 46 to 72, who underwent surgery at Johns Hopkins University between 2009 and 2012 to correct spinal stenosis. Each patient was assigned either home exercise programs or physical therapy to help accelerate their recovery time. About half of the patients also received a series of phone counseling sessions from a trained spinal surgery counselor to discuss the importance of exercise in their recovery. The first and most detailed phone session took place a few weeks before the patients had their surgeries. Two follow-up sessions occurred at 6 weeks and at 3 months after the operation was performed.

The study found that patients who received phone calls participated in physical therapy and home exercise at higher rates, and had less pain and less disability 6 months after their surgery, compared with the standard-approach group. Six months after surgery, 74% of patients who received phone counseling experienced significant improvements on standard measures of physical functioning and self-reported measures of pain, compared with 41% of people who did not receive phone calls.

“Modern orthopedic science has made great strides in surgical techniques to correct spinal deformities and achieved significant progress in developing physical therapies that boost the benefits of surgery, but we have not been all that good at motivating and engaging patients to partake in such post-surgical recovery programs,” said co-investigator Stephen Wegener, PhD, Associate Professor of Physical Medicine and Rehabilitation at Johns Hopkins University.

“The findings of our research suggest we may have found a way to add that missing ingredient that draws patients to be more active participants in their physical rehabilitation and recovery,” stated Dr. Wegener.

Participating in a short series of phone conversations with trained counselors can substantially boost recovery and reduce pain in patients after spinal surgery, according to a study published online ahead of print March 28 in Archives of Physical Medicine and Rehabilitation.

The phone calls were designed to enhance standard pre- and post-operative care by reinforcing the value of continuing with physical therapy and back-strengthening exercise regimens.

“Phone counseling appears to be an easy, low-cost strategy that yields meaningful results by improving patient engagement in physical therapy and at-home exercise programs that are so vital for their recovery,” said lead study author Richard Skolasky Jr., ScD, Associate Professor of Orthopedic Surgery at the Johns Hopkins University School of Medicine in Baltimore.

The study included 122 patients ages 46 to 72, who underwent surgery at Johns Hopkins University between 2009 and 2012 to correct spinal stenosis. Each patient was assigned either home exercise programs or physical therapy to help accelerate their recovery time. About half of the patients also received a series of phone counseling sessions from a trained spinal surgery counselor to discuss the importance of exercise in their recovery. The first and most detailed phone session took place a few weeks before the patients had their surgeries. Two follow-up sessions occurred at 6 weeks and at 3 months after the operation was performed.

The study found that patients who received phone calls participated in physical therapy and home exercise at higher rates, and had less pain and less disability 6 months after their surgery, compared with the standard-approach group. Six months after surgery, 74% of patients who received phone counseling experienced significant improvements on standard measures of physical functioning and self-reported measures of pain, compared with 41% of people who did not receive phone calls.

“Modern orthopedic science has made great strides in surgical techniques to correct spinal deformities and achieved significant progress in developing physical therapies that boost the benefits of surgery, but we have not been all that good at motivating and engaging patients to partake in such post-surgical recovery programs,” said co-investigator Stephen Wegener, PhD, Associate Professor of Physical Medicine and Rehabilitation at Johns Hopkins University.

“The findings of our research suggest we may have found a way to add that missing ingredient that draws patients to be more active participants in their physical rehabilitation and recovery,” stated Dr. Wegener.

Participating in a short series of phone conversations with trained counselors can substantially boost recovery and reduce pain in patients after spinal surgery, according to a study published online ahead of print March 28 in Archives of Physical Medicine and Rehabilitation.

The phone calls were designed to enhance standard pre- and post-operative care by reinforcing the value of continuing with physical therapy and back-strengthening exercise regimens.

“Phone counseling appears to be an easy, low-cost strategy that yields meaningful results by improving patient engagement in physical therapy and at-home exercise programs that are so vital for their recovery,” said lead study author Richard Skolasky Jr., ScD, Associate Professor of Orthopedic Surgery at the Johns Hopkins University School of Medicine in Baltimore.

The study included 122 patients ages 46 to 72, who underwent surgery at Johns Hopkins University between 2009 and 2012 to correct spinal stenosis. Each patient was assigned either home exercise programs or physical therapy to help accelerate their recovery time. About half of the patients also received a series of phone counseling sessions from a trained spinal surgery counselor to discuss the importance of exercise in their recovery. The first and most detailed phone session took place a few weeks before the patients had their surgeries. Two follow-up sessions occurred at 6 weeks and at 3 months after the operation was performed.

The study found that patients who received phone calls participated in physical therapy and home exercise at higher rates, and had less pain and less disability 6 months after their surgery, compared with the standard-approach group. Six months after surgery, 74% of patients who received phone counseling experienced significant improvements on standard measures of physical functioning and self-reported measures of pain, compared with 41% of people who did not receive phone calls.

“Modern orthopedic science has made great strides in surgical techniques to correct spinal deformities and achieved significant progress in developing physical therapies that boost the benefits of surgery, but we have not been all that good at motivating and engaging patients to partake in such post-surgical recovery programs,” said co-investigator Stephen Wegener, PhD, Associate Professor of Physical Medicine and Rehabilitation at Johns Hopkins University.

“The findings of our research suggest we may have found a way to add that missing ingredient that draws patients to be more active participants in their physical rehabilitation and recovery,” stated Dr. Wegener.

An 8-surgeon group in the Southeast had a history of high patient receivables, the result of a long-held culture of “We’ll submit to your insurance and bill you after insurance pays.”

The billing and collections staff worked in the basement—far away and out of sight of the patients who showed up for their postoperative visits owing big bucks.

In a flash of wisdom, the administrator agreed to move the patient-balance collector into a converted closet near the check-out area, and provided the information, tools, and training that enabled her to speak with patients about their balances when they came in for an appointment. In her first month in this role and location, this employee collected more than her annual salary from patients. 

It Takes a Program

This is one of our favorite client success stories, and it illustrates a key point: point-of-service (POS) collections do not have to be complicated. But the process does have to be deliberate and coordinated. Practices cannot simply update the financial policy and hope the staff members magically begin collecting. If this is your strategy, we promise that it will fail.

Successful POS collecting requires a program approach. And this approach starts at the front-end of the billing cycle, not “after insurance pays.”

POS collections have never been more important. Health insurance exchanges and payers are increasing deductibles and coinsurances. Physicians are opting out of network. Given these realities, POS collections are vital to your cash flow and effective receivables management.

If you are starting practice, you have a perfect opportunity to open with POS collecting in place. A solo surgeon whom we set up in practice did so, and has collected up-front for office services, scans, and surgeries from his first day in practice. Today, the practice’s only outstanding patient receivables are those of patients on payment plans—and these are less than 1% of total accounts receivable.

We also converted the “after insurance pays” philosophy of a surgeon in the South, implementing both POS collections and surgical deposits. In the first month, his patient payments increased by 40%. Another solo orthopedist reported an increased take-home salary of $90,000 in the first year after we helped his staff collect surgery deposits.

Six POS Program Elements

In 30 years of implementing or training staff to implement POS collections, we have come to recognize the following 6 key elements to include in your program approach: Policies + Procedures + Technology + Training + Monitoring + Coaching.

At a high level, here are the actions your practice will need to take:

1. Update the financial policy with 1 written standard for all physicians.

2. Develop granular procedures driven by the policy; these are the “how-tos” that enable the staff to collect successfully.

3. Implement new technologies, such as cost estimators, recurring payments, and online bill pay.

4. Schedule formal training to ensure that staff members know how to ask for money. (Do not assume they are, can, or will without training.)

5. Measure and monitor the outcome of patient collections and staff performance.

6. Provide ongoing coaching and oversight to maintain motivation and skills.

A blueprint for addressing each one of these actions follows.

1. Update the financial policy

The policy is the set of expectations on which to build all procedures and training. Dust off this document, and review it as a group with the practice administrator. First, strike old language that says the patient will be balance-billed, or will only be asked in the office for his visit copay. Next, strive for clarity. “You will be asked to pay your financial responsibility at the time of service,” really says nothing. Instead, the policy should be direct:

If you are recommended for surgery, our staff will calculate your coinsurance and unmet deductible amounts: 50% of this amount will be collected as a surgery deposit, and the remaining 50% is due on or before the day of surgery. Payment plans are available.

For office visits and services, break down the policy by coverage type. We find that a table such as the one shown makes expectations clear.

Finally, strive for 1 standard policy for all providers. If every provider is allowed to create his or her own set of collection policies, the practice is setting staff up for complexity overload, and collections will suffer.

2. Develop granular procedures

Few practices take the time to translate the financial policy into written procedures that can be followed by staff. The policy establishes the rules, but the procedures tell staff what to do to implement those rules. For instance:

Create a “POS Playbook” that contains information such as procedures, cost-quotation worksheets, US Poverty guidelines¹, and financing brochures. As old-school as it sounds, a 3-ring binder is great for this information, and makes information access and updates easy.

3. Implement collection technologies

Modern practices use inexpensive (and often free) tools that increase patient convenience and staff efficiency. Implement at least 2 of these useful technologies and watch your POS collections increase:

Reports from your practice management system (PMS). Use the technology you already have. There are 2 standard reports in your PMS or clearinghouse that give front-desk staff the data to ask patients for money. Eligibility status and past-due balance reports indicate amounts owed, unmet deductibles, and the ineligible patients they can collect from when they come in for their appointment.

Online cost estimators. These free, online tools are offered by payers and provide staff with real-time data about a patient’s unmet deductible and coinsurance. When staff members enter Current Procedural Terminology (CPT) codes and the patient’s benefit information into the online cost estimator, they can access valuable information. Many insurance plans offer cost estimators on their web sites. Others deliver the data through statewide or regional portals, such as Availity (www.availity.com). The accuracy of cost-estimator data can vary by region and depends on the data links with payers. Ask your team to evaluate which estimators are best for you based on your payer mix.

Online bill pay. Everyone appreciates the convenience of paying bills online. Most patient portals offer this feature. If yours does not or you do not have a portal, you can offer PayPal (www.paypal.com) on your practice website, or use a system such as Intuit Health (www.intuithealth.com).

Recurring billing. Recurring billing is how you pay for services, such as Netflix, Pandora, or your gym membership: it is automatically billed to a credit card each month. Offer this option to patients as a payment plan method, and staff will no longer need to send costly statements, post monthly check payments, or follow up when a patient is delinquent. Plus, it guarantees payment every month; patients can no longer say, “I forgot.”

TransFirst (www.transfirstassociation.com) and a-claim (www.a-claim.com) offer recurring billing through a “virtual terminal” that staff logs in to at checkout, or during the preprocedure patient counseling process. Both vendors also offer the option of automatically charging a patient’s credit card after their insurance pays, speeding patient account pay-off and negating the need for statements.

Real-time collections scripts based on payer rules. Patient Access, offered by Availity, combines real-time payer data with financial policies that are entered during set-up to create instant, patient-specific scripts that staff members read to the patient in front of them.

4. Schedule formal training

Just because someone can collect a copay does not mean he or she is comfortable with or capable of asking patients for past-due balances, surgical deposits, or large coinsurances. It is the rare staff person who is a “natural” at asking patients for money in a polished and professional manner.

That’s why training staff how to ask patients for money is vital. A front-office supervisor or manager should conduct several training sessions to cover policies and procedures. Training materials should include talking points and scenarios for collecting for office services and past-due balances, and calculating what patients owe, using technology tools. Use role-playing to ensure staff can explain payment plan options and how to apply for patient financing or financial assistance.

Few practices can skip this part of the POS program and still be successful. If your manager or supervisor is not capable of training, it is worth the investment to hire an outside expert. Without thorough training, staff efforts will be suboptimal or, at worst, fail because the staff members will not know how or what to collect.

5. Measure and monitor the outcome

The Hawthorne effect is a psychological phenomenon that says people perform better and make more positive changes as a result of increased attention.² In other words, staff members will perform better, and collect more, if they know someone is paying attention. Trust us on this one.

Employees respect what management inspects. So even if the implementation of POS collections has been a big success, do not take your eyes off the ball.

Stop by the front desk or surgery coordinator’s office a few times a month and ask how much has been collected. Randomly review daily over-the-counter collections logs. And always put POS collections performance on the monthly partner meeting agenda; review a graph that shows monthly collections at checkout and surgery deposits. Keeping tabs on performance enables the practice to take action quickly when collections drop, and before that decline becomes acute.

6. Provide ongoing coaching and oversight

Most practices train once, then wonder why staff motivation (and collections too) fall off after a while. Like that new couch you bought: it was all you could talk about the week after it was delivered. Now, it is only a comfy place to sit. It is the same with collections efforts. When the newness wears off, staff motivation does too, and training principles can be forgotten. That’s human nature. Conduct role-playing in staff meetings each quarter and discuss best practices for handling patient objections. Encourage peer-to-peer observation and coaching to address knowledge gaps and missed collection opportunities. Ongoing training and coaching will tease out training needs and boost your team’s collection confidence and success.

An 8-surgeon group in the Southeast had a history of high patient receivables, the result of a long-held culture of “We’ll submit to your insurance and bill you after insurance pays.”

The billing and collections staff worked in the basement—far away and out of sight of the patients who showed up for their postoperative visits owing big bucks.

In a flash of wisdom, the administrator agreed to move the patient-balance collector into a converted closet near the check-out area, and provided the information, tools, and training that enabled her to speak with patients about their balances when they came in for an appointment. In her first month in this role and location, this employee collected more than her annual salary from patients. 

It Takes a Program

This is one of our favorite client success stories, and it illustrates a key point: point-of-service (POS) collections do not have to be complicated. But the process does have to be deliberate and coordinated. Practices cannot simply update the financial policy and hope the staff members magically begin collecting. If this is your strategy, we promise that it will fail.

Successful POS collecting requires a program approach. And this approach starts at the front-end of the billing cycle, not “after insurance pays.”

POS collections have never been more important. Health insurance exchanges and payers are increasing deductibles and coinsurances. Physicians are opting out of network. Given these realities, POS collections are vital to your cash flow and effective receivables management.

If you are starting practice, you have a perfect opportunity to open with POS collecting in place. A solo surgeon whom we set up in practice did so, and has collected up-front for office services, scans, and surgeries from his first day in practice. Today, the practice’s only outstanding patient receivables are those of patients on payment plans—and these are less than 1% of total accounts receivable.

We also converted the “after insurance pays” philosophy of a surgeon in the South, implementing both POS collections and surgical deposits. In the first month, his patient payments increased by 40%. Another solo orthopedist reported an increased take-home salary of $90,000 in the first year after we helped his staff collect surgery deposits.

Six POS Program Elements

In 30 years of implementing or training staff to implement POS collections, we have come to recognize the following 6 key elements to include in your program approach: Policies + Procedures + Technology + Training + Monitoring + Coaching.

At a high level, here are the actions your practice will need to take:

1. Update the financial policy with 1 written standard for all physicians.

2. Develop granular procedures driven by the policy; these are the “how-tos” that enable the staff to collect successfully.

3. Implement new technologies, such as cost estimators, recurring payments, and online bill pay.

4. Schedule formal training to ensure that staff members know how to ask for money. (Do not assume they are, can, or will without training.)

5. Measure and monitor the outcome of patient collections and staff performance.

6. Provide ongoing coaching and oversight to maintain motivation and skills.

A blueprint for addressing each one of these actions follows.

1. Update the financial policy

The policy is the set of expectations on which to build all procedures and training. Dust off this document, and review it as a group with the practice administrator. First, strike old language that says the patient will be balance-billed, or will only be asked in the office for his visit copay. Next, strive for clarity. “You will be asked to pay your financial responsibility at the time of service,” really says nothing. Instead, the policy should be direct:

If you are recommended for surgery, our staff will calculate your coinsurance and unmet deductible amounts: 50% of this amount will be collected as a surgery deposit, and the remaining 50% is due on or before the day of surgery. Payment plans are available.

For office visits and services, break down the policy by coverage type. We find that a table such as the one shown makes expectations clear.

Finally, strive for 1 standard policy for all providers. If every provider is allowed to create his or her own set of collection policies, the practice is setting staff up for complexity overload, and collections will suffer.

2. Develop granular procedures

Few practices take the time to translate the financial policy into written procedures that can be followed by staff. The policy establishes the rules, but the procedures tell staff what to do to implement those rules. For instance:

Create a “POS Playbook” that contains information such as procedures, cost-quotation worksheets, US Poverty guidelines¹, and financing brochures. As old-school as it sounds, a 3-ring binder is great for this information, and makes information access and updates easy.

3. Implement collection technologies

Modern practices use inexpensive (and often free) tools that increase patient convenience and staff efficiency. Implement at least 2 of these useful technologies and watch your POS collections increase:

Reports from your practice management system (PMS). Use the technology you already have. There are 2 standard reports in your PMS or clearinghouse that give front-desk staff the data to ask patients for money. Eligibility status and past-due balance reports indicate amounts owed, unmet deductibles, and the ineligible patients they can collect from when they come in for their appointment.

Online cost estimators. These free, online tools are offered by payers and provide staff with real-time data about a patient’s unmet deductible and coinsurance. When staff members enter Current Procedural Terminology (CPT) codes and the patient’s benefit information into the online cost estimator, they can access valuable information. Many insurance plans offer cost estimators on their web sites. Others deliver the data through statewide or regional portals, such as Availity (www.availity.com). The accuracy of cost-estimator data can vary by region and depends on the data links with payers. Ask your team to evaluate which estimators are best for you based on your payer mix.

Online bill pay. Everyone appreciates the convenience of paying bills online. Most patient portals offer this feature. If yours does not or you do not have a portal, you can offer PayPal (www.paypal.com) on your practice website, or use a system such as Intuit Health (www.intuithealth.com).

Recurring billing. Recurring billing is how you pay for services, such as Netflix, Pandora, or your gym membership: it is automatically billed to a credit card each month. Offer this option to patients as a payment plan method, and staff will no longer need to send costly statements, post monthly check payments, or follow up when a patient is delinquent. Plus, it guarantees payment every month; patients can no longer say, “I forgot.”

TransFirst (www.transfirstassociation.com) and a-claim (www.a-claim.com) offer recurring billing through a “virtual terminal” that staff logs in to at checkout, or during the preprocedure patient counseling process. Both vendors also offer the option of automatically charging a patient’s credit card after their insurance pays, speeding patient account pay-off and negating the need for statements.

Real-time collections scripts based on payer rules. Patient Access, offered by Availity, combines real-time payer data with financial policies that are entered during set-up to create instant, patient-specific scripts that staff members read to the patient in front of them.

4. Schedule formal training

Just because someone can collect a copay does not mean he or she is comfortable with or capable of asking patients for past-due balances, surgical deposits, or large coinsurances. It is the rare staff person who is a “natural” at asking patients for money in a polished and professional manner.

That’s why training staff how to ask patients for money is vital. A front-office supervisor or manager should conduct several training sessions to cover policies and procedures. Training materials should include talking points and scenarios for collecting for office services and past-due balances, and calculating what patients owe, using technology tools. Use role-playing to ensure staff can explain payment plan options and how to apply for patient financing or financial assistance.

Few practices can skip this part of the POS program and still be successful. If your manager or supervisor is not capable of training, it is worth the investment to hire an outside expert. Without thorough training, staff efforts will be suboptimal or, at worst, fail because the staff members will not know how or what to collect.

5. Measure and monitor the outcome

The Hawthorne effect is a psychological phenomenon that says people perform better and make more positive changes as a result of increased attention.² In other words, staff members will perform better, and collect more, if they know someone is paying attention. Trust us on this one.

Employees respect what management inspects. So even if the implementation of POS collections has been a big success, do not take your eyes off the ball.

Stop by the front desk or surgery coordinator’s office a few times a month and ask how much has been collected. Randomly review daily over-the-counter collections logs. And always put POS collections performance on the monthly partner meeting agenda; review a graph that shows monthly collections at checkout and surgery deposits. Keeping tabs on performance enables the practice to take action quickly when collections drop, and before that decline becomes acute.

6. Provide ongoing coaching and oversight

Most practices train once, then wonder why staff motivation (and collections too) fall off after a while. Like that new couch you bought: it was all you could talk about the week after it was delivered. Now, it is only a comfy place to sit. It is the same with collections efforts. When the newness wears off, staff motivation does too, and training principles can be forgotten. That’s human nature. Conduct role-playing in staff meetings each quarter and discuss best practices for handling patient objections. Encourage peer-to-peer observation and coaching to address knowledge gaps and missed collection opportunities. Ongoing training and coaching will tease out training needs and boost your team’s collection confidence and success.

An 8-surgeon group in the Southeast had a history of high patient receivables, the result of a long-held culture of “We’ll submit to your insurance and bill you after insurance pays.”

The billing and collections staff worked in the basement—far away and out of sight of the patients who showed up for their postoperative visits owing big bucks.

In a flash of wisdom, the administrator agreed to move the patient-balance collector into a converted closet near the check-out area, and provided the information, tools, and training that enabled her to speak with patients about their balances when they came in for an appointment. In her first month in this role and location, this employee collected more than her annual salary from patients. 

It Takes a Program

This is one of our favorite client success stories, and it illustrates a key point: point-of-service (POS) collections do not have to be complicated. But the process does have to be deliberate and coordinated. Practices cannot simply update the financial policy and hope the staff members magically begin collecting. If this is your strategy, we promise that it will fail.

Successful POS collecting requires a program approach. And this approach starts at the front-end of the billing cycle, not “after insurance pays.”

POS collections have never been more important. Health insurance exchanges and payers are increasing deductibles and coinsurances. Physicians are opting out of network. Given these realities, POS collections are vital to your cash flow and effective receivables management.

If you are starting practice, you have a perfect opportunity to open with POS collecting in place. A solo surgeon whom we set up in practice did so, and has collected up-front for office services, scans, and surgeries from his first day in practice. Today, the practice’s only outstanding patient receivables are those of patients on payment plans—and these are less than 1% of total accounts receivable.

We also converted the “after insurance pays” philosophy of a surgeon in the South, implementing both POS collections and surgical deposits. In the first month, his patient payments increased by 40%. Another solo orthopedist reported an increased take-home salary of $90,000 in the first year after we helped his staff collect surgery deposits.

Six POS Program Elements

In 30 years of implementing or training staff to implement POS collections, we have come to recognize the following 6 key elements to include in your program approach: Policies + Procedures + Technology + Training + Monitoring + Coaching.

At a high level, here are the actions your practice will need to take:

1. Update the financial policy with 1 written standard for all physicians.

2. Develop granular procedures driven by the policy; these are the “how-tos” that enable the staff to collect successfully.

3. Implement new technologies, such as cost estimators, recurring payments, and online bill pay.

4. Schedule formal training to ensure that staff members know how to ask for money. (Do not assume they are, can, or will without training.)

5. Measure and monitor the outcome of patient collections and staff performance.

6. Provide ongoing coaching and oversight to maintain motivation and skills.

A blueprint for addressing each one of these actions follows.

1. Update the financial policy

The policy is the set of expectations on which to build all procedures and training. Dust off this document, and review it as a group with the practice administrator. First, strike old language that says the patient will be balance-billed, or will only be asked in the office for his visit copay. Next, strive for clarity. “You will be asked to pay your financial responsibility at the time of service,” really says nothing. Instead, the policy should be direct:

If you are recommended for surgery, our staff will calculate your coinsurance and unmet deductible amounts: 50% of this amount will be collected as a surgery deposit, and the remaining 50% is due on or before the day of surgery. Payment plans are available.

For office visits and services, break down the policy by coverage type. We find that a table such as the one shown makes expectations clear.

Finally, strive for 1 standard policy for all providers. If every provider is allowed to create his or her own set of collection policies, the practice is setting staff up for complexity overload, and collections will suffer.

2. Develop granular procedures

Few practices take the time to translate the financial policy into written procedures that can be followed by staff. The policy establishes the rules, but the procedures tell staff what to do to implement those rules. For instance:

Create a “POS Playbook” that contains information such as procedures, cost-quotation worksheets, US Poverty guidelines¹, and financing brochures. As old-school as it sounds, a 3-ring binder is great for this information, and makes information access and updates easy.

3. Implement collection technologies

Modern practices use inexpensive (and often free) tools that increase patient convenience and staff efficiency. Implement at least 2 of these useful technologies and watch your POS collections increase:

Reports from your practice management system (PMS). Use the technology you already have. There are 2 standard reports in your PMS or clearinghouse that give front-desk staff the data to ask patients for money. Eligibility status and past-due balance reports indicate amounts owed, unmet deductibles, and the ineligible patients they can collect from when they come in for their appointment.

Online cost estimators. These free, online tools are offered by payers and provide staff with real-time data about a patient’s unmet deductible and coinsurance. When staff members enter Current Procedural Terminology (CPT) codes and the patient’s benefit information into the online cost estimator, they can access valuable information. Many insurance plans offer cost estimators on their web sites. Others deliver the data through statewide or regional portals, such as Availity (www.availity.com). The accuracy of cost-estimator data can vary by region and depends on the data links with payers. Ask your team to evaluate which estimators are best for you based on your payer mix.

Online bill pay. Everyone appreciates the convenience of paying bills online. Most patient portals offer this feature. If yours does not or you do not have a portal, you can offer PayPal (www.paypal.com) on your practice website, or use a system such as Intuit Health (www.intuithealth.com).

Recurring billing. Recurring billing is how you pay for services, such as Netflix, Pandora, or your gym membership: it is automatically billed to a credit card each month. Offer this option to patients as a payment plan method, and staff will no longer need to send costly statements, post monthly check payments, or follow up when a patient is delinquent. Plus, it guarantees payment every month; patients can no longer say, “I forgot.”

TransFirst (www.transfirstassociation.com) and a-claim (www.a-claim.com) offer recurring billing through a “virtual terminal” that staff logs in to at checkout, or during the preprocedure patient counseling process. Both vendors also offer the option of automatically charging a patient’s credit card after their insurance pays, speeding patient account pay-off and negating the need for statements.

Real-time collections scripts based on payer rules. Patient Access, offered by Availity, combines real-time payer data with financial policies that are entered during set-up to create instant, patient-specific scripts that staff members read to the patient in front of them.

4. Schedule formal training

Just because someone can collect a copay does not mean he or she is comfortable with or capable of asking patients for past-due balances, surgical deposits, or large coinsurances. It is the rare staff person who is a “natural” at asking patients for money in a polished and professional manner.

That’s why training staff how to ask patients for money is vital. A front-office supervisor or manager should conduct several training sessions to cover policies and procedures. Training materials should include talking points and scenarios for collecting for office services and past-due balances, and calculating what patients owe, using technology tools. Use role-playing to ensure staff can explain payment plan options and how to apply for patient financing or financial assistance.

Few practices can skip this part of the POS program and still be successful. If your manager or supervisor is not capable of training, it is worth the investment to hire an outside expert. Without thorough training, staff efforts will be suboptimal or, at worst, fail because the staff members will not know how or what to collect.

5. Measure and monitor the outcome

The Hawthorne effect is a psychological phenomenon that says people perform better and make more positive changes as a result of increased attention.² In other words, staff members will perform better, and collect more, if they know someone is paying attention. Trust us on this one.

Employees respect what management inspects. So even if the implementation of POS collections has been a big success, do not take your eyes off the ball.

Stop by the front desk or surgery coordinator’s office a few times a month and ask how much has been collected. Randomly review daily over-the-counter collections logs. And always put POS collections performance on the monthly partner meeting agenda; review a graph that shows monthly collections at checkout and surgery deposits. Keeping tabs on performance enables the practice to take action quickly when collections drop, and before that decline becomes acute.

6. Provide ongoing coaching and oversight

Most practices train once, then wonder why staff motivation (and collections too) fall off after a while. Like that new couch you bought: it was all you could talk about the week after it was delivered. Now, it is only a comfy place to sit. It is the same with collections efforts. When the newness wears off, staff motivation does too, and training principles can be forgotten. That’s human nature. Conduct role-playing in staff meetings each quarter and discuss best practices for handling patient objections. Encourage peer-to-peer observation and coaching to address knowledge gaps and missed collection opportunities. Ongoing training and coaching will tease out training needs and boost your team’s collection confidence and success.

Patients with lower limb amputation have a high incidence of hip and knee osteoarthritis (OA) in the residual limb as well as the contralateral limb. A radical surgery, hip disarticulation is generally performed in younger patients after malignancy or trauma. Compliance is poor with existing prostheses, resulting in increased dependency on and use of the remaining sound limb.

In this case report, a crutch-walking 51-year-old woman presented with severe left hip arthritis 25 years after a right hip disarticulation. She underwent total hip arthroplasty (THA), a challenging procedure in a person without a contralateral hip joint. The many complex technical considerations associated with her THA included precise perioperative planning, the selection of appropriate prostheses and bearing surfaces, and the preoperative and intraoperative assessment of limb length and offset. The patient provided written informed consent for print and electronic publication of this case report.

Case Report

A 51-year-old woman presented to our service with a 3-year history of debilitating left hip pain. Twenty-five years earlier, she had been diagnosed with synovial sarcoma of the right knee and underwent limb-sparing surgery, followed by a true hip disarticulation performed for local recurrence. After her surgery, she declined the use of a prosthesis and mobilized with the use of 2 crutches. She has remained otherwise healthy and active, and runs her own business, which involves some lifting and carrying of objects. During the 3 years prior to presentation, she developed progressively debilitating left hip and groin pain, which radiated to the medial aspect of her left knee. Her mobilization distance had reduced to a few hundred meters, and she experienced significant night pain, and start-up pain. Activity modification, weight loss, and nonsteroidal anti-inflammatory medication afforded no relief. She denied any back pain or radicular symptoms.

Clinical examination showed a well-healed scar and pristine stump under her right hemipelvis. Passive range of movement of her left hip was painful for all movements, reduced at flexion (90º) and internal (10º) and external rotation (5º). Examination of her left knee was normal, with a full range of movement and no joint-line tenderness. A high body mass index (>30) was noted. Radiographic imaging confirmed significant OA of the hip joint (Figure 1). Informed consent was obtained for THA. The implants were selected—an uncemented collared Corail Stem (DePuy, Warsaw, Indiana) with a stainless steel dual mobility (DM) Novae SunFit acetabular cup (Serf, Decines, France), with bearing components of ceramic on polyethylene. A preoperative computed tomography (CT) scan of the left hip was performed (Figure 2) to aid templating, which was accomplished using plain films and CT images, with reference to the proximal femur for deciding level of neck cut, planning stem size, and optimizing length and offset, while determining cup size, depth, inclination, and height for the acetabular component.

Prior to surgery, the patient was positioned in the lateral decubitus position, using folded pillows under the medial aspect of her left proximal and distal thigh in lieu of her amputated limb. Pillows were secured to the table with elastic bandage tape. Standard pubic symphysis, lumbosacral, and midthoracic padded bolsters stabilized the pelvis in the normal fashion, with additional elastic bandage tape to further secure the pelvis brim to the table and reduce intraoperative motion. A posterior approach was used. A capsulotomy was performed with the hip in extension and slight abduction, with meticulous preservation of the capsule as the guide for the patient’s native length and offset. Reaming of the acetabulum was line to line, with insertion of an uncemented DM metal-back press-fit hydroxyapatite-coated shell placed in a standard fashion parallel with the transverse acetabular ligament, as described by Archbold and colleagues.¹ The femur was sequentially reamed with broaches until press fit was achieved, and a calcar reamer was used to optimize interface with the collared implant. The surgeon’s standard 4 clinical tests were performed with trial implants after reduction to gauge hip tension, length, and offset. These tests are positive shuck test with hip and knee extension, lack of shuck in hip extension with knee flexion, lack of kick sign in hip extension and knee flexion, and palpation of gluteus medius belly to determine tension. Finally, with the hip returned to the extended and slightly abducted position, the capsule was tested for length and tension. The definitive stem implant was inserted, final testing with trial heads was repeated prior to definitive neck length and head selection, and final reduction was performed. A layered closure was performed, after generous washout. Pillows were taped together and positioned from the bed railing across the midline of the bed to prevent abduction, in the fashion of an abduction pillow.

The patient was mobilized the day after surgery and permitted full weight-bearing. Recovery was uneventful, and the patient returned to work within 6 weeks of surgery after her scheduled appointment and radiographic examination (Figure 3). Ongoing regular clinical and radiologic surveillance are planned.

Discussion

Hip and knee OA in the residual limb is more common for amputees than for the general population.^2,3 THA for OA in amputees has been reported after below-knee amputation in both the ipsilateral and the contralateral hip.⁴ A true hip disarticulation is a rarely performed radical surgical procedure, involving the removal of the entire femur, and is most often related to surgical oncologic treatment or combat-related injuries, both being more common in younger people. Like many patients who have had a hip disarticulation,⁵ our patient declined a prosthesis, finding the design cosmetically unappealing and uncomfortable, in favor of crutch-walking. This accelerated wear of the remaining hip, and is a sobering reminder of the high demand on the bearing surfaces of the implants after her procedure.

The implants chosen for this procedure are critical. We use implants which are proven and reliable. Our institution uses the Corail Stem, an uncemented collared stem with an Orthopaedic Data Evaluation Panel (ODEP) 10A rating,⁶ widely used for THA.⁷ For the acetabulum, we chose the Novae SunFit, a modern version based on Bousquet’s 1976 DM design. The DM cup is a tripolar cup with a fixed porous-coated or cemented metal cup, which articulates with a large mobile polyethylene liner. A standard head in either metal or ceramic is inserted into this liner. The articulation between the head and the liner is constrained, while the articulation between the liner and the metal cup is unconstrained. This interposition of a mobile insert increases the effective head diameter, and the favorable head-neck ratio allows increased range of motion while avoiding early femoral neck impingement with a fixed liner or metal cup. A growing body of evidence indicates that DM cups reduce dislocation rates in primary and revision total knee arthroplasty and, when used with prudence, in selected tumor cases.⁸ A study of 1905 hips, using second-generation DM cups, reported cumulative survival rate of 98.6% at 12.2 years,⁹ with favorable outcomes compared with standard prostheses in the medium term for younger patients,¹⁰ and in the longer term,¹¹ without increasing polyethylene wear.¹²

We use DM cups for 2 patient cohorts: first, for all patients older than 75 years because, in this age group, the risk of dislocation is higher than the risk of revision for wear-induced lysis; and second, in younger patients with any neuromuscular, cognitive, or mechanical risk factors that would excessively increase the risk of dislocation. This reflects the balance of risks in arthroplasty, with the ever-present trade-off between polyethylene-induced osteolysis and stability. Dislocation of the remaining sound limb for this young, active, agile patient would be a catastrophic complication. Given our patient’s risk factors for dislocation—female, an amputee with a high risk of falling, high body mass index, and lack of a contralateral limb to restrict adduction—the balance of risks favored hip stability over wear. We chose, therefore, a DM cup, using a ceramic-head-on-polyethylene-insert surface-bearing combination.

CT scanning is routinely performed in our institution to optimize preoperative templating. The preoperative CT images enable accurate planning, notably for the extramedullary reconstruction,¹³ and are used in addition to acetates and standard radiographs. This encourages preservation of acetabular bone stock by selecting the smallest suitable cup, reduces the risk of femoral fracture by giving an accurate prediction of the stem size, and ensures accuracy of restoring the patient’s offset and length. Although limb-length discrepancy was not an issue for this patient with a single sound limb, the sequalae of excessively increasing offset or length (eg, gluteus medius tendinopathy and trochanteric bursitis) would arguably be more debilitating than for someone who could offload weight to the “good hip.” For these reasons, marrying the preoperative templating with on-table testing with trial prostheses and restoring the native capsular tension is vital.

The importance of on-table positioning for proximal amputees undergoing hip arthroplasty has been highlighted.¹⁴ Lacking the normal bony constraints increases the risk of intraoperative on-table movement, which, in turn, risks reducing the accuracy of implant positioning. Crude limb-length checking using the contralateral knee is not possible. In addition, the lack of a contralateral hip joint causes a degree of compensatory pelvic tilt, which raises the option of increasing the coverage to compensate for obligate adduction during single-leg, crutch-walking gait. Lacking established guidelines to accommodate these variables, we inserted the cup in a standard fashion, at 45º, referencing acetabular version using the transverse acetabular ligament,¹ and used the smallest stable cup after line-to-line reaming.

This case of THA in a young, crutch-walking patient with a contralateral true hip disarticulation highlights the importance of meticulous preoperative planning, implant selection appropriate for the patient in question, perioperative positioning, and the technical and operative challenges of restoring the patient’s normal hip architecture. 

Patients with lower limb amputation have a high incidence of hip and knee osteoarthritis (OA) in the residual limb as well as the contralateral limb. A radical surgery, hip disarticulation is generally performed in younger patients after malignancy or trauma. Compliance is poor with existing prostheses, resulting in increased dependency on and use of the remaining sound limb.

In this case report, a crutch-walking 51-year-old woman presented with severe left hip arthritis 25 years after a right hip disarticulation. She underwent total hip arthroplasty (THA), a challenging procedure in a person without a contralateral hip joint. The many complex technical considerations associated with her THA included precise perioperative planning, the selection of appropriate prostheses and bearing surfaces, and the preoperative and intraoperative assessment of limb length and offset. The patient provided written informed consent for print and electronic publication of this case report.

Case Report

A 51-year-old woman presented to our service with a 3-year history of debilitating left hip pain. Twenty-five years earlier, she had been diagnosed with synovial sarcoma of the right knee and underwent limb-sparing surgery, followed by a true hip disarticulation performed for local recurrence. After her surgery, she declined the use of a prosthesis and mobilized with the use of 2 crutches. She has remained otherwise healthy and active, and runs her own business, which involves some lifting and carrying of objects. During the 3 years prior to presentation, she developed progressively debilitating left hip and groin pain, which radiated to the medial aspect of her left knee. Her mobilization distance had reduced to a few hundred meters, and she experienced significant night pain, and start-up pain. Activity modification, weight loss, and nonsteroidal anti-inflammatory medication afforded no relief. She denied any back pain or radicular symptoms.

Clinical examination showed a well-healed scar and pristine stump under her right hemipelvis. Passive range of movement of her left hip was painful for all movements, reduced at flexion (90º) and internal (10º) and external rotation (5º). Examination of her left knee was normal, with a full range of movement and no joint-line tenderness. A high body mass index (>30) was noted. Radiographic imaging confirmed significant OA of the hip joint (Figure 1). Informed consent was obtained for THA. The implants were selected—an uncemented collared Corail Stem (DePuy, Warsaw, Indiana) with a stainless steel dual mobility (DM) Novae SunFit acetabular cup (Serf, Decines, France), with bearing components of ceramic on polyethylene. A preoperative computed tomography (CT) scan of the left hip was performed (Figure 2) to aid templating, which was accomplished using plain films and CT images, with reference to the proximal femur for deciding level of neck cut, planning stem size, and optimizing length and offset, while determining cup size, depth, inclination, and height for the acetabular component.

Prior to surgery, the patient was positioned in the lateral decubitus position, using folded pillows under the medial aspect of her left proximal and distal thigh in lieu of her amputated limb. Pillows were secured to the table with elastic bandage tape. Standard pubic symphysis, lumbosacral, and midthoracic padded bolsters stabilized the pelvis in the normal fashion, with additional elastic bandage tape to further secure the pelvis brim to the table and reduce intraoperative motion. A posterior approach was used. A capsulotomy was performed with the hip in extension and slight abduction, with meticulous preservation of the capsule as the guide for the patient’s native length and offset. Reaming of the acetabulum was line to line, with insertion of an uncemented DM metal-back press-fit hydroxyapatite-coated shell placed in a standard fashion parallel with the transverse acetabular ligament, as described by Archbold and colleagues.¹ The femur was sequentially reamed with broaches until press fit was achieved, and a calcar reamer was used to optimize interface with the collared implant. The surgeon’s standard 4 clinical tests were performed with trial implants after reduction to gauge hip tension, length, and offset. These tests are positive shuck test with hip and knee extension, lack of shuck in hip extension with knee flexion, lack of kick sign in hip extension and knee flexion, and palpation of gluteus medius belly to determine tension. Finally, with the hip returned to the extended and slightly abducted position, the capsule was tested for length and tension. The definitive stem implant was inserted, final testing with trial heads was repeated prior to definitive neck length and head selection, and final reduction was performed. A layered closure was performed, after generous washout. Pillows were taped together and positioned from the bed railing across the midline of the bed to prevent abduction, in the fashion of an abduction pillow.

The patient was mobilized the day after surgery and permitted full weight-bearing. Recovery was uneventful, and the patient returned to work within 6 weeks of surgery after her scheduled appointment and radiographic examination (Figure 3). Ongoing regular clinical and radiologic surveillance are planned.

Discussion

Hip and knee OA in the residual limb is more common for amputees than for the general population.^2,3 THA for OA in amputees has been reported after below-knee amputation in both the ipsilateral and the contralateral hip.⁴ A true hip disarticulation is a rarely performed radical surgical procedure, involving the removal of the entire femur, and is most often related to surgical oncologic treatment or combat-related injuries, both being more common in younger people. Like many patients who have had a hip disarticulation,⁵ our patient declined a prosthesis, finding the design cosmetically unappealing and uncomfortable, in favor of crutch-walking. This accelerated wear of the remaining hip, and is a sobering reminder of the high demand on the bearing surfaces of the implants after her procedure.

The implants chosen for this procedure are critical. We use implants which are proven and reliable. Our institution uses the Corail Stem, an uncemented collared stem with an Orthopaedic Data Evaluation Panel (ODEP) 10A rating,⁶ widely used for THA.⁷ For the acetabulum, we chose the Novae SunFit, a modern version based on Bousquet’s 1976 DM design. The DM cup is a tripolar cup with a fixed porous-coated or cemented metal cup, which articulates with a large mobile polyethylene liner. A standard head in either metal or ceramic is inserted into this liner. The articulation between the head and the liner is constrained, while the articulation between the liner and the metal cup is unconstrained. This interposition of a mobile insert increases the effective head diameter, and the favorable head-neck ratio allows increased range of motion while avoiding early femoral neck impingement with a fixed liner or metal cup. A growing body of evidence indicates that DM cups reduce dislocation rates in primary and revision total knee arthroplasty and, when used with prudence, in selected tumor cases.⁸ A study of 1905 hips, using second-generation DM cups, reported cumulative survival rate of 98.6% at 12.2 years,⁹ with favorable outcomes compared with standard prostheses in the medium term for younger patients,¹⁰ and in the longer term,¹¹ without increasing polyethylene wear.¹²

We use DM cups for 2 patient cohorts: first, for all patients older than 75 years because, in this age group, the risk of dislocation is higher than the risk of revision for wear-induced lysis; and second, in younger patients with any neuromuscular, cognitive, or mechanical risk factors that would excessively increase the risk of dislocation. This reflects the balance of risks in arthroplasty, with the ever-present trade-off between polyethylene-induced osteolysis and stability. Dislocation of the remaining sound limb for this young, active, agile patient would be a catastrophic complication. Given our patient’s risk factors for dislocation—female, an amputee with a high risk of falling, high body mass index, and lack of a contralateral limb to restrict adduction—the balance of risks favored hip stability over wear. We chose, therefore, a DM cup, using a ceramic-head-on-polyethylene-insert surface-bearing combination.

CT scanning is routinely performed in our institution to optimize preoperative templating. The preoperative CT images enable accurate planning, notably for the extramedullary reconstruction,¹³ and are used in addition to acetates and standard radiographs. This encourages preservation of acetabular bone stock by selecting the smallest suitable cup, reduces the risk of femoral fracture by giving an accurate prediction of the stem size, and ensures accuracy of restoring the patient’s offset and length. Although limb-length discrepancy was not an issue for this patient with a single sound limb, the sequalae of excessively increasing offset or length (eg, gluteus medius tendinopathy and trochanteric bursitis) would arguably be more debilitating than for someone who could offload weight to the “good hip.” For these reasons, marrying the preoperative templating with on-table testing with trial prostheses and restoring the native capsular tension is vital.

The importance of on-table positioning for proximal amputees undergoing hip arthroplasty has been highlighted.¹⁴ Lacking the normal bony constraints increases the risk of intraoperative on-table movement, which, in turn, risks reducing the accuracy of implant positioning. Crude limb-length checking using the contralateral knee is not possible. In addition, the lack of a contralateral hip joint causes a degree of compensatory pelvic tilt, which raises the option of increasing the coverage to compensate for obligate adduction during single-leg, crutch-walking gait. Lacking established guidelines to accommodate these variables, we inserted the cup in a standard fashion, at 45º, referencing acetabular version using the transverse acetabular ligament,¹ and used the smallest stable cup after line-to-line reaming.

This case of THA in a young, crutch-walking patient with a contralateral true hip disarticulation highlights the importance of meticulous preoperative planning, implant selection appropriate for the patient in question, perioperative positioning, and the technical and operative challenges of restoring the patient’s normal hip architecture. 

Patients with lower limb amputation have a high incidence of hip and knee osteoarthritis (OA) in the residual limb as well as the contralateral limb. A radical surgery, hip disarticulation is generally performed in younger patients after malignancy or trauma. Compliance is poor with existing prostheses, resulting in increased dependency on and use of the remaining sound limb.

In this case report, a crutch-walking 51-year-old woman presented with severe left hip arthritis 25 years after a right hip disarticulation. She underwent total hip arthroplasty (THA), a challenging procedure in a person without a contralateral hip joint. The many complex technical considerations associated with her THA included precise perioperative planning, the selection of appropriate prostheses and bearing surfaces, and the preoperative and intraoperative assessment of limb length and offset. The patient provided written informed consent for print and electronic publication of this case report.

Case Report

A 51-year-old woman presented to our service with a 3-year history of debilitating left hip pain. Twenty-five years earlier, she had been diagnosed with synovial sarcoma of the right knee and underwent limb-sparing surgery, followed by a true hip disarticulation performed for local recurrence. After her surgery, she declined the use of a prosthesis and mobilized with the use of 2 crutches. She has remained otherwise healthy and active, and runs her own business, which involves some lifting and carrying of objects. During the 3 years prior to presentation, she developed progressively debilitating left hip and groin pain, which radiated to the medial aspect of her left knee. Her mobilization distance had reduced to a few hundred meters, and she experienced significant night pain, and start-up pain. Activity modification, weight loss, and nonsteroidal anti-inflammatory medication afforded no relief. She denied any back pain or radicular symptoms.

Clinical examination showed a well-healed scar and pristine stump under her right hemipelvis. Passive range of movement of her left hip was painful for all movements, reduced at flexion (90º) and internal (10º) and external rotation (5º). Examination of her left knee was normal, with a full range of movement and no joint-line tenderness. A high body mass index (>30) was noted. Radiographic imaging confirmed significant OA of the hip joint (Figure 1). Informed consent was obtained for THA. The implants were selected—an uncemented collared Corail Stem (DePuy, Warsaw, Indiana) with a stainless steel dual mobility (DM) Novae SunFit acetabular cup (Serf, Decines, France), with bearing components of ceramic on polyethylene. A preoperative computed tomography (CT) scan of the left hip was performed (Figure 2) to aid templating, which was accomplished using plain films and CT images, with reference to the proximal femur for deciding level of neck cut, planning stem size, and optimizing length and offset, while determining cup size, depth, inclination, and height for the acetabular component.

Prior to surgery, the patient was positioned in the lateral decubitus position, using folded pillows under the medial aspect of her left proximal and distal thigh in lieu of her amputated limb. Pillows were secured to the table with elastic bandage tape. Standard pubic symphysis, lumbosacral, and midthoracic padded bolsters stabilized the pelvis in the normal fashion, with additional elastic bandage tape to further secure the pelvis brim to the table and reduce intraoperative motion. A posterior approach was used. A capsulotomy was performed with the hip in extension and slight abduction, with meticulous preservation of the capsule as the guide for the patient’s native length and offset. Reaming of the acetabulum was line to line, with insertion of an uncemented DM metal-back press-fit hydroxyapatite-coated shell placed in a standard fashion parallel with the transverse acetabular ligament, as described by Archbold and colleagues.¹ The femur was sequentially reamed with broaches until press fit was achieved, and a calcar reamer was used to optimize interface with the collared implant. The surgeon’s standard 4 clinical tests were performed with trial implants after reduction to gauge hip tension, length, and offset. These tests are positive shuck test with hip and knee extension, lack of shuck in hip extension with knee flexion, lack of kick sign in hip extension and knee flexion, and palpation of gluteus medius belly to determine tension. Finally, with the hip returned to the extended and slightly abducted position, the capsule was tested for length and tension. The definitive stem implant was inserted, final testing with trial heads was repeated prior to definitive neck length and head selection, and final reduction was performed. A layered closure was performed, after generous washout. Pillows were taped together and positioned from the bed railing across the midline of the bed to prevent abduction, in the fashion of an abduction pillow.

The patient was mobilized the day after surgery and permitted full weight-bearing. Recovery was uneventful, and the patient returned to work within 6 weeks of surgery after her scheduled appointment and radiographic examination (Figure 3). Ongoing regular clinical and radiologic surveillance are planned.

Discussion

Hip and knee OA in the residual limb is more common for amputees than for the general population.^2,3 THA for OA in amputees has been reported after below-knee amputation in both the ipsilateral and the contralateral hip.⁴ A true hip disarticulation is a rarely performed radical surgical procedure, involving the removal of the entire femur, and is most often related to surgical oncologic treatment or combat-related injuries, both being more common in younger people. Like many patients who have had a hip disarticulation,⁵ our patient declined a prosthesis, finding the design cosmetically unappealing and uncomfortable, in favor of crutch-walking. This accelerated wear of the remaining hip, and is a sobering reminder of the high demand on the bearing surfaces of the implants after her procedure.

The implants chosen for this procedure are critical. We use implants which are proven and reliable. Our institution uses the Corail Stem, an uncemented collared stem with an Orthopaedic Data Evaluation Panel (ODEP) 10A rating,⁶ widely used for THA.⁷ For the acetabulum, we chose the Novae SunFit, a modern version based on Bousquet’s 1976 DM design. The DM cup is a tripolar cup with a fixed porous-coated or cemented metal cup, which articulates with a large mobile polyethylene liner. A standard head in either metal or ceramic is inserted into this liner. The articulation between the head and the liner is constrained, while the articulation between the liner and the metal cup is unconstrained. This interposition of a mobile insert increases the effective head diameter, and the favorable head-neck ratio allows increased range of motion while avoiding early femoral neck impingement with a fixed liner or metal cup. A growing body of evidence indicates that DM cups reduce dislocation rates in primary and revision total knee arthroplasty and, when used with prudence, in selected tumor cases.⁸ A study of 1905 hips, using second-generation DM cups, reported cumulative survival rate of 98.6% at 12.2 years,⁹ with favorable outcomes compared with standard prostheses in the medium term for younger patients,¹⁰ and in the longer term,¹¹ without increasing polyethylene wear.¹²

We use DM cups for 2 patient cohorts: first, for all patients older than 75 years because, in this age group, the risk of dislocation is higher than the risk of revision for wear-induced lysis; and second, in younger patients with any neuromuscular, cognitive, or mechanical risk factors that would excessively increase the risk of dislocation. This reflects the balance of risks in arthroplasty, with the ever-present trade-off between polyethylene-induced osteolysis and stability. Dislocation of the remaining sound limb for this young, active, agile patient would be a catastrophic complication. Given our patient’s risk factors for dislocation—female, an amputee with a high risk of falling, high body mass index, and lack of a contralateral limb to restrict adduction—the balance of risks favored hip stability over wear. We chose, therefore, a DM cup, using a ceramic-head-on-polyethylene-insert surface-bearing combination.

CT scanning is routinely performed in our institution to optimize preoperative templating. The preoperative CT images enable accurate planning, notably for the extramedullary reconstruction,¹³ and are used in addition to acetates and standard radiographs. This encourages preservation of acetabular bone stock by selecting the smallest suitable cup, reduces the risk of femoral fracture by giving an accurate prediction of the stem size, and ensures accuracy of restoring the patient’s offset and length. Although limb-length discrepancy was not an issue for this patient with a single sound limb, the sequalae of excessively increasing offset or length (eg, gluteus medius tendinopathy and trochanteric bursitis) would arguably be more debilitating than for someone who could offload weight to the “good hip.” For these reasons, marrying the preoperative templating with on-table testing with trial prostheses and restoring the native capsular tension is vital.

The importance of on-table positioning for proximal amputees undergoing hip arthroplasty has been highlighted.¹⁴ Lacking the normal bony constraints increases the risk of intraoperative on-table movement, which, in turn, risks reducing the accuracy of implant positioning. Crude limb-length checking using the contralateral knee is not possible. In addition, the lack of a contralateral hip joint causes a degree of compensatory pelvic tilt, which raises the option of increasing the coverage to compensate for obligate adduction during single-leg, crutch-walking gait. Lacking established guidelines to accommodate these variables, we inserted the cup in a standard fashion, at 45º, referencing acetabular version using the transverse acetabular ligament,¹ and used the smallest stable cup after line-to-line reaming.

This case of THA in a young, crutch-walking patient with a contralateral true hip disarticulation highlights the importance of meticulous preoperative planning, implant selection appropriate for the patient in question, perioperative positioning, and the technical and operative challenges of restoring the patient’s normal hip architecture. 

Hip fractures, the most severe and costly fall-related fractures, account for 350,000 hospital admissions per year.¹ The majority of hip fractures result from low-impact falls, typically in patients over age 60 years. In fact, the increase in hip fracture with age is nearly exponential.^2,3 With the predicted aging of our population, hip fractures will continue to increase in volume. Between 2000 and 2050, the elderly US population will increase by 135%,⁴ proportionately increasing the number of projected hip fractures. Considering that hip fractures account for 72% of total costs in terms of orthopedic fracture care in the elderly, the dramatic rise in hip fractures is of great concern for future costs of health care delivery in this field.^5-7

In an effort to move toward a value-based system in which costs are reduced while quality of care is maintained, Medicare recently unveiled a new bundled payment system of reimbursement. Through this system, hospitals will be reimbursed for treatment provided to Medicare beneficiaries based on the expected costs of care, instead of through the traditional fee-for-service model. Given this development, orthopedic surgeons will need to develop interventions that reduce costs while maintaining quality of care after hip fracture surgery.

One of the most significant ramifications of a value-based system is that reimbursement for hip fractures may be standardized based on a single diagnosis regardless of the actual costs associated with treatment.⁸ In hip fracture cases, however, a wide range of factors, including degree of communition of the bone, presence of medical comorbidities,⁹ and amount of soft-tissue injury, can dramatically increase recovery time. In fact, one of the most important determinants of treatment costs related to hospital length of stay (LOS) is whether the fracture is a femoral neck or intertrochanteric fracture.^10,11 Type of fracture is a significant determinant of surgical options, and these can dramatically change patient outcomes and costs of surgical care.^12-16 In addition, hospital recovery time or LOS can vary widely based on type of surgery. As hospitalization costs account for 44% of the direct medical costs for hip fractures,¹⁷ differences in LOS can have major financial implications in a value-based system of reimbursement in which all forms of hip fracture are reimbursed a standard amount.

We conducted a study to analyze differences in hospital LOS for different forms of hip fracture repair to determine the potential financial repercussions of a bundled payment model of reimbursement. By performing a retrospective chart review at a large, level I trauma center, we were able to compare LOS and associated costs for total hip arthroplasty (THA), hemiarthroplasty (HA), cephalomedullary nailing (CMN), open reduction and internal fixation (ORIF), and closed reduction and percutaneous pinning (CRPP).

Materials and Methods

After receiving institutional review board approval for this study, we retrospectively reviewed all hip fracture cases treated at a level I trauma center between January 2000 and December 2009. Current Procedural Terminology (CPT) codes were searched for cases of low-energy falls that caused hip fractures that were resolved with THA, HA, CMN, ORIF, or CRPP. Patients who underwent HA or THA were grouped for analysis. Patients who were over age 60 years and had acetabular, proximal femoral, trochanteric, or femoral neck fractures were included in our search. Patients who had incomplete medical records or did not meet the age criterion were excluded from analysis.

We reviewed patient charts in our institutional electronic medical records database to collect these data: date of birth, age, sex, date of admission, date of discharge, American Society of Anesthesiologists (ASA) Physical Status score, complications, height, weight, start and stop times of procedure, whether or not the procedure was an emergent procedure, days from admission to surgery, 90-day readmissions, days from surgery to discharge, and general category of operation. We also recorded individual comorbidities, including prior myocardial infarction, dysrhythmia, atrial fibrillation, congestive heart failure, heart block, cerebrovascular disease, chronic obstructive pulmonary disease, emphysema, current smoking status, smoking history, renal disease, dialysis, cancer, and diabetes. Duration of surgery was calculated from recorded start and stop times. Body mass index was calculated using height and weight recorded during initial stay. LOS was recorded as the difference between the admission and discharge dates.

Mean total cost to the hospital ($4530/d patient was hospitalized) was obtained from the institution’s financial services. All fractional LOS values were rounded to the nearest whole number and multiplied by the per diem cost. Student t test was used to compare mean LOS and costs of HA/THA with those of all the other procedures. Additional tests were run to analyze differences in LOS and type of surgeries performed throughout the 9-year period. A multivariate regression model controlling for ASA score, body mass index, age, sex, and comorbidities was developed to analyze differences in LOS and costs for patients who underwent HA/THA versus CMN, ORIF, and CRPP. Significance was set at P = .05.

Results

Our search identified 720 patients who were over age 60 years and underwent operative fixation for hip fracture at our level I trauma center between 2000 and 2009. Of these 720 patients, 105 who had incomplete charts or did not meet the age criteria were excluded, leaving 615 patients (with complete records of isolated low-energy hip fractures) for analysis.

Table 1 lists the demographics of our patient population. The majority of patients had undergone ORIF (30.24%) or HA/THA (45.69%). CRPP was the least common procedure (9.92%) after CMN (14.15%). Mean age was 78.4 years; the majority of patients were between 75 and 89 years of age. Mean hospital LOS was 6.91 days. The majority of patients (n = 414; 67.32%) were female. ASA scores had a narrow distribution, with most patients assigned a score of 3. The readmission rate was significantly higher for HA/THA (39.1%) than for ORIF (28.5%; P = .02) and CRPP (24.6%; P = .04).

Table 2 lists mean LOS and associated costs for each procedure compared with HA/THA. Mean LOS for all patients was 6.91 days, with associated hospitalization costs of $30,011.25. Patients who underwent HA/THA had the longest mean LOS (7.43 days) and highest mean hospitalization costs ($33,657.90). In comparison, patients who underwent ORIF had a mean LOS of 6.59 days with $29,852.70 in costs (P = .04). CRPP also had a significantly (P < .003) shorter LOS (5.59 days) and lower costs ($25,322.70). Although CMN had a mean LOS of 6.89 days and $31,211.70 in costs, the difference in LOS was not significantly different from that of HA/THA. The proportion of surgeries that were HA/THA, CMN, ORIF, and CRPP did not change significantly through the 9-year period (P = .19). Similarly, mean LOS did not change significantly for any of the types of surgery through this period (Table 3).

Figure 1 provides the distribution of LOS for all 4 procedures. The interquartile range (IQR) for patients who underwent HA/THA was 4 to 9 days (median, 6 days). Patients who underwent CMN also had a median LOS of 6 days and an IQR of 4 to 8 days. Both ORIF (IQR, 4-8 days) and CRPP (IQR, 3-6 days) were associated with a median LOS of 5 days.

Figure 2 shows mean hospitalization costs based on type of procedure. HA/THA had the highest mean cost, $33,657.90, or $8335.20 more than CRPP ($25,322.70). Patients who underwent CMN had a mean cost of $31,211.70, versus $29,852.70 for patients who underwent ORIF.

Table 4 summarizes the multivariate analysis results. After ASA score, sex, age, and comorbidities were controlled for, there was an overall significant relationship involving surgical treatment, LOS, and associated hospitalization costs for HA/THA, ORIF, and CRPP. Compared with HA/THA, ORIF had $3805.20 less in costs (P = .042) and 0.84 fewer hospital days. Patients who underwent CRPP were hospitalized for significantly fewer days (1.63) and associated costs ($7383.90) (P = .0076). There was no significant difference in LOS and costs between HA/THA and CMN. Of the controlled variables, only ASA score (P < .001) and male sex (P = .001) were significantly associated with changes in LOS and costs. There was no significant association with comorbidities, LOS, or costs.

Discussion

In this study of surgical intervention in patients with hip fractures, we determined that HA/THA was associated with significantly increased hospital LOS and costs than ORIF and CRPP. Although arthroplasty had an increased mean LOS compared with CMN, the difference was not statistically significant. In addition to type of procedure, both male sex (P = .001) and preoperative ASA score (P < .001) were significant predictors of LOS and costs. These findings are supported by other studies in which preoperative functioning was found to be a strong predictor of increased LOS and costs among hip fracture patients,¹⁸ most likely because of increased risk for complications.¹⁹

Although our study was the first to directly compare LOS and costs for HA/THA and CMN, other investigators have analyzed the effect of surgical complications on LOS for patients treated with THA, HA, and CMN. In a study on the effects of surgical complications on LOS after hip fracture surgery, Foss and colleagues¹⁷ reported that the proportion of CMN patients (31%) with complications was larger than that of HA patients (19%) and THA patients (0%). They also reported that surgical complications were associated with significantly increased LOS during primary admission. Similarly, Edwards and colleagues²⁰ found that the infection risk was higher with CMN (3.1%) than with THA (0%) and HA (0%-2.3%) and that infections were associated with increased LOS (P > .001). However, further statistical analysis revealed that the odds of developing an infection were not significantly higher with CMN than with other studies.²⁰ Similarly, other studies have reported low rates of complications, including nonunion, with CMN.^21,22 In our study, we found no significant difference in LOS and costs for CMN and HA/THA after controlling for ASA score, which is known to be associated with a higher risk for complications.^18,19

The largest difference in LOS and costs after controlling for potential confounding variables was between HA/THA and CRPP ($7383.90). To our knowledge, only one study has performed a comparative analysis of LOS for CRPP and other surgical treatments for hip fractures. For femoral neck fractures treated between 1990 and 1994, Fekete and colleagues²³ found that LOS was 14.9 days for ORIF cases and 12.1 days for CRPP cases—a difference of 2.8 days. In comparison, we found a 1-day difference in mean LOS between ORIF cases (6.59 days) and CRPP cases (5.59 days).

Other studies of LOS and associated costs over a 2-year period have found that ORIF is overall more costly than HA/THA. For example, Keating and colleagues¹³ compared total costs of care, including LOS, for healthy older patients with displaced intracapsular hip fractures treated with ORIF, bipolar HA, or THA. Although ORIF was initially less costly than HA/THA, overall ORIF costs over 2 years were significantly higher because of readmissions, which increased overall LOS. Similarly, in cases of displaced femoral fractures, Iorio and colleagues¹⁵ found that LOS was 6.4 days for ORIF, 4.9 days for unipolar HA, 6.2 days for bipolar HA, and 5.5 days for cemented and hybrid THA. However, when overall projected costs were estimated, including the costs of rehabilitation and of (probable) revision arthroplasty, ORIF was estimated to cost more over a 2-year period because of the need for additional care and in-patient stays. In contrast, we found that hospitalization costs were $3805.20 lower for ORIF than for HA/THA, even after adjusting for comorbidities, and that ORIF had a lower overall readmission rate. Early discharge of patients who are at risk for subsequent complications may have played a significant role in increasing readmission rates for arthroplasty patients. These findings indicate the complexities involved in a bundled payment system of reimbursement, in which a single payment for both initial stay and related readmissions will force orthopedists to consider long-term hospitalization costs when deciding on length of postoperative care and the most cost-effective surgical treatment.

One of the limitations of this study is its retrospective design. Although selection of our sample from a single level I trauma center reduced differences in cost and patient care protocols between institutions, it also reduced the generalizability of our actual costs. In addition, for some patients, LOS may have increased because of delays in surgery or discharge, lack of operating room availability, or need for further medical clearance for additional procedures. Day of admission could also have significantly affected LOS. However, the effects of these confounding factors were reduced because of the large sample analyzed. As stated earlier, overall LOS depends on both initial in-patient stays and readmissions. Therefore, long-term prospective studies that compare LOS and associated costs for patients with hip fractures treated with ORIF, CRPP, HA/THA, and CMN are needed.

Conclusion

It has been recently suggested that hip fracture repair be included in the National Pilot Program on Payment Bundling, which will potentially reimburse orthopedic surgeons a standardized amount for hip fracture surgery regardless of actual treatment costs.⁸ In this model, it will be essential to understand how type of fracture and surgical procedure can influence LOS and therefore hip fracture treatment costs. We found that, based on these factors, mean LOS ranged from 5.59 to 7.43 days, which translates to a cost range of $25,322.70 to $33,657.90. Before a standardized bundled payment system is implemented, further studies are needed to identify other factors that can significantly affect the cost of hip fracture repair.

Hip fractures, the most severe and costly fall-related fractures, account for 350,000 hospital admissions per year.¹ The majority of hip fractures result from low-impact falls, typically in patients over age 60 years. In fact, the increase in hip fracture with age is nearly exponential.^2,3 With the predicted aging of our population, hip fractures will continue to increase in volume. Between 2000 and 2050, the elderly US population will increase by 135%,⁴ proportionately increasing the number of projected hip fractures. Considering that hip fractures account for 72% of total costs in terms of orthopedic fracture care in the elderly, the dramatic rise in hip fractures is of great concern for future costs of health care delivery in this field.^5-7

In an effort to move toward a value-based system in which costs are reduced while quality of care is maintained, Medicare recently unveiled a new bundled payment system of reimbursement. Through this system, hospitals will be reimbursed for treatment provided to Medicare beneficiaries based on the expected costs of care, instead of through the traditional fee-for-service model. Given this development, orthopedic surgeons will need to develop interventions that reduce costs while maintaining quality of care after hip fracture surgery.

One of the most significant ramifications of a value-based system is that reimbursement for hip fractures may be standardized based on a single diagnosis regardless of the actual costs associated with treatment.⁸ In hip fracture cases, however, a wide range of factors, including degree of communition of the bone, presence of medical comorbidities,⁹ and amount of soft-tissue injury, can dramatically increase recovery time. In fact, one of the most important determinants of treatment costs related to hospital length of stay (LOS) is whether the fracture is a femoral neck or intertrochanteric fracture.^10,11 Type of fracture is a significant determinant of surgical options, and these can dramatically change patient outcomes and costs of surgical care.^12-16 In addition, hospital recovery time or LOS can vary widely based on type of surgery. As hospitalization costs account for 44% of the direct medical costs for hip fractures,¹⁷ differences in LOS can have major financial implications in a value-based system of reimbursement in which all forms of hip fracture are reimbursed a standard amount.

We conducted a study to analyze differences in hospital LOS for different forms of hip fracture repair to determine the potential financial repercussions of a bundled payment model of reimbursement. By performing a retrospective chart review at a large, level I trauma center, we were able to compare LOS and associated costs for total hip arthroplasty (THA), hemiarthroplasty (HA), cephalomedullary nailing (CMN), open reduction and internal fixation (ORIF), and closed reduction and percutaneous pinning (CRPP).

Materials and Methods

After receiving institutional review board approval for this study, we retrospectively reviewed all hip fracture cases treated at a level I trauma center between January 2000 and December 2009. Current Procedural Terminology (CPT) codes were searched for cases of low-energy falls that caused hip fractures that were resolved with THA, HA, CMN, ORIF, or CRPP. Patients who underwent HA or THA were grouped for analysis. Patients who were over age 60 years and had acetabular, proximal femoral, trochanteric, or femoral neck fractures were included in our search. Patients who had incomplete medical records or did not meet the age criterion were excluded from analysis.

We reviewed patient charts in our institutional electronic medical records database to collect these data: date of birth, age, sex, date of admission, date of discharge, American Society of Anesthesiologists (ASA) Physical Status score, complications, height, weight, start and stop times of procedure, whether or not the procedure was an emergent procedure, days from admission to surgery, 90-day readmissions, days from surgery to discharge, and general category of operation. We also recorded individual comorbidities, including prior myocardial infarction, dysrhythmia, atrial fibrillation, congestive heart failure, heart block, cerebrovascular disease, chronic obstructive pulmonary disease, emphysema, current smoking status, smoking history, renal disease, dialysis, cancer, and diabetes. Duration of surgery was calculated from recorded start and stop times. Body mass index was calculated using height and weight recorded during initial stay. LOS was recorded as the difference between the admission and discharge dates.

Mean total cost to the hospital ($4530/d patient was hospitalized) was obtained from the institution’s financial services. All fractional LOS values were rounded to the nearest whole number and multiplied by the per diem cost. Student t test was used to compare mean LOS and costs of HA/THA with those of all the other procedures. Additional tests were run to analyze differences in LOS and type of surgeries performed throughout the 9-year period. A multivariate regression model controlling for ASA score, body mass index, age, sex, and comorbidities was developed to analyze differences in LOS and costs for patients who underwent HA/THA versus CMN, ORIF, and CRPP. Significance was set at P = .05.

Results

Our search identified 720 patients who were over age 60 years and underwent operative fixation for hip fracture at our level I trauma center between 2000 and 2009. Of these 720 patients, 105 who had incomplete charts or did not meet the age criteria were excluded, leaving 615 patients (with complete records of isolated low-energy hip fractures) for analysis.

Table 1 lists the demographics of our patient population. The majority of patients had undergone ORIF (30.24%) or HA/THA (45.69%). CRPP was the least common procedure (9.92%) after CMN (14.15%). Mean age was 78.4 years; the majority of patients were between 75 and 89 years of age. Mean hospital LOS was 6.91 days. The majority of patients (n = 414; 67.32%) were female. ASA scores had a narrow distribution, with most patients assigned a score of 3. The readmission rate was significantly higher for HA/THA (39.1%) than for ORIF (28.5%; P = .02) and CRPP (24.6%; P = .04).

Table 2 lists mean LOS and associated costs for each procedure compared with HA/THA. Mean LOS for all patients was 6.91 days, with associated hospitalization costs of $30,011.25. Patients who underwent HA/THA had the longest mean LOS (7.43 days) and highest mean hospitalization costs ($33,657.90). In comparison, patients who underwent ORIF had a mean LOS of 6.59 days with $29,852.70 in costs (P = .04). CRPP also had a significantly (P < .003) shorter LOS (5.59 days) and lower costs ($25,322.70). Although CMN had a mean LOS of 6.89 days and $31,211.70 in costs, the difference in LOS was not significantly different from that of HA/THA. The proportion of surgeries that were HA/THA, CMN, ORIF, and CRPP did not change significantly through the 9-year period (P = .19). Similarly, mean LOS did not change significantly for any of the types of surgery through this period (Table 3).

Figure 1 provides the distribution of LOS for all 4 procedures. The interquartile range (IQR) for patients who underwent HA/THA was 4 to 9 days (median, 6 days). Patients who underwent CMN also had a median LOS of 6 days and an IQR of 4 to 8 days. Both ORIF (IQR, 4-8 days) and CRPP (IQR, 3-6 days) were associated with a median LOS of 5 days.

Figure 2 shows mean hospitalization costs based on type of procedure. HA/THA had the highest mean cost, $33,657.90, or $8335.20 more than CRPP ($25,322.70). Patients who underwent CMN had a mean cost of $31,211.70, versus $29,852.70 for patients who underwent ORIF.

Table 4 summarizes the multivariate analysis results. After ASA score, sex, age, and comorbidities were controlled for, there was an overall significant relationship involving surgical treatment, LOS, and associated hospitalization costs for HA/THA, ORIF, and CRPP. Compared with HA/THA, ORIF had $3805.20 less in costs (P = .042) and 0.84 fewer hospital days. Patients who underwent CRPP were hospitalized for significantly fewer days (1.63) and associated costs ($7383.90) (P = .0076). There was no significant difference in LOS and costs between HA/THA and CMN. Of the controlled variables, only ASA score (P < .001) and male sex (P = .001) were significantly associated with changes in LOS and costs. There was no significant association with comorbidities, LOS, or costs.

Discussion

In this study of surgical intervention in patients with hip fractures, we determined that HA/THA was associated with significantly increased hospital LOS and costs than ORIF and CRPP. Although arthroplasty had an increased mean LOS compared with CMN, the difference was not statistically significant. In addition to type of procedure, both male sex (P = .001) and preoperative ASA score (P < .001) were significant predictors of LOS and costs. These findings are supported by other studies in which preoperative functioning was found to be a strong predictor of increased LOS and costs among hip fracture patients,¹⁸ most likely because of increased risk for complications.¹⁹

Although our study was the first to directly compare LOS and costs for HA/THA and CMN, other investigators have analyzed the effect of surgical complications on LOS for patients treated with THA, HA, and CMN. In a study on the effects of surgical complications on LOS after hip fracture surgery, Foss and colleagues¹⁷ reported that the proportion of CMN patients (31%) with complications was larger than that of HA patients (19%) and THA patients (0%). They also reported that surgical complications were associated with significantly increased LOS during primary admission. Similarly, Edwards and colleagues²⁰ found that the infection risk was higher with CMN (3.1%) than with THA (0%) and HA (0%-2.3%) and that infections were associated with increased LOS (P > .001). However, further statistical analysis revealed that the odds of developing an infection were not significantly higher with CMN than with other studies.²⁰ Similarly, other studies have reported low rates of complications, including nonunion, with CMN.^21,22 In our study, we found no significant difference in LOS and costs for CMN and HA/THA after controlling for ASA score, which is known to be associated with a higher risk for complications.^18,19

The largest difference in LOS and costs after controlling for potential confounding variables was between HA/THA and CRPP ($7383.90). To our knowledge, only one study has performed a comparative analysis of LOS for CRPP and other surgical treatments for hip fractures. For femoral neck fractures treated between 1990 and 1994, Fekete and colleagues²³ found that LOS was 14.9 days for ORIF cases and 12.1 days for CRPP cases—a difference of 2.8 days. In comparison, we found a 1-day difference in mean LOS between ORIF cases (6.59 days) and CRPP cases (5.59 days).

Other studies of LOS and associated costs over a 2-year period have found that ORIF is overall more costly than HA/THA. For example, Keating and colleagues¹³ compared total costs of care, including LOS, for healthy older patients with displaced intracapsular hip fractures treated with ORIF, bipolar HA, or THA. Although ORIF was initially less costly than HA/THA, overall ORIF costs over 2 years were significantly higher because of readmissions, which increased overall LOS. Similarly, in cases of displaced femoral fractures, Iorio and colleagues¹⁵ found that LOS was 6.4 days for ORIF, 4.9 days for unipolar HA, 6.2 days for bipolar HA, and 5.5 days for cemented and hybrid THA. However, when overall projected costs were estimated, including the costs of rehabilitation and of (probable) revision arthroplasty, ORIF was estimated to cost more over a 2-year period because of the need for additional care and in-patient stays. In contrast, we found that hospitalization costs were $3805.20 lower for ORIF than for HA/THA, even after adjusting for comorbidities, and that ORIF had a lower overall readmission rate. Early discharge of patients who are at risk for subsequent complications may have played a significant role in increasing readmission rates for arthroplasty patients. These findings indicate the complexities involved in a bundled payment system of reimbursement, in which a single payment for both initial stay and related readmissions will force orthopedists to consider long-term hospitalization costs when deciding on length of postoperative care and the most cost-effective surgical treatment.

One of the limitations of this study is its retrospective design. Although selection of our sample from a single level I trauma center reduced differences in cost and patient care protocols between institutions, it also reduced the generalizability of our actual costs. In addition, for some patients, LOS may have increased because of delays in surgery or discharge, lack of operating room availability, or need for further medical clearance for additional procedures. Day of admission could also have significantly affected LOS. However, the effects of these confounding factors were reduced because of the large sample analyzed. As stated earlier, overall LOS depends on both initial in-patient stays and readmissions. Therefore, long-term prospective studies that compare LOS and associated costs for patients with hip fractures treated with ORIF, CRPP, HA/THA, and CMN are needed.

Conclusion

It has been recently suggested that hip fracture repair be included in the National Pilot Program on Payment Bundling, which will potentially reimburse orthopedic surgeons a standardized amount for hip fracture surgery regardless of actual treatment costs.⁸ In this model, it will be essential to understand how type of fracture and surgical procedure can influence LOS and therefore hip fracture treatment costs. We found that, based on these factors, mean LOS ranged from 5.59 to 7.43 days, which translates to a cost range of $25,322.70 to $33,657.90. Before a standardized bundled payment system is implemented, further studies are needed to identify other factors that can significantly affect the cost of hip fracture repair.

Hip fractures, the most severe and costly fall-related fractures, account for 350,000 hospital admissions per year.¹ The majority of hip fractures result from low-impact falls, typically in patients over age 60 years. In fact, the increase in hip fracture with age is nearly exponential.^2,3 With the predicted aging of our population, hip fractures will continue to increase in volume. Between 2000 and 2050, the elderly US population will increase by 135%,⁴ proportionately increasing the number of projected hip fractures. Considering that hip fractures account for 72% of total costs in terms of orthopedic fracture care in the elderly, the dramatic rise in hip fractures is of great concern for future costs of health care delivery in this field.^5-7

In an effort to move toward a value-based system in which costs are reduced while quality of care is maintained, Medicare recently unveiled a new bundled payment system of reimbursement. Through this system, hospitals will be reimbursed for treatment provided to Medicare beneficiaries based on the expected costs of care, instead of through the traditional fee-for-service model. Given this development, orthopedic surgeons will need to develop interventions that reduce costs while maintaining quality of care after hip fracture surgery.

One of the most significant ramifications of a value-based system is that reimbursement for hip fractures may be standardized based on a single diagnosis regardless of the actual costs associated with treatment.⁸ In hip fracture cases, however, a wide range of factors, including degree of communition of the bone, presence of medical comorbidities,⁹ and amount of soft-tissue injury, can dramatically increase recovery time. In fact, one of the most important determinants of treatment costs related to hospital length of stay (LOS) is whether the fracture is a femoral neck or intertrochanteric fracture.^10,11 Type of fracture is a significant determinant of surgical options, and these can dramatically change patient outcomes and costs of surgical care.^12-16 In addition, hospital recovery time or LOS can vary widely based on type of surgery. As hospitalization costs account for 44% of the direct medical costs for hip fractures,¹⁷ differences in LOS can have major financial implications in a value-based system of reimbursement in which all forms of hip fracture are reimbursed a standard amount.

We conducted a study to analyze differences in hospital LOS for different forms of hip fracture repair to determine the potential financial repercussions of a bundled payment model of reimbursement. By performing a retrospective chart review at a large, level I trauma center, we were able to compare LOS and associated costs for total hip arthroplasty (THA), hemiarthroplasty (HA), cephalomedullary nailing (CMN), open reduction and internal fixation (ORIF), and closed reduction and percutaneous pinning (CRPP).

Materials and Methods

After receiving institutional review board approval for this study, we retrospectively reviewed all hip fracture cases treated at a level I trauma center between January 2000 and December 2009. Current Procedural Terminology (CPT) codes were searched for cases of low-energy falls that caused hip fractures that were resolved with THA, HA, CMN, ORIF, or CRPP. Patients who underwent HA or THA were grouped for analysis. Patients who were over age 60 years and had acetabular, proximal femoral, trochanteric, or femoral neck fractures were included in our search. Patients who had incomplete medical records or did not meet the age criterion were excluded from analysis.

We reviewed patient charts in our institutional electronic medical records database to collect these data: date of birth, age, sex, date of admission, date of discharge, American Society of Anesthesiologists (ASA) Physical Status score, complications, height, weight, start and stop times of procedure, whether or not the procedure was an emergent procedure, days from admission to surgery, 90-day readmissions, days from surgery to discharge, and general category of operation. We also recorded individual comorbidities, including prior myocardial infarction, dysrhythmia, atrial fibrillation, congestive heart failure, heart block, cerebrovascular disease, chronic obstructive pulmonary disease, emphysema, current smoking status, smoking history, renal disease, dialysis, cancer, and diabetes. Duration of surgery was calculated from recorded start and stop times. Body mass index was calculated using height and weight recorded during initial stay. LOS was recorded as the difference between the admission and discharge dates.

Mean total cost to the hospital ($4530/d patient was hospitalized) was obtained from the institution’s financial services. All fractional LOS values were rounded to the nearest whole number and multiplied by the per diem cost. Student t test was used to compare mean LOS and costs of HA/THA with those of all the other procedures. Additional tests were run to analyze differences in LOS and type of surgeries performed throughout the 9-year period. A multivariate regression model controlling for ASA score, body mass index, age, sex, and comorbidities was developed to analyze differences in LOS and costs for patients who underwent HA/THA versus CMN, ORIF, and CRPP. Significance was set at P = .05.

Results

Our search identified 720 patients who were over age 60 years and underwent operative fixation for hip fracture at our level I trauma center between 2000 and 2009. Of these 720 patients, 105 who had incomplete charts or did not meet the age criteria were excluded, leaving 615 patients (with complete records of isolated low-energy hip fractures) for analysis.

Table 1 lists the demographics of our patient population. The majority of patients had undergone ORIF (30.24%) or HA/THA (45.69%). CRPP was the least common procedure (9.92%) after CMN (14.15%). Mean age was 78.4 years; the majority of patients were between 75 and 89 years of age. Mean hospital LOS was 6.91 days. The majority of patients (n = 414; 67.32%) were female. ASA scores had a narrow distribution, with most patients assigned a score of 3. The readmission rate was significantly higher for HA/THA (39.1%) than for ORIF (28.5%; P = .02) and CRPP (24.6%; P = .04).

Table 2 lists mean LOS and associated costs for each procedure compared with HA/THA. Mean LOS for all patients was 6.91 days, with associated hospitalization costs of $30,011.25. Patients who underwent HA/THA had the longest mean LOS (7.43 days) and highest mean hospitalization costs ($33,657.90). In comparison, patients who underwent ORIF had a mean LOS of 6.59 days with $29,852.70 in costs (P = .04). CRPP also had a significantly (P < .003) shorter LOS (5.59 days) and lower costs ($25,322.70). Although CMN had a mean LOS of 6.89 days and $31,211.70 in costs, the difference in LOS was not significantly different from that of HA/THA. The proportion of surgeries that were HA/THA, CMN, ORIF, and CRPP did not change significantly through the 9-year period (P = .19). Similarly, mean LOS did not change significantly for any of the types of surgery through this period (Table 3).

Figure 1 provides the distribution of LOS for all 4 procedures. The interquartile range (IQR) for patients who underwent HA/THA was 4 to 9 days (median, 6 days). Patients who underwent CMN also had a median LOS of 6 days and an IQR of 4 to 8 days. Both ORIF (IQR, 4-8 days) and CRPP (IQR, 3-6 days) were associated with a median LOS of 5 days.

Figure 2 shows mean hospitalization costs based on type of procedure. HA/THA had the highest mean cost, $33,657.90, or $8335.20 more than CRPP ($25,322.70). Patients who underwent CMN had a mean cost of $31,211.70, versus $29,852.70 for patients who underwent ORIF.

Table 4 summarizes the multivariate analysis results. After ASA score, sex, age, and comorbidities were controlled for, there was an overall significant relationship involving surgical treatment, LOS, and associated hospitalization costs for HA/THA, ORIF, and CRPP. Compared with HA/THA, ORIF had $3805.20 less in costs (P = .042) and 0.84 fewer hospital days. Patients who underwent CRPP were hospitalized for significantly fewer days (1.63) and associated costs ($7383.90) (P = .0076). There was no significant difference in LOS and costs between HA/THA and CMN. Of the controlled variables, only ASA score (P < .001) and male sex (P = .001) were significantly associated with changes in LOS and costs. There was no significant association with comorbidities, LOS, or costs.

Discussion

In this study of surgical intervention in patients with hip fractures, we determined that HA/THA was associated with significantly increased hospital LOS and costs than ORIF and CRPP. Although arthroplasty had an increased mean LOS compared with CMN, the difference was not statistically significant. In addition to type of procedure, both male sex (P = .001) and preoperative ASA score (P < .001) were significant predictors of LOS and costs. These findings are supported by other studies in which preoperative functioning was found to be a strong predictor of increased LOS and costs among hip fracture patients,¹⁸ most likely because of increased risk for complications.¹⁹

Although our study was the first to directly compare LOS and costs for HA/THA and CMN, other investigators have analyzed the effect of surgical complications on LOS for patients treated with THA, HA, and CMN. In a study on the effects of surgical complications on LOS after hip fracture surgery, Foss and colleagues¹⁷ reported that the proportion of CMN patients (31%) with complications was larger than that of HA patients (19%) and THA patients (0%). They also reported that surgical complications were associated with significantly increased LOS during primary admission. Similarly, Edwards and colleagues²⁰ found that the infection risk was higher with CMN (3.1%) than with THA (0%) and HA (0%-2.3%) and that infections were associated with increased LOS (P > .001). However, further statistical analysis revealed that the odds of developing an infection were not significantly higher with CMN than with other studies.²⁰ Similarly, other studies have reported low rates of complications, including nonunion, with CMN.^21,22 In our study, we found no significant difference in LOS and costs for CMN and HA/THA after controlling for ASA score, which is known to be associated with a higher risk for complications.^18,19

The largest difference in LOS and costs after controlling for potential confounding variables was between HA/THA and CRPP ($7383.90). To our knowledge, only one study has performed a comparative analysis of LOS for CRPP and other surgical treatments for hip fractures. For femoral neck fractures treated between 1990 and 1994, Fekete and colleagues²³ found that LOS was 14.9 days for ORIF cases and 12.1 days for CRPP cases—a difference of 2.8 days. In comparison, we found a 1-day difference in mean LOS between ORIF cases (6.59 days) and CRPP cases (5.59 days).

Other studies of LOS and associated costs over a 2-year period have found that ORIF is overall more costly than HA/THA. For example, Keating and colleagues¹³ compared total costs of care, including LOS, for healthy older patients with displaced intracapsular hip fractures treated with ORIF, bipolar HA, or THA. Although ORIF was initially less costly than HA/THA, overall ORIF costs over 2 years were significantly higher because of readmissions, which increased overall LOS. Similarly, in cases of displaced femoral fractures, Iorio and colleagues¹⁵ found that LOS was 6.4 days for ORIF, 4.9 days for unipolar HA, 6.2 days for bipolar HA, and 5.5 days for cemented and hybrid THA. However, when overall projected costs were estimated, including the costs of rehabilitation and of (probable) revision arthroplasty, ORIF was estimated to cost more over a 2-year period because of the need for additional care and in-patient stays. In contrast, we found that hospitalization costs were $3805.20 lower for ORIF than for HA/THA, even after adjusting for comorbidities, and that ORIF had a lower overall readmission rate. Early discharge of patients who are at risk for subsequent complications may have played a significant role in increasing readmission rates for arthroplasty patients. These findings indicate the complexities involved in a bundled payment system of reimbursement, in which a single payment for both initial stay and related readmissions will force orthopedists to consider long-term hospitalization costs when deciding on length of postoperative care and the most cost-effective surgical treatment.

One of the limitations of this study is its retrospective design. Although selection of our sample from a single level I trauma center reduced differences in cost and patient care protocols between institutions, it also reduced the generalizability of our actual costs. In addition, for some patients, LOS may have increased because of delays in surgery or discharge, lack of operating room availability, or need for further medical clearance for additional procedures. Day of admission could also have significantly affected LOS. However, the effects of these confounding factors were reduced because of the large sample analyzed. As stated earlier, overall LOS depends on both initial in-patient stays and readmissions. Therefore, long-term prospective studies that compare LOS and associated costs for patients with hip fractures treated with ORIF, CRPP, HA/THA, and CMN are needed.

Conclusion

It has been recently suggested that hip fracture repair be included in the National Pilot Program on Payment Bundling, which will potentially reimburse orthopedic surgeons a standardized amount for hip fracture surgery regardless of actual treatment costs.⁸ In this model, it will be essential to understand how type of fracture and surgical procedure can influence LOS and therefore hip fracture treatment costs. We found that, based on these factors, mean LOS ranged from 5.59 to 7.43 days, which translates to a cost range of $25,322.70 to $33,657.90. Before a standardized bundled payment system is implemented, further studies are needed to identify other factors that can significantly affect the cost of hip fracture repair.

Glenohumeral internal rotation deficit (GIRD) can be observed in overhead athletes and is thought to play a role in generating pain and rotator cuff weakness in the dominant shoulder with sport. It is unclear what is an acceptable value of GIRD in a population of overhead athletes and whether it should be based solely on internal rotation deficit or should include total range of motion (ROM) deficit.^1,2 Acquired GIRD in the athlete’s throwing shoulder has been thoroughly documented in the literature as a loss of internal rotation relative to the nonthrowing shoulder, with etiologies including bony adaptations (increased humeral retroversion), muscular tightness, and posterior capsular tightness.^1,3-11 In particular, the repetitive torsional stresses acting on the throwing shoulder of baseball players is thought to produce, over the long term, structural adaptations such as increased humeral retroversion.^5,12-14 Further, for shoulders with posterior-inferior capsular tightness, cadaveric studies have shown increased contact pressure at the coracoacromial arch during simulated follow-through.¹⁵ Athletes of other overhead and throwing sports, such as football, softball, tennis, and volleyball, may show similar adaptations in overhead motion.^9,16,17

GIRD has been associated with a variety of pathologic conditions, including scapular dyskinesis, internal and secondary impingement, partial articular-sided rotator cuff tears, damage to the biceps–labral complex, and ulnar collateral ligament insufficiency.^10,12,18-22

Restriction from engaging in exacerbating activities (eg, throwing) and compliance with a specific stretching program reduces or eliminates GIRD in the majority of cases.^1,23-28 In the few cases in which conservative management fails, operative intervention may be indicated.^1,23,29,30 Few investigators have detailed an operative technique for selective arthroscopic capsular release of the posterior-inferior capsule or evaluated the ability of athletes to return to sport after such surgery.

In this article, we present our technique for arthroscopic posterior-inferior capsular release and report the results of applying this technique in a population of athletes with symptomatic GIRD that was unresponsive to nonoperative treatment and was preventing them from returning to sport.

We hypothesized that selective arthroscopic surgical release of the posterior-inferior capsule would improve symptomatic GIRD and result in a return to sport in the majority of cases unresponsive to nonoperative treatment.

Materials and Methods

Patients

After obtaining institutional review board approval, we retrospectively reviewed patient charts and collected data. Study inclusion criteria were arthroscopic selective posterior-inferior capsular release between 2004 and 2008; failure to resume sport after minimum 3 months of physical therapy, including use of sleeper stretch, active joint mobilization by licensed physical therapist, and sport-specific restriction from exacerbating activities (eg, throwing for baseball players); and active participation in overhead sport.^1,27 Exclusion criteria were generalized adhesive capsulitis, labral pathology producing glenohumeral joint instability (Bankart or reverse Bankart lesion), high-grade or full-thickness tearing of rotator cuff, and clinically significant partial-thickness tearing or instability of long head of biceps tendon.

Assessment

One of 3 authors (Dr. Buss, Dr. Codding, or Dr. Dahm) used a bubble goniometer to measure passive internal rotation. Patients were positioned supine with 90° of thoracohumeral abduction and 90° of elbow flexion. The examiner’s hand stabilized the scapula against the examination table, in accordance with published techniques.^1,26 Active internal rotation was measured at 0° of thoracohumeral abduction by noting the most superior spinal segment reached. Before and after surgery, passive internal rotation measurements were taken on both arms. GIRD was determined by the difference between dominant and nondominant arm measurements; segmental differences were obtained by subtracting segments achieved between the dominant and nondominant arms.

Before surgery and at minimum 2-year follow-up after surgery, patients completed a subjective questionnaire, which included the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form, for assessment of both arms. ASES scores are reliable, valid, and responsive in evaluating shoulder pain and function.^15,31 Patients also answered questions about their ability to return to play, their level of play after surgery, and whether they would undergo the procedure again.

Surgical Technique

After induction of general anesthesia and standard preparation and draping, the patient is placed in a standard beach-chair position and examined. Diagnostic arthroscopy is then performed. In all patients, intra-articular evaluation revealed a thickened, contracted posterior band of the inferior glenohumeral ligament. This finding is consistent with other studies of patients with significant GIRD.^1,14,22,30

On completion of the diagnostic portion of the arthroscopy, attention is turned to the selective posterior-inferior capsular release. Key to proper execution of the release is establishing a posterior-inferior accessory portal. This is accomplished while viewing from a standard posterior (“soft spot”) portal and determining the appropriate location and angle of entry by spinal needle localization. Typically, an entry point is selected about 4 cm distal and 1 cm lateral to the standard posterior portal. An 18-gauge spinal needle introduced at this location is angled about 15° superiorly and about 20° medially. Once the appropriate vector is determined, a skin incision is made, and a Wissinger rod is introduced, over which a small-diameter cannula is passed. A hooked-tip electrocautery device is used to divide the posterior capsule from the glenoid labrum between the 8- and 6-o’clock positions in the right shoulder (Figure). Care is taken to perform the release immediately adjacent to the glenoid labrum and using short bursts of cautery in order to minimize risk of injury to the teres minor branch of the axillary nerve. Adequate release is confirmed by reassessing passive internal rotation under anesthesia. Additional procedures are performed, if necessary, after completion of the capsular release.

Postoperative rehabilitation consists initially of pendulum exercises and scapular retraction starting on postoperative day 1. Once the swelling from the surgical procedure subsides, typically within 1 week, passive and active-assisted ROM and gentle posterior capsular mobilization are initiated under the direction of a licensed physical therapist. Active ROM is allowed once the patient regains normal scapulothoracic rhythm. Strengthening consists initially of isometrics followed by light resistance strengthening for the rotator cuff and scapular stabilizers once active ROM and scapulothoracic rhythm return to normal. Passive internal rotation stretching, including use of the sleeper stretch, is implemented as soon as tolerated and continues throughout the rehabilitation process.³²

Statistical Analysis

Statistical analysis was performed with Stata Release 11 (StataCorp, College Station, Texas). Paired t tests were used to assess preoperative and postoperative mean differences in ASES scores, in passive glenohumeral internal rotation, and in active glenohumeral internal rotation; independent-samples t tests were used to assess side-to-side differences. Significance was set at P < .05.

Results

Fifteen overhead athletes met the study inclusion criteria. Two were lost to follow-up. Of the remaining 13 patients, 6 underwent isolated arthroscopic posterior-inferior capsular release, and 7 had concomitant procedures (6 subacromial decompressions, 1 superior labrum anterior-posterior [SLAP] repair). There were 11 male athletes and 2 female athletes. Twelve of the 13 patients were right-hand–dominant. Mean age at time of surgery was 21 years (range, 16-33 years). There were 10 baseball players (6 pitchers, 4 position players); the other 3 patients played softball (1), volleyball (1), or tennis (1). Six patients played at high school level, 5 at college level, 1 at professional level, and 1 at amateur level. All 13 patients underwent a minimum of 3 months of comprehensive rehabilitation, which included use of the sleeper stretch, active joint mobilization by a licensed physical therapist, and sport-specific restriction from exacerbating activities. Mean duration of symptoms before surgery was 18 months (range, 4-48 months). Mean postoperative follow-up was 31 months (range, 24-59 months). Mean ASES score was 71.5 (range, 33-95) before surgery and 86.9 (range, 60-100) after surgery (P < .001). Mean GIRD improved from 43.1° (range, 30°-60°) before surgery to 9.7° (range, –7° to 40°) after surgery (P < .001). Mean active internal rotation difference improved from 3.8 vertebral segments before surgery to 2.6 vertebral segments after surgery; this difference was not statistically significant (P = .459). Ten (77%) of the 13 patients returned to their preoperative level of play or a higher level; the other 3 (23%) did not return to their preoperative level of play but continued to compete in a different position (Table). Eleven patients (85%) stated they would repeat the procedure. One of the 2 patients who would not repeat the procedure was in the isolated posterior-inferior capsular release group; the other was in the concomitant-procedure group (subacromial decompression). Total glenohumeral ROM of dominant arm was 122° before surgery and 136° after surgery (P = .04). There was no significant difference in total ROM between dominant and nondominant arms after surgery (136° and 141°; P = .12), but the preoperative difference was significant (122° vs 141°; P = .022).

Discussion

GIRD has been associated with various pathologic conditions of the upper extremity. In 1991, Verna²⁸ found that a majority of 39 professional baseball pitchers with significant GIRD had shoulder problems that affected playing time. More recently, GIRD has been associated with a progression of injuries, including scapular dyskinesia, internal and secondary impingement, articular-sided partial rotator cuff tears, rotator cuff weakness, damage to the biceps–labral complex, and ulnar collateral ligament insufficiency.^12,18-22 In a cadaveric study of humeral head translation, Harryman and colleagues³³ noted an anterosuperior migration of the humeral head during flexion and concluded it resulted from a loose anterior and tight posterior glenohumeral capsule, leading to loss of glenohumeral internal rotation. More recently, posterosuperior migration of the humeral head has been postulated, with GIRD secondary to an essential posterior capsular contracture.¹ Tyler and colleagues³⁴ clinically linked posterior capsular tightness with GIRD, and both cadaveric and magnetic resonance imaging studies have supported the finding that posterior capsular contracture leads to posterosuperior humeral head migration in association with GIRD.^14,20 Such a disruption in normal glenohumeral joint mechanics could produce phenomena of internal or secondary acromiohumeral impingement and pain.

More recently, in a large cohort of professional baseball pitchers, a significant correlation was found between the incidence of rotator cuff strength deficits and GIRD.³⁵ More than 40% of the pitchers with GIRD of at least 35° had a measureable rotator cuff strength deficit in the throwing shoulder.

Burkhart and colleagues²³ concluded that the shoulder most at risk for developing “dead arm” has GIRD and an advanced form of scapular dyskinesia known as SICK scapula (the phenomenon involves Scapula malposition, Inferior medial border prominence, Coracoid pain and malposition, and dysKinesis of scapular movement).

Most athletes with symptoms attributed to GIRD respond to conservative management. A posterior-inferior capsular stretching program focused on regaining internal rotation in the throwing arm has been shown to return about 90% of athletes to play.¹ Numerous studies have indicated that enrollment in a compliant stretching program reduces GIRD.^1,23-27 However, nonoperative treatment fails in a reported 10% of patients with GIRD; these patients may respond to operative treatment.¹

More specifically, for patients who do not respond to conservative treatment, a posterior-inferior capsular release may be indicated.^1,29 Ticker and colleagues²² identified 9 patients who had lost internal rotation and had a posterior capsular contracture at arthroscopy. That study, however, was not performed on overhead or throwing athletes. Yoneda and colleagues³⁰ followed 16 overhead throwing athletes after arthroscopic posterior-inferior capsular release and found favorable preliminary clinical results. Eleven of the 16 patients returned to their preinjury level of performance; the other 5 returned to a lower level. In addition, all 4 patients who underwent isolated arthroscopic capsular release had throwing power restored to between 90% and 100%.

In the present study, 10 of 13 patients who underwent arthroscopic posterior-inferior capsular release returned to their preoperative level of play or a higher level. Mean passive GIRD improved significantly from before surgery to after surgery. ASES scores likewise were significantly improved from before surgery to after surgery. The active internal rotation difference as measured by vertebral segment level was not significantly changed after surgery. This lack of improvement may stem from the more complex musculoligamentous interactions governing active internal rotation versus isolated, passive internal rotation. Another possible explanation for lack of improvement is that the interobserver and intraobserver reliability of this method is lower.³⁶

At 2-year follow-up, the patient who had undergone concomitant SLAP repair demonstrated a 23% improvement in ASES score and more internal rotation on the dominant arm relative to the nondominant arm. This patient returned to a level of play at least as good as his preoperative level. Although we could not determine its statistical significance, this patient’s improvement suggests that the SLAP repair did not reduce the efficacy of the posterior-inferior capsular release.

Limitations of this study include its relatively small cohort (precluded statistical comparisons between groups), the proportion of patients (7/13) who had concomitant surgeries, and the limited options for patient outcome scores. Although the ASES score is a validated outcome score, the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow (KJOC) score or the Disabilities of the Arm, Shoulder, and Hand (DASH) score may be more appropriate in an athletic population. In addition, although all study patients had GIRD that was unresponsive to a concerted trial of nonoperative management, we did not have a control group (nonoperatively treated patients) for comparison. Finally, we did not obtain computed tomography scans or account for the potential contribution of humeral retroversion to GIRD in this group of patients.

Conclusion

Selective arthroscopic posterior-inferior capsular release can be recommended as a reasonable operative solution for overhead athletes with symptomatic GIRD that has not responded to conservative management. In the present study, ASES scores improved significantly, and 77% of our athlete-patients returned to sport at their preoperative level of play or a higher level.

Glenohumeral internal rotation deficit (GIRD) can be observed in overhead athletes and is thought to play a role in generating pain and rotator cuff weakness in the dominant shoulder with sport. It is unclear what is an acceptable value of GIRD in a population of overhead athletes and whether it should be based solely on internal rotation deficit or should include total range of motion (ROM) deficit.^1,2 Acquired GIRD in the athlete’s throwing shoulder has been thoroughly documented in the literature as a loss of internal rotation relative to the nonthrowing shoulder, with etiologies including bony adaptations (increased humeral retroversion), muscular tightness, and posterior capsular tightness.^1,3-11 In particular, the repetitive torsional stresses acting on the throwing shoulder of baseball players is thought to produce, over the long term, structural adaptations such as increased humeral retroversion.^5,12-14 Further, for shoulders with posterior-inferior capsular tightness, cadaveric studies have shown increased contact pressure at the coracoacromial arch during simulated follow-through.¹⁵ Athletes of other overhead and throwing sports, such as football, softball, tennis, and volleyball, may show similar adaptations in overhead motion.^9,16,17

GIRD has been associated with a variety of pathologic conditions, including scapular dyskinesis, internal and secondary impingement, partial articular-sided rotator cuff tears, damage to the biceps–labral complex, and ulnar collateral ligament insufficiency.^10,12,18-22

Restriction from engaging in exacerbating activities (eg, throwing) and compliance with a specific stretching program reduces or eliminates GIRD in the majority of cases.^1,23-28 In the few cases in which conservative management fails, operative intervention may be indicated.^1,23,29,30 Few investigators have detailed an operative technique for selective arthroscopic capsular release of the posterior-inferior capsule or evaluated the ability of athletes to return to sport after such surgery.

In this article, we present our technique for arthroscopic posterior-inferior capsular release and report the results of applying this technique in a population of athletes with symptomatic GIRD that was unresponsive to nonoperative treatment and was preventing them from returning to sport.

We hypothesized that selective arthroscopic surgical release of the posterior-inferior capsule would improve symptomatic GIRD and result in a return to sport in the majority of cases unresponsive to nonoperative treatment.

Materials and Methods

Patients

After obtaining institutional review board approval, we retrospectively reviewed patient charts and collected data. Study inclusion criteria were arthroscopic selective posterior-inferior capsular release between 2004 and 2008; failure to resume sport after minimum 3 months of physical therapy, including use of sleeper stretch, active joint mobilization by licensed physical therapist, and sport-specific restriction from exacerbating activities (eg, throwing for baseball players); and active participation in overhead sport.^1,27 Exclusion criteria were generalized adhesive capsulitis, labral pathology producing glenohumeral joint instability (Bankart or reverse Bankart lesion), high-grade or full-thickness tearing of rotator cuff, and clinically significant partial-thickness tearing or instability of long head of biceps tendon.

Assessment

One of 3 authors (Dr. Buss, Dr. Codding, or Dr. Dahm) used a bubble goniometer to measure passive internal rotation. Patients were positioned supine with 90° of thoracohumeral abduction and 90° of elbow flexion. The examiner’s hand stabilized the scapula against the examination table, in accordance with published techniques.^1,26 Active internal rotation was measured at 0° of thoracohumeral abduction by noting the most superior spinal segment reached. Before and after surgery, passive internal rotation measurements were taken on both arms. GIRD was determined by the difference between dominant and nondominant arm measurements; segmental differences were obtained by subtracting segments achieved between the dominant and nondominant arms.

Before surgery and at minimum 2-year follow-up after surgery, patients completed a subjective questionnaire, which included the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form, for assessment of both arms. ASES scores are reliable, valid, and responsive in evaluating shoulder pain and function.^15,31 Patients also answered questions about their ability to return to play, their level of play after surgery, and whether they would undergo the procedure again.

Surgical Technique

After induction of general anesthesia and standard preparation and draping, the patient is placed in a standard beach-chair position and examined. Diagnostic arthroscopy is then performed. In all patients, intra-articular evaluation revealed a thickened, contracted posterior band of the inferior glenohumeral ligament. This finding is consistent with other studies of patients with significant GIRD.^1,14,22,30

On completion of the diagnostic portion of the arthroscopy, attention is turned to the selective posterior-inferior capsular release. Key to proper execution of the release is establishing a posterior-inferior accessory portal. This is accomplished while viewing from a standard posterior (“soft spot”) portal and determining the appropriate location and angle of entry by spinal needle localization. Typically, an entry point is selected about 4 cm distal and 1 cm lateral to the standard posterior portal. An 18-gauge spinal needle introduced at this location is angled about 15° superiorly and about 20° medially. Once the appropriate vector is determined, a skin incision is made, and a Wissinger rod is introduced, over which a small-diameter cannula is passed. A hooked-tip electrocautery device is used to divide the posterior capsule from the glenoid labrum between the 8- and 6-o’clock positions in the right shoulder (Figure). Care is taken to perform the release immediately adjacent to the glenoid labrum and using short bursts of cautery in order to minimize risk of injury to the teres minor branch of the axillary nerve. Adequate release is confirmed by reassessing passive internal rotation under anesthesia. Additional procedures are performed, if necessary, after completion of the capsular release.

Postoperative rehabilitation consists initially of pendulum exercises and scapular retraction starting on postoperative day 1. Once the swelling from the surgical procedure subsides, typically within 1 week, passive and active-assisted ROM and gentle posterior capsular mobilization are initiated under the direction of a licensed physical therapist. Active ROM is allowed once the patient regains normal scapulothoracic rhythm. Strengthening consists initially of isometrics followed by light resistance strengthening for the rotator cuff and scapular stabilizers once active ROM and scapulothoracic rhythm return to normal. Passive internal rotation stretching, including use of the sleeper stretch, is implemented as soon as tolerated and continues throughout the rehabilitation process.³²

Statistical Analysis

Statistical analysis was performed with Stata Release 11 (StataCorp, College Station, Texas). Paired t tests were used to assess preoperative and postoperative mean differences in ASES scores, in passive glenohumeral internal rotation, and in active glenohumeral internal rotation; independent-samples t tests were used to assess side-to-side differences. Significance was set at P < .05.

Results

Fifteen overhead athletes met the study inclusion criteria. Two were lost to follow-up. Of the remaining 13 patients, 6 underwent isolated arthroscopic posterior-inferior capsular release, and 7 had concomitant procedures (6 subacromial decompressions, 1 superior labrum anterior-posterior [SLAP] repair). There were 11 male athletes and 2 female athletes. Twelve of the 13 patients were right-hand–dominant. Mean age at time of surgery was 21 years (range, 16-33 years). There were 10 baseball players (6 pitchers, 4 position players); the other 3 patients played softball (1), volleyball (1), or tennis (1). Six patients played at high school level, 5 at college level, 1 at professional level, and 1 at amateur level. All 13 patients underwent a minimum of 3 months of comprehensive rehabilitation, which included use of the sleeper stretch, active joint mobilization by a licensed physical therapist, and sport-specific restriction from exacerbating activities. Mean duration of symptoms before surgery was 18 months (range, 4-48 months). Mean postoperative follow-up was 31 months (range, 24-59 months). Mean ASES score was 71.5 (range, 33-95) before surgery and 86.9 (range, 60-100) after surgery (P < .001). Mean GIRD improved from 43.1° (range, 30°-60°) before surgery to 9.7° (range, –7° to 40°) after surgery (P < .001). Mean active internal rotation difference improved from 3.8 vertebral segments before surgery to 2.6 vertebral segments after surgery; this difference was not statistically significant (P = .459). Ten (77%) of the 13 patients returned to their preoperative level of play or a higher level; the other 3 (23%) did not return to their preoperative level of play but continued to compete in a different position (Table). Eleven patients (85%) stated they would repeat the procedure. One of the 2 patients who would not repeat the procedure was in the isolated posterior-inferior capsular release group; the other was in the concomitant-procedure group (subacromial decompression). Total glenohumeral ROM of dominant arm was 122° before surgery and 136° after surgery (P = .04). There was no significant difference in total ROM between dominant and nondominant arms after surgery (136° and 141°; P = .12), but the preoperative difference was significant (122° vs 141°; P = .022).

Discussion

GIRD has been associated with various pathologic conditions of the upper extremity. In 1991, Verna²⁸ found that a majority of 39 professional baseball pitchers with significant GIRD had shoulder problems that affected playing time. More recently, GIRD has been associated with a progression of injuries, including scapular dyskinesia, internal and secondary impingement, articular-sided partial rotator cuff tears, rotator cuff weakness, damage to the biceps–labral complex, and ulnar collateral ligament insufficiency.^12,18-22 In a cadaveric study of humeral head translation, Harryman and colleagues³³ noted an anterosuperior migration of the humeral head during flexion and concluded it resulted from a loose anterior and tight posterior glenohumeral capsule, leading to loss of glenohumeral internal rotation. More recently, posterosuperior migration of the humeral head has been postulated, with GIRD secondary to an essential posterior capsular contracture.¹ Tyler and colleagues³⁴ clinically linked posterior capsular tightness with GIRD, and both cadaveric and magnetic resonance imaging studies have supported the finding that posterior capsular contracture leads to posterosuperior humeral head migration in association with GIRD.^14,20 Such a disruption in normal glenohumeral joint mechanics could produce phenomena of internal or secondary acromiohumeral impingement and pain.

More recently, in a large cohort of professional baseball pitchers, a significant correlation was found between the incidence of rotator cuff strength deficits and GIRD.³⁵ More than 40% of the pitchers with GIRD of at least 35° had a measureable rotator cuff strength deficit in the throwing shoulder.

Burkhart and colleagues²³ concluded that the shoulder most at risk for developing “dead arm” has GIRD and an advanced form of scapular dyskinesia known as SICK scapula (the phenomenon involves Scapula malposition, Inferior medial border prominence, Coracoid pain and malposition, and dysKinesis of scapular movement).

Most athletes with symptoms attributed to GIRD respond to conservative management. A posterior-inferior capsular stretching program focused on regaining internal rotation in the throwing arm has been shown to return about 90% of athletes to play.¹ Numerous studies have indicated that enrollment in a compliant stretching program reduces GIRD.^1,23-27 However, nonoperative treatment fails in a reported 10% of patients with GIRD; these patients may respond to operative treatment.¹

More specifically, for patients who do not respond to conservative treatment, a posterior-inferior capsular release may be indicated.^1,29 Ticker and colleagues²² identified 9 patients who had lost internal rotation and had a posterior capsular contracture at arthroscopy. That study, however, was not performed on overhead or throwing athletes. Yoneda and colleagues³⁰ followed 16 overhead throwing athletes after arthroscopic posterior-inferior capsular release and found favorable preliminary clinical results. Eleven of the 16 patients returned to their preinjury level of performance; the other 5 returned to a lower level. In addition, all 4 patients who underwent isolated arthroscopic capsular release had throwing power restored to between 90% and 100%.

In the present study, 10 of 13 patients who underwent arthroscopic posterior-inferior capsular release returned to their preoperative level of play or a higher level. Mean passive GIRD improved significantly from before surgery to after surgery. ASES scores likewise were significantly improved from before surgery to after surgery. The active internal rotation difference as measured by vertebral segment level was not significantly changed after surgery. This lack of improvement may stem from the more complex musculoligamentous interactions governing active internal rotation versus isolated, passive internal rotation. Another possible explanation for lack of improvement is that the interobserver and intraobserver reliability of this method is lower.³⁶

At 2-year follow-up, the patient who had undergone concomitant SLAP repair demonstrated a 23% improvement in ASES score and more internal rotation on the dominant arm relative to the nondominant arm. This patient returned to a level of play at least as good as his preoperative level. Although we could not determine its statistical significance, this patient’s improvement suggests that the SLAP repair did not reduce the efficacy of the posterior-inferior capsular release.

Limitations of this study include its relatively small cohort (precluded statistical comparisons between groups), the proportion of patients (7/13) who had concomitant surgeries, and the limited options for patient outcome scores. Although the ASES score is a validated outcome score, the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow (KJOC) score or the Disabilities of the Arm, Shoulder, and Hand (DASH) score may be more appropriate in an athletic population. In addition, although all study patients had GIRD that was unresponsive to a concerted trial of nonoperative management, we did not have a control group (nonoperatively treated patients) for comparison. Finally, we did not obtain computed tomography scans or account for the potential contribution of humeral retroversion to GIRD in this group of patients.

Conclusion

Selective arthroscopic posterior-inferior capsular release can be recommended as a reasonable operative solution for overhead athletes with symptomatic GIRD that has not responded to conservative management. In the present study, ASES scores improved significantly, and 77% of our athlete-patients returned to sport at their preoperative level of play or a higher level.

Glenohumeral internal rotation deficit (GIRD) can be observed in overhead athletes and is thought to play a role in generating pain and rotator cuff weakness in the dominant shoulder with sport. It is unclear what is an acceptable value of GIRD in a population of overhead athletes and whether it should be based solely on internal rotation deficit or should include total range of motion (ROM) deficit.^1,2 Acquired GIRD in the athlete’s throwing shoulder has been thoroughly documented in the literature as a loss of internal rotation relative to the nonthrowing shoulder, with etiologies including bony adaptations (increased humeral retroversion), muscular tightness, and posterior capsular tightness.^1,3-11 In particular, the repetitive torsional stresses acting on the throwing shoulder of baseball players is thought to produce, over the long term, structural adaptations such as increased humeral retroversion.^5,12-14 Further, for shoulders with posterior-inferior capsular tightness, cadaveric studies have shown increased contact pressure at the coracoacromial arch during simulated follow-through.¹⁵ Athletes of other overhead and throwing sports, such as football, softball, tennis, and volleyball, may show similar adaptations in overhead motion.^9,16,17

GIRD has been associated with a variety of pathologic conditions, including scapular dyskinesis, internal and secondary impingement, partial articular-sided rotator cuff tears, damage to the biceps–labral complex, and ulnar collateral ligament insufficiency.^10,12,18-22

Restriction from engaging in exacerbating activities (eg, throwing) and compliance with a specific stretching program reduces or eliminates GIRD in the majority of cases.^1,23-28 In the few cases in which conservative management fails, operative intervention may be indicated.^1,23,29,30 Few investigators have detailed an operative technique for selective arthroscopic capsular release of the posterior-inferior capsule or evaluated the ability of athletes to return to sport after such surgery.

In this article, we present our technique for arthroscopic posterior-inferior capsular release and report the results of applying this technique in a population of athletes with symptomatic GIRD that was unresponsive to nonoperative treatment and was preventing them from returning to sport.

We hypothesized that selective arthroscopic surgical release of the posterior-inferior capsule would improve symptomatic GIRD and result in a return to sport in the majority of cases unresponsive to nonoperative treatment.

Materials and Methods

Patients

After obtaining institutional review board approval, we retrospectively reviewed patient charts and collected data. Study inclusion criteria were arthroscopic selective posterior-inferior capsular release between 2004 and 2008; failure to resume sport after minimum 3 months of physical therapy, including use of sleeper stretch, active joint mobilization by licensed physical therapist, and sport-specific restriction from exacerbating activities (eg, throwing for baseball players); and active participation in overhead sport.^1,27 Exclusion criteria were generalized adhesive capsulitis, labral pathology producing glenohumeral joint instability (Bankart or reverse Bankart lesion), high-grade or full-thickness tearing of rotator cuff, and clinically significant partial-thickness tearing or instability of long head of biceps tendon.

Assessment

One of 3 authors (Dr. Buss, Dr. Codding, or Dr. Dahm) used a bubble goniometer to measure passive internal rotation. Patients were positioned supine with 90° of thoracohumeral abduction and 90° of elbow flexion. The examiner’s hand stabilized the scapula against the examination table, in accordance with published techniques.^1,26 Active internal rotation was measured at 0° of thoracohumeral abduction by noting the most superior spinal segment reached. Before and after surgery, passive internal rotation measurements were taken on both arms. GIRD was determined by the difference between dominant and nondominant arm measurements; segmental differences were obtained by subtracting segments achieved between the dominant and nondominant arms.

Before surgery and at minimum 2-year follow-up after surgery, patients completed a subjective questionnaire, which included the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form, for assessment of both arms. ASES scores are reliable, valid, and responsive in evaluating shoulder pain and function.^15,31 Patients also answered questions about their ability to return to play, their level of play after surgery, and whether they would undergo the procedure again.

Surgical Technique

After induction of general anesthesia and standard preparation and draping, the patient is placed in a standard beach-chair position and examined. Diagnostic arthroscopy is then performed. In all patients, intra-articular evaluation revealed a thickened, contracted posterior band of the inferior glenohumeral ligament. This finding is consistent with other studies of patients with significant GIRD.^1,14,22,30

On completion of the diagnostic portion of the arthroscopy, attention is turned to the selective posterior-inferior capsular release. Key to proper execution of the release is establishing a posterior-inferior accessory portal. This is accomplished while viewing from a standard posterior (“soft spot”) portal and determining the appropriate location and angle of entry by spinal needle localization. Typically, an entry point is selected about 4 cm distal and 1 cm lateral to the standard posterior portal. An 18-gauge spinal needle introduced at this location is angled about 15° superiorly and about 20° medially. Once the appropriate vector is determined, a skin incision is made, and a Wissinger rod is introduced, over which a small-diameter cannula is passed. A hooked-tip electrocautery device is used to divide the posterior capsule from the glenoid labrum between the 8- and 6-o’clock positions in the right shoulder (Figure). Care is taken to perform the release immediately adjacent to the glenoid labrum and using short bursts of cautery in order to minimize risk of injury to the teres minor branch of the axillary nerve. Adequate release is confirmed by reassessing passive internal rotation under anesthesia. Additional procedures are performed, if necessary, after completion of the capsular release.

Postoperative rehabilitation consists initially of pendulum exercises and scapular retraction starting on postoperative day 1. Once the swelling from the surgical procedure subsides, typically within 1 week, passive and active-assisted ROM and gentle posterior capsular mobilization are initiated under the direction of a licensed physical therapist. Active ROM is allowed once the patient regains normal scapulothoracic rhythm. Strengthening consists initially of isometrics followed by light resistance strengthening for the rotator cuff and scapular stabilizers once active ROM and scapulothoracic rhythm return to normal. Passive internal rotation stretching, including use of the sleeper stretch, is implemented as soon as tolerated and continues throughout the rehabilitation process.³²

Statistical Analysis

Statistical analysis was performed with Stata Release 11 (StataCorp, College Station, Texas). Paired t tests were used to assess preoperative and postoperative mean differences in ASES scores, in passive glenohumeral internal rotation, and in active glenohumeral internal rotation; independent-samples t tests were used to assess side-to-side differences. Significance was set at P < .05.

Results

Fifteen overhead athletes met the study inclusion criteria. Two were lost to follow-up. Of the remaining 13 patients, 6 underwent isolated arthroscopic posterior-inferior capsular release, and 7 had concomitant procedures (6 subacromial decompressions, 1 superior labrum anterior-posterior [SLAP] repair). There were 11 male athletes and 2 female athletes. Twelve of the 13 patients were right-hand–dominant. Mean age at time of surgery was 21 years (range, 16-33 years). There were 10 baseball players (6 pitchers, 4 position players); the other 3 patients played softball (1), volleyball (1), or tennis (1). Six patients played at high school level, 5 at college level, 1 at professional level, and 1 at amateur level. All 13 patients underwent a minimum of 3 months of comprehensive rehabilitation, which included use of the sleeper stretch, active joint mobilization by a licensed physical therapist, and sport-specific restriction from exacerbating activities. Mean duration of symptoms before surgery was 18 months (range, 4-48 months). Mean postoperative follow-up was 31 months (range, 24-59 months). Mean ASES score was 71.5 (range, 33-95) before surgery and 86.9 (range, 60-100) after surgery (P < .001). Mean GIRD improved from 43.1° (range, 30°-60°) before surgery to 9.7° (range, –7° to 40°) after surgery (P < .001). Mean active internal rotation difference improved from 3.8 vertebral segments before surgery to 2.6 vertebral segments after surgery; this difference was not statistically significant (P = .459). Ten (77%) of the 13 patients returned to their preoperative level of play or a higher level; the other 3 (23%) did not return to their preoperative level of play but continued to compete in a different position (Table). Eleven patients (85%) stated they would repeat the procedure. One of the 2 patients who would not repeat the procedure was in the isolated posterior-inferior capsular release group; the other was in the concomitant-procedure group (subacromial decompression). Total glenohumeral ROM of dominant arm was 122° before surgery and 136° after surgery (P = .04). There was no significant difference in total ROM between dominant and nondominant arms after surgery (136° and 141°; P = .12), but the preoperative difference was significant (122° vs 141°; P = .022).

Discussion

GIRD has been associated with various pathologic conditions of the upper extremity. In 1991, Verna²⁸ found that a majority of 39 professional baseball pitchers with significant GIRD had shoulder problems that affected playing time. More recently, GIRD has been associated with a progression of injuries, including scapular dyskinesia, internal and secondary impingement, articular-sided partial rotator cuff tears, rotator cuff weakness, damage to the biceps–labral complex, and ulnar collateral ligament insufficiency.^12,18-22 In a cadaveric study of humeral head translation, Harryman and colleagues³³ noted an anterosuperior migration of the humeral head during flexion and concluded it resulted from a loose anterior and tight posterior glenohumeral capsule, leading to loss of glenohumeral internal rotation. More recently, posterosuperior migration of the humeral head has been postulated, with GIRD secondary to an essential posterior capsular contracture.¹ Tyler and colleagues³⁴ clinically linked posterior capsular tightness with GIRD, and both cadaveric and magnetic resonance imaging studies have supported the finding that posterior capsular contracture leads to posterosuperior humeral head migration in association with GIRD.^14,20 Such a disruption in normal glenohumeral joint mechanics could produce phenomena of internal or secondary acromiohumeral impingement and pain.

More recently, in a large cohort of professional baseball pitchers, a significant correlation was found between the incidence of rotator cuff strength deficits and GIRD.³⁵ More than 40% of the pitchers with GIRD of at least 35° had a measureable rotator cuff strength deficit in the throwing shoulder.

Burkhart and colleagues²³ concluded that the shoulder most at risk for developing “dead arm” has GIRD and an advanced form of scapular dyskinesia known as SICK scapula (the phenomenon involves Scapula malposition, Inferior medial border prominence, Coracoid pain and malposition, and dysKinesis of scapular movement).

Most athletes with symptoms attributed to GIRD respond to conservative management. A posterior-inferior capsular stretching program focused on regaining internal rotation in the throwing arm has been shown to return about 90% of athletes to play.¹ Numerous studies have indicated that enrollment in a compliant stretching program reduces GIRD.^1,23-27 However, nonoperative treatment fails in a reported 10% of patients with GIRD; these patients may respond to operative treatment.¹

More specifically, for patients who do not respond to conservative treatment, a posterior-inferior capsular release may be indicated.^1,29 Ticker and colleagues²² identified 9 patients who had lost internal rotation and had a posterior capsular contracture at arthroscopy. That study, however, was not performed on overhead or throwing athletes. Yoneda and colleagues³⁰ followed 16 overhead throwing athletes after arthroscopic posterior-inferior capsular release and found favorable preliminary clinical results. Eleven of the 16 patients returned to their preinjury level of performance; the other 5 returned to a lower level. In addition, all 4 patients who underwent isolated arthroscopic capsular release had throwing power restored to between 90% and 100%.

In the present study, 10 of 13 patients who underwent arthroscopic posterior-inferior capsular release returned to their preoperative level of play or a higher level. Mean passive GIRD improved significantly from before surgery to after surgery. ASES scores likewise were significantly improved from before surgery to after surgery. The active internal rotation difference as measured by vertebral segment level was not significantly changed after surgery. This lack of improvement may stem from the more complex musculoligamentous interactions governing active internal rotation versus isolated, passive internal rotation. Another possible explanation for lack of improvement is that the interobserver and intraobserver reliability of this method is lower.³⁶

At 2-year follow-up, the patient who had undergone concomitant SLAP repair demonstrated a 23% improvement in ASES score and more internal rotation on the dominant arm relative to the nondominant arm. This patient returned to a level of play at least as good as his preoperative level. Although we could not determine its statistical significance, this patient’s improvement suggests that the SLAP repair did not reduce the efficacy of the posterior-inferior capsular release.

Limitations of this study include its relatively small cohort (precluded statistical comparisons between groups), the proportion of patients (7/13) who had concomitant surgeries, and the limited options for patient outcome scores. Although the ASES score is a validated outcome score, the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow (KJOC) score or the Disabilities of the Arm, Shoulder, and Hand (DASH) score may be more appropriate in an athletic population. In addition, although all study patients had GIRD that was unresponsive to a concerted trial of nonoperative management, we did not have a control group (nonoperatively treated patients) for comparison. Finally, we did not obtain computed tomography scans or account for the potential contribution of humeral retroversion to GIRD in this group of patients.

Conclusion

Selective arthroscopic posterior-inferior capsular release can be recommended as a reasonable operative solution for overhead athletes with symptomatic GIRD that has not responded to conservative management. In the present study, ASES scores improved significantly, and 77% of our athlete-patients returned to sport at their preoperative level of play or a higher level.