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Gordon AM, Magruder ML, Schwartz J, Ng MK, Erez O, Mont MA. Preoperative Depression Screening for Primary Total Knee Arthroplasty: An Evaluation of Its Modifiability on Outcomes in Patients Who Have Depression. J Arthroplasty 2024; 39:2040-2046. [PMID: 38382629 DOI: 10.1016/j.arth.2024.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 01/24/2024] [Accepted: 02/13/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Few studies have evaluated preoperative depression screenings in patients who have depression. We studied whether depression screenings before total knee arthroplasty (TKA) were associated with lower: 1) medical complications; 2) emergency department (ED) utilizations and readmissions; 3) implant complications; and 4) costs. METHODS A nationwide sample from January 1, 2010, to April 30, 2021, was collected using an insurance database. Depression patients were 1:1 propensity-score matched based on those who had (n = 29,009) and did not have (n = 29,009) preoperative depression screenings or psychotherapy visits within 3 months of TKA. A case-matched population who did not have depression was compared (n = 144,994). A 90-day period was used to compare complications and health-care utilization and 2-year follow-up for periprosthetic joint infections (PJIs) and implant survivorship. Costs were 90-day reimbursements. Logistic regression models computed odds ratios (ORs) of depression screening on dependent variables. P values less than .001 were significant. RESULTS Patients who did not receive preoperative screening were associated with higher medical complications (18.7 versus 5.2%, OR: 4.15, P < .0001) and ED utilizations (11.5 versus 3.2%, OR: 3.93, P < .0001) than depressed patients who received screening. Patients who had screening had lower medical complications (5.2 versus 5.9%, OR: 0.88, P < .0001) and ED utilizations compared to patients who did not have depression (3.2 versus 3.8%, OR: 0.87, P = .0001). Two-year PJI incidences (3.0 versus 1.3%, OR: 2.63, P < .0001) and TKA revisions (4.3 versus 2.1%, OR: 2.46, P < .0001) were greater in depression patients who were not screened preoperatively versus screened patients. Depression patients who had screening had lower PJIs (1.3 versus 1.8%, OR: 0.74, P < .0001) compared to nondepressed patients. Reimbursements ($13,949 versus $11,982; P < .0001) were higher in depression patients who did not have screening. CONCLUSIONS Preoperative screening was associated with improved outcomes in depression patients. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Adam M Gordon
- Department of Orthopaedic Surgery and Rehabilitation, Maimonides Medical Center, Brooklyn, New York; Questrom School of Business, Boston University, Boston, Massachusetts
| | - Matthew L Magruder
- Department of Orthopaedic Surgery and Rehabilitation, Maimonides Medical Center, Brooklyn, New York
| | - Jake Schwartz
- Department of Orthopaedic Surgery and Rehabilitation, Maimonides Medical Center, Brooklyn, New York
| | - Mitchell K Ng
- Department of Orthopaedic Surgery and Rehabilitation, Maimonides Medical Center, Brooklyn, New York
| | - Orry Erez
- Department of Orthopaedic Surgery and Rehabilitation, Maimonides Medical Center, Brooklyn, New York
| | - Michael A Mont
- Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
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Xie J, Hu Y, Su W, Chen S, Wang J, Liang S, Chen M, Wang H, Ma T. PLGA nanoparticles engineering extracellular vesicles from human umbilical cord mesenchymal stem cells ameliorates polyethylene particles induced periprosthetic osteolysis. J Nanobiotechnology 2023; 21:398. [PMID: 37904168 PMCID: PMC10617042 DOI: 10.1186/s12951-023-02177-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/26/2023] [Indexed: 11/01/2023] Open
Abstract
The wear particle-induced dissolution of bone around implants is a significant pathological factor in aseptic loosening, and controlling prosthetic aseptic loosening holds crucial social significance. While human umbilical cord mesenchymal stem cell-derived exosomes (HucMSCs-Exos, Exos) have been found to effectively promote osteogenesis and angiogenesis, their role in periprosthetic osteolysis remains unexplored. To enhance their in vivo application, we engineered HucMSCs-Exos-encapsulated poly lactic-co-glycolic acid (PLGA) nanoparticles (PLGA-Exos). In our study, we demonstrate that PLGA-Exos stimulate osteogenic differentiation while inhibiting the generation of reactive oxygen species (ROS) and subsequent osteoclast differentiation in vitro. In vivo imaging revealed that PLGA-Exos released exosomes slowly and maintained a therapeutic concentration. Our in vivo experiments demonstrated that PLGA-Exos effectively suppressed osteolysis induced by polyethylene particles. These findings suggest that PLGA-Exos hold potential as a therapeutic approach for the prevention and treatment of periprosthetic osteolysis. Furthermore, they provide novel insights for the clinical management of osteolysis.
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Affiliation(s)
- Jie Xie
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yihe Hu
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Weiping Su
- Department of Orthopaedics, The 3rd Xiangya Hospital, Central South University, Changsha, China
| | - Sijie Chen
- Department of Ultrasound Diagnosis, Second Xiangya Hospital, Central South University, Changsha, China
| | - Jiahao Wang
- Department of Orthopedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Shuailong Liang
- Department of Orthopedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Mingyu Chen
- Department of Ultrasound Diagnosis, Second Xiangya Hospital, Central South University, Changsha, China
| | - Haoyi Wang
- Department of Orthopedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Tianliang Ma
- Department of Orthopedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China.
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Dove JH, Kutschke MJ, Fadale PD, Akelman E. Resilience in Residency and Beyond. JBJS Rev 2023; 11:01874474-202306000-00012. [PMID: 37315162 DOI: 10.2106/jbjs.rvw.22.00242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
» Distinct from the burnout and wellness continuum, resilience is a developed and refined characteristic that propels an individual toward personal and professional success.» We propose a clinical resilience triangle consisting of 3 components that define resilience: grit, competence, and hope.» Resilience is a dynamic trait that should be built during residency and constantly fortified in independent practice so that orthopaedic surgeons may acquire and hone the skills and mental fortitude required to take on the overwhelming challenges that we all inevitably face.
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Affiliation(s)
- James H Dove
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Cutting-Edge Approaches in Arthroplasty: Before, during and after Surgery. J Pers Med 2022; 12:jpm12101671. [PMID: 36294810 PMCID: PMC9605126 DOI: 10.3390/jpm12101671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 09/29/2022] [Indexed: 12/02/2022] Open
Abstract
Personalised medicine was introduced in arthroplasty a long time ago with the aim of respecting each individual person for their unique personal characteristics in order to further improve outcomes [...].
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Cremeans-Smith JK, Greene K, Delahanty DL. Resilience and recovery from total knee arthroplasty (TKA): a pathway for optimizing patient outcomes. J Behav Med 2022; 45:481-489. [DOI: 10.1007/s10865-022-00287-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 01/12/2022] [Indexed: 10/19/2022]
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Zhang JK, Barron J, Arvesen J, Israel H, Kim C, Kaar SG. Effect of Patient Resilience and the Single Assessment Numeric Evaluation (SANE) Score on Return to Sport Following Anterior Cruciate Ligament Reconstruction Surgery. THE ARCHIVES OF BONE AND JOINT SURGERY 2021; 9:512-518. [PMID: 34692933 DOI: 10.22038/abjs.2021.48823.2562] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 03/19/2021] [Indexed: 11/06/2022]
Abstract
Background This study aims to determine the effect of resilience, as measured by the Brief Resilience Scale (BRS), and perceived self-efficacy of knee function, as measured by the Single Assessment Numeric Evaluation (SANE) score on return to sport outcomes following ACL Reconstruction (ACLR) surgery. Methods Seventy-one patients undergoing ACLR surgery were followed up for a minimum of one year. At six-months post-op, ACLR patients completed the BRS and the SANE score. Patients were stratified into low, normal, and high resilience groups, and outcome scores were calculated. Results The median return to sports participation, in months post-operatively, for the low, normal, and high resiliency groups were 7.1, 7.3, and 7.2 months, respectively (P=0.78). A multiple logistic regression analysis revealed that the SANE score was a significant predictor of return to sport at nine months when adjusted for age, sex, and BRS score (P=0.01). Patients that returned to sport by nine months demonstrated a mean SANE score of 92.7, compared to a mean of 85.7 (P=0.08). In patients who had returned to sport, neither the BRS resilience group nor the SANE score were significant predictors of the returned level of competition status (P=0.06; P=0.18). Conclusion The SANE score may serve as a significant predictor of return to sport when adjusted for age, sex, and BRS score. Resilience, as measured by the BRS, was not significantly associated with return to sport, but may have utility in specific patient populations.
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Affiliation(s)
- Justin K Zhang
- Department of Orthopedics, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - John Barron
- Department of General Surgery, Cleveland Clinic School of Medicine, Cleveland, OH, USA
| | - John Arvesen
- Department of Orthopedics, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Heidi Israel
- Department of Orthopedics, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Christopher Kim
- The Iowa Clinic, Department of Orthopedic Surgery, Sports Medicine and Shoulder Surgery, Des Moines, IA, USA
| | - Scott G Kaar
- Department of Orthopedics, Saint Louis University School of Medicine, St. Louis, MO, USA
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Haffar A, Bryan S, Harwood M, Lonner JH. Patient Resilience Has Moderate Correlation With Functional Outcomes, but Not Satisfaction, After Primary Unilateral Total Knee Arthroplasty. Arthroplast Today 2021; 10:123-127. [PMID: 34355052 PMCID: PMC8321890 DOI: 10.1016/j.artd.2021.06.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/09/2021] [Accepted: 06/16/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND As many as 20% of patients who undergo total knee arthroplasty (TKA) are dissatisfied. Psychological factors have been shown to play a role in outcomes after TKA. The purpose of this study was to investigate the impact of patient resilience on functional outcomes and satisfaction after primary unilateral TKA. METHODS Eighty-six patients who underwent primary unilateral TKA by a single surgeon were studied. Primary outcomes were the Brief Resilience Scale (BRS), mental health component of the Veterans Rand 12-Item Health Survey (VR-12 MCS), Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, and New Knee Society Score. Correlations between BRS and dependent variables were found by using Spearmen's Rho Correlation testing. Unadjusted and adjusted regressions were run using the delta values as the dependent outcome and the BRS score as the main independent value, with data presented as an estimate of 95% confidence interval P value. RESULTS Resilience significantly correlated with male sex (P = .031), preoperative VR-12 MCS scores (P = .013), and postoperative VR-12 MCS scores (P < .001). BRS had moderate correlation with postoperative Knee Society Scores (KSS) Functional Activity Scores, as this approached, but did not achieve statistical significance (P = .062). There was no correlation between BRS and postoperative KSS Patient Expectations score, KSS Patient Satisfaction score, or total postoperative opioid usage. CONCLUSIONS Primary TKA patients with greater resilience are more likely to be male and have better mental health characteristics than those with lower resilience. Patients with greater resilience also tended to have improved knee function after TKA, although this was not statistically significant. Resiliency did not correlate with postoperative opioid consumption or patient satisfaction after TKA.
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Affiliation(s)
- Amer Haffar
- Department of Orthopaedic Surgery and Sports Medicine, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Sean Bryan
- Department of Orthopaedic Surgery and Sports Medicine, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Marc Harwood
- Department of Orthopaedic Surgery and Sports Medicine, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Jess H. Lonner
- Department of Orthopaedic Surgery and Sports Medicine, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
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Van Meirhaeghe JP, Alarkawi D, Kowalik T, Du-Moulin W, Molnar R, Adie S. Predicting dissatisfaction following total hip arthroplasty using a Bayesian model averaging approach: Results from the Australian Arthroplasty Clinical Outcomes Registry National (ACORN). ANZ J Surg 2021; 91:1908-1913. [PMID: 34268856 DOI: 10.1111/ans.17063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 06/26/2021] [Accepted: 06/29/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Total hip arthroplasty (THA) provides excellent pain relief and improved function in patients with painful arthritis. The aim of this study was to identify rates and predictors of dissatisfaction following THA. METHODS Data were collected prospectively from the Australian Arthroplasty Clinical Outcomes Registry National (ACORN) database between 2014 and 2016 from 2096 patients who underwent THA. Data included baseline demographics, patient-reported outcome measures (PROMs) and postoperative clinical outcomes. Patients were dichotomized into two groups based on their 6-month response to the satisfaction question answered on a Likert scale. Eighteen predefined variables were analyzed. PROMs included full Oxford Hip Score, EQ-5D, and patient satisfaction. A Bayesian model averaging approach was used to build the best predictive model for dissatisfaction. Multiple logistic regression techniques were applied to quantify the effect size of the best model. RESULTS At 6 months following THA, 95.4% of patients (n = 2000) were satisfied with surgical outcome and 4.6% (n = 96) were dissatisfied. The only variable that was significantly associated with dissatisfaction after THA was "complications after discharge." This result was consistent for both the complete and imputed dataset (odds ratio 4.78, 95% confidence interval 2.60-8.80, P < 0.001 and odds ratio 3.8, 95% confidence interval 2.60-5.60, P < 0.001, respectively). CONCLUSION Our study confirms the high rates of patient satisfaction following THA, with postoperative complications being the only determinant of dissatisfaction. Optimization of patients prior to surgery, reducing postoperative complications, may further improve satisfaction rates after THA.
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Affiliation(s)
- Jan P Van Meirhaeghe
- Department of Orthopaedics, Sydney Orthopaedic Trauma and Reconstructive Surgery, Sydney, New South Wales, Australia
| | - Dunia Alarkawi
- Bone Biology Division, Garvan Institute of Medical Research, School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Tom Kowalik
- Department of Orthopaedics, Sydney Orthopaedic Trauma and Reconstructive Surgery, Sydney, New South Wales, Australia
| | - Will Du-Moulin
- Department of Orthopaedics, Sydney Orthopaedic Trauma and Reconstructive Surgery, Sydney, New South Wales, Australia
| | - Robert Molnar
- Department of Orthopaedics, Sydney Orthopaedic Trauma and Reconstructive Surgery, Sydney, New South Wales, Australia.,Department of Orthopaedics, St. George and Sutherland Hospitals, Sydney, New South Wales, Australia.,Department of Orthopaedics, St. George and Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Sam Adie
- Department of Orthopaedics, Sydney Orthopaedic Trauma and Reconstructive Surgery, Sydney, New South Wales, Australia.,Department of Orthopaedics, St. George and Sutherland Hospitals, Sydney, New South Wales, Australia.,Department of Orthopaedics, St. George and Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia
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Elmasry SS, Chalmers BP, Kahlenberg CA, Mayman DJ, Wright TM, Westrich GH, Cross MB, Sculco PK, Imhauser CW. Simulation of preoperative flexion contracture in a computational model of total knee arthroplasty: Development and evaluation. J Biomech 2021; 120:110367. [PMID: 33887615 PMCID: PMC8183383 DOI: 10.1016/j.jbiomech.2021.110367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 01/29/2021] [Accepted: 03/01/2021] [Indexed: 02/07/2023]
Abstract
Preoperative flexion contracture is a risk factor for patient dissatisfaction following primary total knee arthroplasty (TKA). Previous studies utilizing surgical navigation technology and cadaveric models attempted to identify operative techniques to correct knees with flexion contracture and minimize undesirable outcomes such as knee instability. However, no consensus has emerged on a surgical strategy to treat this clinical condition. Therefore, the purpose of this study was to develop and evaluate a computational model of TKA with flexion contracture that can be used to devise surgical strategies that restore knee extension and to understand factors that cause negative outcomes. We developed six computational models of knees implanted with a posteriorly stabilized TKA using a measured resection technique. We incorporated tensions in the collateral ligaments representative of those achieved in TKA using reference data from a cadaveric experiment and determined tensions in the posterior capsule elements in knees with flexion contracture by simulating a passive extension exam. Subject-specific extension moments were calculated and used to evaluate the amount of knee extension that would be restored after incrementally resecting the distal femur. Model predictions of the extension angle after resecting the distal femur by 2 and 4 mm were within 1.2° (p ≥ 0.32) and 1.6° (p ≥ 0.25), respectively, of previous studies. Accordingly, the presented computational method could be a credible surrogate to study the mechanical impact of flexion contracture in TKA and to evaluate its surgical treatment.
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Affiliation(s)
- Shady S Elmasry
- Department of Biomechanics, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY, USA; Department of Mechanical Design and Production, Faculty of Engineering, Cairo University, Egypt.
| | - Brian P Chalmers
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY, USA
| | - Cynthia A Kahlenberg
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY, USA
| | - David J Mayman
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY, USA
| | - Timothy M Wright
- Department of Biomechanics, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY, USA
| | - Geoffrey H Westrich
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY, USA
| | - Michael B Cross
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY, USA
| | - Peter K Sculco
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY, USA
| | - Carl W Imhauser
- Department of Biomechanics, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY, USA
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Schwartz AM, Wilson JM, Farley KX, Roberson JR, Guild GN, Bradbury TL. Modifiability of Depression's Impact on Early Revision, Narcotic Usage, and Outcomes After Total Hip Arthroplasty: The Impact of Psychotherapy. J Arthroplasty 2020; 35:2904-2910. [PMID: 32553794 DOI: 10.1016/j.arth.2020.05.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/06/2020] [Accepted: 05/08/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Depression is known to negatively influence functional recovery, patient satisfaction, narcotic requirements, implant survivorship, and perioperative resource utilization after total hip arthroplasty (THA). The degree to which this effect is modifiable is largely unknown, with mixed results on preoperative pharmacological intervention, and concomitant concerns over side effects. We aim to investigate the influence of psychotherapy before THA on surgical outcomes, medical complications, and resource utilization. METHODS A retrospective chart review of Truven MarketScan Databases was performed to generate 3 cohorts: patients without depression, patients with depression who did not receive preoperative psychotherapy, and patients with depression who received psychotherapy before surgery. Outcomes of interest were resource utilization, surgical and medical complications, narcotic requirements, and 1-year and 3-year revision rates. RESULTS On multivariate analysis, depressed patients who did not receive psychotherapy were more likely to be discharged to inpatient rehabilitation facility (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.10-1.48, P < .001) and require 2 or more postoperative narcotic prescriptions (OR 1.20, 95% CI 1.06-1.37, P = .004) than depressed patients who received psychotherapy. Patients who did not receive psychotherapy were more likely to have continued narcotic requirements within 1 year after surgery (OR 1.23, 95% CI 1.08-1.39, P < .001) and undergo revision at 1 year (OR 1.74, 95% CI 1.17-2.58, P = .006) and 3 years (OR 1.92, 95% CI 1.10-3.34, P = .021) than depressed patients who received psychotherapy. CONCLUSION The negative influence of depression on narcotic requirements, resource utilization, and implant survivorship after THA appears to be modifiable with preoperative psychotherapy.
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Affiliation(s)
- Andrew M Schwartz
- Department of Orthopaedic Surgery, Emory Orthopaedics & Spine Center, Atlanta, GA
| | - Jacob M Wilson
- Department of Orthopaedic Surgery, Emory Orthopaedics & Spine Center, Atlanta, GA
| | - Kevin X Farley
- Department of Orthopaedic Surgery, Emory Orthopaedics & Spine Center, Atlanta, GA
| | - James R Roberson
- Department of Orthopaedic Surgery, Emory Orthopaedics & Spine Center, Atlanta, GA
| | - George N Guild
- Department of Orthopaedic Surgery, Emory Orthopaedics & Spine Center, Atlanta, GA
| | - Thomas L Bradbury
- Department of Orthopaedic Surgery, Emory Orthopaedics & Spine Center, Atlanta, GA
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