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Background: Surgeon caseload has been shown to affect both health and economic outcomes in arthroscopic rotator cuff repair. Although previous studies have investigated disparities in access to care, little is known about disparities between low- and high-volume surgeons and facilities. Purpose: To identify where disparities may exist regarding access to high-volume surgeons and facilities. Study Design: Cross-sectional study. Methods: Univariate analysis was performed to analyze differences in the caseload between low- and high-volume surgeons and facilities. Cutoff values were set at 50 cases per year for high-volume surgeons and 125 cases annually for high-volume facilities. Multiple linear regression was then used to develop a cost model incorporating all variables significant under univariate analysis. We collected 18,616 cases with Current Procedural Terminology code 29827 (“arthroscopic rotator cuff repair”) from the 2014 Florida State Ambulatory Surgery and Services Databases. Results: A greater proportion of the caseload for low-volume surgeons and facilities was composed of patients who were of lower socioeconomic status, had government-subsidized insurance, or lived in areas with low-income ZIP codes. Low-volume surgeons and facilities also had higher total charges, higher postoperative admission rates, and lower distal clavicle excision rates ( P < .001). In our cost model, a low facility volume significantly increased costs. Subacromial decompression, postoperative admission, distal clavicle excision, male sex, and government-subsidized insurance were all significant factors for increased costs in multivariate cost analysis. Conclusion: There are disparities in access to high-volume surgeons and facilities for patients undergoing arthroscopic rotator cuff repair in Florida. Patients with a lower socioeconomic status, government-subsidized insurance, and low income all faced decreased access to these high-volume groups. High-volume surgeons and facilities were associated with lower total charges, higher rates of distal clavicle excision, and lower readmission rates. Low-volume facilities added a significant amount of cost, even when controlling for all other significant variables. It is important for providers to be aware of these disparities and work to address them in their own practices.

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Background: Tarsal navicular bone stress injuries (BSIs) are considered “high risk” because of prolonged healing times and higher rates of nonunion in adult populations but, to our knowledge, have not been comprehensively examined in adolescent athletes. Purpose: To describe the characteristics of tarsal navicular BSIs in adolescents. Study Design: Case series; Level of evidence, 4. Methods: A retrospective analysis of patients aged 10 to 19 years with a radiographically diagnosed tarsal navicular BSI was performed at 8 academic centers over a 9-year study period. Age, sex, body mass index (BMI), primary sport, physical examination findings, imaging, treatment, surgical technique, return-to-sport time, and complications were analyzed. Results: Among 110 patients (mean age, 14.7 ± 2.7 years; 65% female), common primary sports were cross-country/track and field (29/92 [32%]) and gymnastics/dance (25/92 [27%]). Grade 4 BSIs were identified in 44% (48/110) of patients, with fracture lines present on radiography or magnetic resonance imaging. Nonoperative treatment (mean age, 14.4 ± 2.6 years), consisting of protected weightbearing and either a protective boot (69/88 [78%]) or a cast (19/88 [22%]), was trialed in all patients and was successful in 94 patients (85%). Operative treatment (mean age, 17.1 ± 1.4 years) was ultimately pursued for 16 patients (15%). Patients who required surgery had a higher BMI and a higher percentage of fracture lines present on imaging (nonoperative: 36/94 [38%]; operative: 14/16 [88%]). The median time to return to weightbearing, running, and full sport was significantly longer in duration for the operative group than the nonoperative group ( P <.05). Complications associated with surgery included 1 case each of delayed union, nonunion, and painful implants, the latter of which required secondary surgery. Conclusion: Adolescent tarsal navicular BSIs were identified most commonly in female patients in leanness sports. Adolescents who required surgery were more likely to be older, have higher BMIs, and have grade 4 BSIs, and they returned to sport within a median of 5 months after single- or double-screw fixation with a low risk of postoperative complications. A better understanding of the presenting signs and symptoms and appropriate diagnostic imaging of navicular BSIs may lead to an earlier diagnosis and improved outcomes.

Objectives: To describe demographic and presenting clinical characteristics, diagnostic features, treatment approaches, and clinical outcomes of adolescent tarsal navicular BSI’s. Methods: A retrospective chart review of patients with tarsal navicular BSIs was performed at eight academic centers. Diagnosis was confirmed by radiologic imaging in all cases. The following variables were collected utilizing a REDCap database and analyzed with basic descriptive and comparative statistics: age, sex, primary sport, physical exam (PE) findings, diagnostic imaging modality, treatment modalities, surgical technique (when applicable), time of protected weight-bearing, time to running, and time to return to sport. Results: 110 patients (mean age: 14.7 years +/-2.7 years; 65% female) met inclusion criteria, 103 (94%) of whom reported a primary sport, most commonly cross country/track and field (33%) and gymnastics/dance (27%). Common PE findings included navicular tenderness (96%), pain with walking (89%), and pain with resisted inversion (55%). Both x-ray and MRI were obtained in the majority of patients (91%), while CT was obtained for 30%. A radiologically detectable fracture line was present in 44%, most commonly on the dorsal navicular cortex. Non-operative treatment was successful in 85% of patients, consisting of protective boot (79%) or cast (21%). Operative treatment was pursued for 15% of patients, with 73% treated with open reduction internal fixation and 27% undergoing percutaneous screw fixation. All operative patients underwent fixation with either 1 (50%) or 2 screws (50%). Bone grafting was performed in 5 patients (31%). Significant differences between non-operative and operative cohorts included presence of fracture line (38% vs. 88%, P<0.001), age (14.3 years vs. 17.1, P<0.001), time of protected weightbearing (7 weeks vs 10 weeks, P=0.012), time to running (12 weeks vs 18 weeks, P=0.001), and time to return to sport (14 weeks vs 20 weeks, P=0.001). Conclusions: Adolescent tarsal navicular BSIs occur most commonly in sports involving repetitive loading, such as cross country, track and field, gymnastics, and dance. The most common PE findings are navicular tenderness to palpation, pain with walking, and pain with resisted inversion. Patients that ultimately require surgical treatment were more likely to have a radiologic fracture line, prolonged return to weightbearing, running and sport than those successfully treated non-operatively. [Table: see text][Table: see text]