Abstract
Background
Recurrent shoulder instability is a debilitating condition that can lead to chronic pain, decreased function, and inability to return to activities or sport. This retrospective epidemiology study was performed to report 90-day postoperative complications and costs of Latarjet, anterior bone block reconstruction, arthroscopic, and open Bankart repair for shoulder instability.
Methods
Patients 18 years and older who underwent four primary shoulder surgeries from 2010 to 2019 were identified using national claims data. Patient demographics, comorbidities, and 90-day postoperative complications were analyzed using univariate analysis and multivariable logistic regression. Total and itemized 90-day reimbursements were determined for each procedure.
Results
The 90-day medical and surgery-specific complication rates were highest for anterior bone block reconstruction, followed by Latarjet. Arthroscopic Bankart repair had the highest 90-day costs and primary procedure costs compared to other procedures.
Conclusion
Anterior bone block reconstruction and Latarjet procedures were associated with the highest rates of 90-day medical and surgery-specific complications, while arthroscopic Bankart repair was associated with the highest costs.
Keywords: Shoulder instability, Latarjet, Bankart, anterior bone block reconstruction, complications, cost
Introduction
Recurrent shoulder instability is a debilitating condition that can lead to chronic pain, decreased function, and inability to return to activities or sport. The coracoid bone transfer (Latarjet) procedure, anterior bone block reconstruction, arthroscopic Bankart repair, and less commonly, the open Bankart repair are surgical treatments for shoulder instability in patients who have failed nonoperative management. Larger degrees of glenoid bone loss or failure of arthroscopic procedures may warrant more involved surgeries, such as anterior bone block reconstruction or Latarjet procedures. 1
Currently, arthroscopic Bankart repair is the most utilized procedure for anterior shoulder instability, has a low risk of complications, and is reserved for patients without critical bone loss. 2 Open Bankart stabilization is used by some surgeons based on certain preferences or in specific patient populations. 3 Finally, the Latarjet procedure, which can be performed arthroscopically or open, is used for patients with significant glenoid bone loss or in certain revision scenarios. 4 A national epidemiological study in the United States from 2007 to 2015 showed that arthroscopic stabilization was the most common procedure but also showed an increasing utilization of the Latarjet procedure. 4 Major limitations of these studies are attributed to their small patient cohorts or review of heterogeneous literature.5–13 Some reviews pool studies from multiple countries of origin and give a wide range of recurrence rates. One major issue with these studies is that surgical indication and complication rates can vary greatly due to different practice patterns in different countries.
The purpose of this epidemiological study was to report the 90-day complication rates and costs of Latarjet, anterior bone block reconstruction, arthroscopic and open Bankart repair using a large, all-payer national cohort. As these procedures are performed in different patient populations with different preoperative characteristics, we aim to present summary epidemiological data of healthcare utilization for shoulder instability procedures. These data can be important for future research in shoulder instability as well as preoperative patient counseling.
Methods
Data source
Data for this analysis was queried using the Mariner subset of the PearlDiver Database (PearlDiver Technologies; www.pearldiverinc.com, Colorado Springs, CO, USA). Mariner is an all-payer administrative claims dataset containing data for over 120 million patients on patient demographics, comorbidities, postoperative complications, and reimbursements. Patient claims are tracked longitudinally and can be identified based on Current Procedural Terminology (CPT) codes and International Classification of Diseases (ICD), 9th Edition and 10th Revision, codes. In addition, this dataset allows for longitudinal tracking of a specific patient across different payers and insurance plans. This unique capability prevents loss to follow-up based on changes in insurance type, a limitation of other databases. Adult patients who underwent primary arthroscopic Bankart repair (CPT 29806), open Bankart repair (23455), Latarjet (i.e. coracoid process transfer, 23462, including open and arthroscopic techniques), and open anterior bone block reconstruction (23460) for shoulder instability with at least 2-year follow-up were included in this study. Baseline patient demographics and comorbidities are detailed in Table 1.
Table 1.
Bivariate analysis of 90-day postoperative medical complications.
| Arthroscopic Bankart | Open Bankart | Latarjet | Anterior bone block | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| N | % | N | % | P-value* | N | % | P-value* | N | % | P-value* | |
| Total medical complications | 36 | 0.05% | 59 | 2.62% | <0.001 | 30 | 2.29% | <0.001 | 11 | 4.25% | <0.001 |
| Anemia | 0 | 0.00% | 3 | 0.13% | <0.001 | 3 | 0.23% | <0.001 | 3 | 1.16% | <0.001 |
| Arrhythmia | 16 | 0.02% | 24 | 1.07% | <0.001 | 14 | 1.07% | <0.001 | 5 | 1.93% | <0.001 |
| Deep venous thrombosis (DVT) | 1 | 0.00% | 4 | 0.18% | <0.001 | 4 | 0.31% | <0.001 | 2 | 0.77% | <0.001 |
| Pulmonary embolism (PE) | 1 | 0.00% | 1 | 0.04% | 0.073 | 2 | 0.15% | <0.001 | 1 | 0.39% | <0.001 |
| Pneumonia | 1 | 0.00% | 9 | 0.40% | <0.001 | 8 | 0.61% | <0.001 | 2 | 0.77% | <0.001 |
| Respiratory complication | 1 | 0.00% | 3 | 0.13% | <0.001 | 5 | 0.38% | <0.001 | 1 | 0.39% | <0.001 |
| Urinary tract infection (UTI) | 20 | 0.03% | 46 | 2.04% | <0.001 | 21 | 1.61% | <0.001 | 5 | 1.93% | <0.001 |
*All p-values are reported with arthroscopic Bankart repair as the Referent.
Outcome measures
Outcome measures included 90-day medical postoperative complications (sepsis, deep venous thromboembolism (DVT), pulmonary embolism (PE), arrhythmias, pneumonia, respiratory complications, and urinary tract infections (UTIs)) and 90-day surgery-specific postoperative complications (bleeding complication, blood transfusion, surgical site infection (SSI), and upper extremity mononeuropathy). The billing codes used to define these complications can be found in online Supplemental material.
Ninety-day postoperative costs were compared between the procedures and itemized based on the service provided: primary procedure (based on primary surgical CPT code), anesthesia, imaging, diagnostic laboratory work, postoperative office visits, and inpatient or outpatient physical or occupational therapy. All costs were reported as reimbursements from the perspective of the payer.
Statistical analysis
Bivariate analysis was performed on patient demographics, comorbidities, 90-day postoperative complications, and costs. Postoperative complications that were significant at p < 0.05 were further assessed as outcome measures on multivariable logistic regression controlling for baseline demographics and comorbidities. Consistent with prior methodology, multivariable logistic regression controlled for all demographics and comorbidity variables which reached significance at p < 0.1 on univariate analysis.14,15 Since arthroscopic Bankart was the most commonly utilized procedure, the odds ratios for the other procedures (i.e. open Bankart, Latarjet, and anterior bone block) were all reported in reference to arthroscopic Bankart. Significance for regression analyses was set at p < 0.05. Multivariable regression analysis outcomes were reported as odds ratios (OR) and the 95% Confidence Interval (CI) All statistical analyses were performed using the R software provided within the PearlDiver analytic environment.
Results
Study population
In total, there were 86,470 patients who underwent a procedure for shoulder instability/dislocation from 2010 to 2017. Of these, 74,459 were primary shoulder instability procedures with at least 2-year follow-up including arthroscopic Bankart repair (94.8%, N = 70,642) which was the most frequently performed surgery, followed by open Bankart repair (3.0%, N = 2250), Latarjet (1.8%, N = 1308), and anterior bone block reconstruction (0.4%, N = 259). Most patients were women (67%) and < 25 years old (37%). Detailed information on baseline demographics and comorbidities is shown in online Supplemental material.
90-day postoperative medical complications
The 90-day incidence of total medical complications was highest for anterior bone block reconstruction (4.3%), followed by Latarjet (2.3%), open Bankart repair (2.6%), and arthroscopic Bankart repair (0.05%) (p < 0.001; Table 1).
On multivariable regression analysis and relative to arthroscopic Bankart repair, open Bankart repair had significantly greater odds of UTI (OR = 1.8, CI = 1.4–2.4) (p < 0.05; Table 2). Relative to arthroscopic Bankart, Latarjet had significantly greater odds of anemia (OR = 4.02, CI = 1.19–15.51, p = 0.025), arrhythmias (OR = 1.81, CI = 1.18–2.68), respiratory complications (OR = 2.84, CI = 1.12–7.24), and UTI (OR = 1.87, CI = 1.32–2.65, p < 0.001) and (p < 0.05; Table 3). Relative to arthroscopic Bankart, anterior bone block reconstruction had significantly greater odds of anemia (OR = 14.72, CI = 4.22–51.33) and DVT (OR = 4.3, CI = 1.3–13.9) (p < 0.05; Table 3). There were no significant differences in the other 90-day postoperative medical complications (Table 3).
Table 2.
Bivariate analysis of 90-day postoperative surgery-related complications.
| Arthroscopic Bankart | Open Bankart | Latarjet | Anterior bone block | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| N | % | N | % | P-value* | N | % | P-value* | N | % | P-value* | |
| Total surgical complications | 361 | 0.50% | 25 | 1.11% | <0.001 | 32 | 2.46% | <0.001 | 10 | 3.86% | <0.001 |
| Mononeuropathy | 261 | 0.37% | 12 | 0.53% | <0.001 | 14 | 1.07% | <0.001 | 0 | 0.00% | 0.913 |
| Surgical site infection (SSI) | 126 | 0.18% | 18 | 0.80% | <0.001 | 18 | 1.38% | <0.001 | 7 | 2.70% | <0.001 |
| Bleeding complication | 41 | 0.06% | 8 | 0.36% | <0.001 | 15 | 1.15% | <0.001 | 5 | 1.93% | <0.001 |
| Transfusion | 2 | 0.00% | 2 | 0.09% | <0.001 | 2 | 0.15% | <0.001 | 1 | 0.39% | <0.001 |
Table 3.
Multivariable logistic regression analysis of 90-day medical postoperative complications.
| Procedure a | Odds ratio | 95% CI | P-value | |
|---|---|---|---|---|
| Total medical | Open Bankart | 1.95 | 1.12–4.45 | 0.034 |
| complications | Latarjet | 2.50 | 1.57–7.31 | 0.016 |
| Anterior bone block | 2.41 | 1.89–32.36 | <0.001 | |
| Anemia | Open Bankart | 1.76 | 0.54–5.75 | 0.352 |
| Latarjet | 4.02 | 1.19–13.51 | 0.025 | |
| Anterior bone block | 14.72 | 4.22–51.33 | <0.001 | |
| Arrhythmia | Open Bankart | 1.20 | 0.83–1.68 | 0.317 |
| Latarjet | 1.81 | 1.18–2.68 | 0.004 | |
| Anterior bone block | 2.04 | 0.93–4.49 | 0.075 | |
| Deep venous thrombosis (DVT) | Open Bankart | 0.61 | 0.23–1.67 | 0.338 |
| Latarjet | 1.11 | 0.27–2.97 | 0.859 | |
| Anterior bone block | 4.25 | 1.31–13.85 | 0.016 | |
| Pulmonary embolism (PE) | Open Bankart | — | — | — |
| Latarjet | 0.67 | 0.11–2.12 | 0.571 | |
| Anterior bone block | 1.36 | 0.19–9.88 | 0.764 | |
| Pneumonia | Open Bankart | 1.21 | 0.73–2.00 | 0.469 |
| Latarjet | 1.29 | 0.63–2.32 | 0.440 | |
| Anterior bone block | 1.12 | 0.28–4.57 | 0.870 | |
| Respiratory complication | Open Bankart | 1.18 | 0.43–3.28 | 0.745 |
| Latarjet | 2.84 | 1.12–7.24 | 0.029 | |
| Anterior bone block | 2.76 | 0.37–20.30 | 0.320 | |
| Urinary tract infection (UTI) | Open Bankart | 1.83 | 1.40–2.40 | <0.001 |
| Latarjet | 1.87 | 1.32–2.65 | <0.001 | |
| Anterior bone block | 1.09 | 0.48–2.49 | 0.836 |
All odds ratios and confidence intervals are reported with arthroscopic Bankart repair as the Referent.
90-day postoperative surgery-specific complications
The 90-day incidence of total surgery-specific complications was highest for anterior bone block reconstruction (3.9%), followed by Latarjet (2.5%), open Bankart repair (1.1%), and arthroscopic Bankart repair (0.5%) (p < 0.001; Table 2). (Table 4)
Table 4.
Multivariable logistic regression analysis of 90-day surgery-specific postoperative complications.
| Procedure a | Odds Ratio | 95% CI | P-value | |
|---|---|---|---|---|
| Total surgery-specific | Open Bankart | 4.78 | 3.11–6.32 | <0.001 |
| complications | Latarjet | 9.21 | 3.90–12.23 | <0.001 |
| Anterior bone block | 11.11 | 4.11–31.47 | <0.001 | |
| Surgical site infection (SSI) | Open Bankart | 4.17 | 2.61–6.67 | <0.001 |
| Latarjet | 8.99 | 5.69–14.19 | <0.001 | |
| Anterior bone block | 13.06 | 6.19–27.52 | <0.001 | |
| Mononeuropathy | Open Bankart | 1.48 | 0.90–2.43 | 0.118 |
| Latarjet | 2.85 | 1.76–4.61 | <0.001 | |
| Anterior bone block | 0.00 | 0.00–891.00 | 0.952 | |
| Open Bankart | 5.59 | 2.65–11.78 | <0.001 | |
| Bleeding complication | Latarjet | 20.61 | 11.32–37.53 | <0.001 |
| Anterior bone block | 19.87 | 6.73–58.64 | <0.001 | |
| Open Bankart | 1.92 | 0.45–5.49 | 0.290 | |
| Transfusion | Latarjet | 3.90 | 1.13–13.42 | 0.031 |
| Anterior bone block | 3.49 | 0.45–27.17 | 0.232 |
All odds ratios and confidence intervals are reported with arthroscopic Bankart repair as the Referent.
On multivariable regression analysis and relative to arthroscopic Bankart repair, open Bankart had significantly greater odds of bleeding complications (OR = 5.6, CI = 2.7–11.8) and SSI (OR = 4.2, CI = 2.6–6.7, p < 0.001; Table 5). Relative to arthroscopic Bankart, Latarjet had significantly greater odds of bleeding complications (OR = 20.6, CI = 11.3–37.5), transfusions (OR = 3.90, CI = 1.13–3.42), SSI (OR = 8.99, CI = 5.69–14.19), and mononeuropathy (OR = 2.9, CI = 1.8–4.7) (p < 0.001; Table 5). Relative to arthroscopic Bankart, anterior bone block had significantly greater odds of bleeding complications (OR = 19.9, CI = 6.7–58.6) and SSI (OR = 13.1, CI = 6.2–27.6) (p < 0.001; Table 5). There were no significant differences in the other 90-day postoperative surgery-related complications (Table 5).
Table 5.
Reimbursements by service type.
| Arthroscopic Bankart | Open Bankart | P-value | Latarjet | P-value | Anterior bone block | P-value | |
|---|---|---|---|---|---|---|---|
| Total 90-day costs | $5413.01 | $5036.80 | 0.234 | $4815.12 | 0.015 | $4404.95 | 0.004 |
| Primary procedure | $2760.20 | $1255.45 | <0.001 | $1689.24 | <0.001 | $1018.46 | <0.001 |
| Anesthesia | $830.07 | $777.85 | 0.431 | $848.17 | 0.662 | $971.34 | 0.648 |
| Imaging | $394.81 | $683.56 | 0.013 | $533.13 | 0.034 | $451.77 | 0.437 |
| Diagnostic laboratory work | $859.23 | $791.92 | 0.601 | $920.97 | 0.736 | $1204.25 | 0.409 |
| Office visit | $281.08 | $291.34 | 0.663 | $268.13 | 0.647 | $224.02 | 0.062 |
| Physical/occupational therapy | $249.73 | $268.50 | 0.645 | $204.44 | 0.074 | $389.70 | 0.164 |
Cost
The average total 90-day cost was $4917 across all procedures assessed: $5413 for arthroscopic Bankart repair, $5037 for open Bankart repair, $4815 for Latarjet, and $4405 for anterior bone block reconstruction (Table 5). Total 90-day costs were significantly lower for Latarjet and anterior bone block relative to arthroscopic Bankart repair. Itemized reimbursements for the primary procedure was significantly lower for open Bankart repair, Latarjet, and anterior bone block relative to arthroscopic Bankart repair (p < 0.001; Table 5). Costs of imaging were significantly higher for open Bankart repair and Latarjet relative to arthroscopic Bankart repair (p < 0.001 for both; Table 5).
Discussion
In this large, epidemiological study using a national cohort of patients with shoulder instability, primary anterior bone block reconstruction, and Latarjet procedures were associated with the highest rates of 90-day postoperative complications including bleeding complication, transfusion, and SSI, while Latarjet was associated with the highest rate of mononeuropathy. The most common procedure performed was arthroscopic Bankart, followed by open Bankart, Latarjet, and anterior bone block reconstruction. Our secondary analysis showed that arthroscopic Bankart repair was associated with the highest costs. To our knowledge, this is the largest study using a national cohort assessing epidemiological outcomes for these shoulder instability procedures. While this study presents a large sample of epidemiological data, conclusions about the relative superiority of one procedure over the other cannot be made. However, the absolute complication rates and costs reported here are useful for future research on these procedures and for preoperative patient counseling.
The methodology of this national study differs from prior systematic reviews or multicenter cohorts assessing shoulder instability procedures as this study uses a national, all-payer cohort, which may be more reflective of overall treatment patterns in the United States rather than at high volume, specialized centers. The overall lower complication rate seen in our study of patients who underwent arthroscopic Bankart repair when compared to open Bankart repair and Latarjet is similar to those in a prior review. 10 In a systematic review and meta-analysis, Haroun et al. identified 4 studies with 379 total patients and showed a complication rate of 9% after Latarjet and 1% after arthroscopic Bankart repair. 11 Other studies have reported complication rates as high as 66% for Latarjet and 2.3% for Bankart repair, but this includes complications during follow-up of up to 35 years for Latarjet, not limited to 90-days postoperatively as in our study. 5 In the present study, patients undergoing the Latarjet procedure were at higher risk of 90-day surgery-specific complications including SSI and bleeding complications compared to arthroscopic Bankart repair. In addition, upper extremity neuropathy was nearly twice as high in the Latarjet group compared with the arthroscopic Bankart repair group. The higher complication rate following Latarjet observed in this study is congruent with prior reports.5,7,16–20
The results of this study demonstrate that arthroscopic Bankart repair was associated with significantly greater procedure costs than open Bankart, Latarjet, or anterior bone block reconstruction. One reason for this increased cost may be due to implants used during arthroscopic stabilization. In a cost analysis study, Chalmers et al. analyzed factors affecting costs of arthroscopic treatment of glenohumeral instability and noted that of the total cost, 41% of costs were attributed to surgical implants while 39% of costs were from facility utilization. 21 They also found that increased anchor use was associated with higher overall costs. 21 Although no studies assess direct procedure costs between primary Bankart repair and Latarjet or anterior bone block reconstruction, there is one study that compared costs of revision arthroscopic stabilization to Latarjet. 22 Mahkni et al. studied the cost-effectiveness of these procedures and showed that Latarjet costs $1615 less than revision arthroscopic stabilization, which is similar to the findings of the present study. 22 The overall costs estimated by Makhnie et al. for revision arthroscopic stabilization and Latarjet were $15,287 and $13,672, respectively, which are higher than those found in the present study. One reason for this difference may be that Makhni et al. estimated costs using charges from hospital invoices collected in a prior study, not true costs or allowed charges by the insurance companies which are usually lower.22,23 Despite variability in cost between these procedures, all have been shown to be cost-effective in treating patients with instability.12,22–24
Although this study presents a large, national cohort of patients, there are several limitations. Many of the limitations are attributed to the utilization of a database. PearlDiver is limited to the utilization of billing codes and thus relies on the accurate coding of these diagnoses and procedural codes. In addition to accurate coding, we are limited to the information provided by these codes and cannot observe functional outcomes or extrapolate socioeconomic status. In addition, we cannot control for the severity of shoulder instability and other patient characteristics, which have been shown in past studies to be inherently different. 24 For example, a high degree of glenoid bone loss would likely favor anterior bone block or Latarjet procedures. Because PearlDiver does not include these patient details, an analysis based on glenoid bone loss or severity of instability, could not be performed. Furthermore, we could not specify between arthroscopic and open Latarjet techniques. Additionally, comorbidity burden was higher in the Latarjet, anterior bone block, and open Bankart groups compared to the arthroscopic Bankart group which may have been reflective of younger, healthier population of patients in the general community practice. Therefore, the comparative analysis between different procedures should be taken in this context and we do not recommend making comparisons of the superiority of one procedure compared to another based on this study. The data are presented in this study as epidemiological summary statistics, which can be important for future research and can provide surgeons and patients with objective information on complications and reoperation rates after shoulder instability procedures. Nonetheless, the purpose of this study was to determine complication and reoperation profiles for each of the four instability procedures as they are currently indicated by the US surgeons, and not to make direct comparisons of the procedures since indications may vary between them. Additionally, this study could not compare the number of instability episodes before or after surgery, patient-reported outcomes after surgery, or other subjective outcome measures. A limitation to the reimbursement information is the lack of distinction between the intra-operative period from the perioperative period. PearlFiver can distinguish reimbursements by day but cannot determine whether these reimbursements were during the intraoperative period on the day of surgery or pre- or postoperative.
Conclusion
Anterior bone block reconstruction and Latarjet procedures were associated with the highest rates of 90-day complications while arthroscopic Bankart repair was associated with the highest costs. These epidemiological results are important for future research in shoulder instability as well as patient counseling. Further research observing long-term surgical complications such as reoperations will expand the existing knowledge of the differences in the shoulder instability procedures.
Supplemental Material
Supplemental material, sj-docx-1-sel-10.1177_17585732221116814 for Epidemiology of shoulder instability procedures: A comprehensive analysis of complications and costs by Matthew J Best, Kevin Y Wang, Suresh K Nayar and Amil R Agarwal, R Timothy Kreulen, Sribava Sharma, Edward G McFarland, Uma Srikumaran in Shoulder & Elbow
Footnotes
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iDs: Matthew J Best https://orcid.org/0000-0002-4401-2834
Uma Srikumaran https://orcid.org/0000-0002-2314-8855
Supplemental Material: Supplemental material for this article is available online.
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Supplementary Materials
Supplemental material, sj-docx-1-sel-10.1177_17585732221116814 for Epidemiology of shoulder instability procedures: A comprehensive analysis of complications and costs by Matthew J Best, Kevin Y Wang, Suresh K Nayar and Amil R Agarwal, R Timothy Kreulen, Sribava Sharma, Edward G McFarland, Uma Srikumaran in Shoulder & Elbow