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Shitara H, Ichinose T, Sasaki T, Hamano N, Kamiyama M, Miyamoto R, Ino F, Nakase K, Honda A, Yamamoto A, Takagishi K, Chikuda H. Preoperative Nutrition Impacts Retear Rate After Arthroscopic Rotator Cuff Repair. J Bone Joint Surg Am 2024:00004623-990000000-01179. [PMID: 39213337 DOI: 10.2106/jbjs.23.01189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
BACKGROUND A rotator cuff retear following arthroscopic rotator cuff repair (ARCR) is a concern in older patients. However, only a few of its risk factors are amenable to preoperative intervention. We aimed to elucidate the relationship between preoperative nutritional status and rotator cuff retears after ARCR. METHODS This single-center retrospective study included patients aged ≥65 years with rotator cuff tears who underwent ARCR. The Geriatric Nutritional Risk Index (GNRI) was used to assess preoperative nutritional status. Data collection encompassed patient demographics, clinical assessments, and surgical specifics. Patients were divided into healed and retear groups based on 2-year post-ARCR magnetic resonance imaging results. Logistic regression analysis was conducted to adjust for confounding factors and detect independent risk factors for retears. The GNRI cutoff value for retear prediction was determined by a stratum-specific likelihood ratio; clinical outcomes were compared based on the cutoff values obtained. RESULTS Overall, 143 patients were included. The retear rate was 20.3%. The albumin level, GNRI, postoperative shoulder strength of abduction and external rotation, and postoperative Japanese Orthopaedic Association and Constant scores in the retear group were significantly lower than those in the healed group. The logistic regression analysis showed that low risk of morbidity and mortality (compared with no risk) based on the GNRI (odds ratio [OR], 3.39) and medial-lateral tear size per mm (OR = 1.10) were independent risk factors for a retear 2 years after ARCR. Stratum-specific likelihood ratio analysis identified data-driven strata as GNRI < 103, 103 ≤ GNRI < 109, and GNRI ≥ 109. Univariate analysis showed that patients with GNRI < 103 had a significantly higher retear risk than those with 103 ≤ GNRI < 109 and those with GNRI ≥ 109. Logistic regression analysis showed that GNRI < 103 compared with 103 ≤ GNRI < 109 (OR = 3.88) and GNRI < 103 compared with GNRI ≥ 109 (OR = 5.62), along with the medial-lateral tear size per mm (OR = 1.10), were independent risk factors for a retear at 2 years after ARCR. CONCLUSIONS When assessing the risk of a retear after ARCR, GNRI ≥ 103 may indicate good preoperative nutritional status. However, more data are essential to ascertain the importance of this finding. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Hitoshi Shitara
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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Tedesco A, Sharma AK, Acharya N, Rublev G, Hashmi S, Wu HH, Lee YP, Scolaro J, Bhatia N. The Role of Perioperative Nutritional Status and Supplementation in Orthopaedic Surgery: A Review of Postoperative Outcomes. JBJS Rev 2024; 12:01874474-202404000-00004. [PMID: 38619394 DOI: 10.2106/jbjs.rvw.23.00242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
» Identification of malnourished and at-risk patients should be a standardized part of the preoperative evaluation process for every patient.» Malnourishment is defined as a disorder of energy, protein, and nutrients based on the presence of insufficient energy intake, weight loss, muscle atrophy, loss of subcutaneous fat, localized or generalized fluid accumulation, or diminished functional status.» Malnutrition has been associated with worse outcomes postoperatively across a variety of orthopaedic procedures because malnourished patients do not have a robust metabolic reserve available for recovery after surgery.» Screening assessment and basic laboratory studies may indicate patients' nutritional risk; however, laboratory values are often not specific for malnutrition, necessitating the use of prognostic screening tools.» Nutrition consultation and perioperative supplementation with amino acids and micronutrients are 2 readily available interventions that orthopaedic surgeons can select for malnourished patients.
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Affiliation(s)
- Amanda Tedesco
- School of Medicine, University of California, Irvine, Irvine, California
| | - Abhinav K Sharma
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, Orange, California
| | - Nischal Acharya
- School of Medicine, University of California, Irvine, Irvine, California
| | - George Rublev
- David Tvildiani Medical University, Tbilisi, Georgia
| | - Sohaib Hashmi
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, Orange, California
| | - Hao-Hua Wu
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, Orange, California
| | - Yu-Po Lee
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, Orange, California
| | - John Scolaro
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, Orange, California
| | - Nitin Bhatia
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, Orange, California
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Jennewine BR, Throckmorton TW, Pierce AS, Miller AH, Azar AT, Sharp CD, Azar FM, Bernholt DL, Brolin TJ. Patient-selection algorithm for outpatient shoulder arthroplasty in ambulatory surgery center: a retrospective update. J Shoulder Elbow Surg 2024; 33:900-907. [PMID: 37625693 DOI: 10.1016/j.jse.2023.07.018] [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: 04/03/2023] [Revised: 07/05/2023] [Accepted: 07/16/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Outpatient total shoulder arthroplasty (TSA) presents a safe alternative to inpatient arthroplasty, while helping meet the rapidly rising volume of shoulder arthroplasty needs and minimizing health care costs. Identifying the correct patient for outpatient surgery is critical to maintaining the safety standards with TSA. This study sought to update an ambulatory surgery center (ASC) TSA patient-selection algorithm previously published by our institution. METHODS A retrospective chart review of TSAs was performed in an ASC at a single institution to collect patient demographics, perioperative risk factors, and postoperative outcomes with regard to reoperations, hospital admissions, and complications. The existing ASC algorithm for outpatient TSA was altered based on collected perioperative information, review of pertinent literature, and anesthesiology recommendations. RESULTS A total of 319 TSAs were performed in an ASC in 298 patients over 7 years. Medically related complications occurred in 3 patients (0.9%) within 90 days of surgery, 2 of whom required hospital admission (0.6%) for acute kidney injury and pulmonary embolus. There were no instances of major cardiac events. Orthopedic-related complications occurred in 11 patients (3.4%), with hematoma development requiring evacuation and instability requiring revision being the most common causes. CONCLUSIONS There was a low rate of perioperative complications and hospital admissions, confirming the safety of TSAs in an ASC setting. Based on prior literature and the population included, a pre-existing patient-selection algorithm was updated to better reflect increased comfort, knowledge, and data regarding safe patient selection for TSA in an ASC.
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Affiliation(s)
- Brenton R Jennewine
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Thomas W Throckmorton
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Andrew S Pierce
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Andrew H Miller
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Adrian T Azar
- College of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | | | - Frederick M Azar
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - David L Bernholt
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Tyler J Brolin
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA.
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Bowcutt JT, Shibuya N, Jupiter DC. Preoperative Serum Albumin and Other Risk Factors Related to 30-Day Postoperative Complications in Total Ankle Arthroplasty. J Foot Ankle Surg 2023; 62:981-985. [PMID: 37549784 DOI: 10.1053/j.jfas.2023.07.008] [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: 04/06/2023] [Revised: 06/08/2023] [Accepted: 07/29/2023] [Indexed: 08/09/2023]
Abstract
This study investigates effects of preoperative albumin on 30-day total ankle arthroplasty (TAA) outcomes. Additionally, other preoperative risk factors are addressed, including American Anesthesia Society (ASA) class, functional status, chronic obstructive pulmonary disease (COPD), diabetes, smoking status, time of operation, and age. Outcomes assessed were readmission, return to operating room, surgical site infection, wound dehiscence, and total length of stay (TLOS). Data were extracted from the National Surgical Quality Improvement Program database. Bivariate comparisons were analyzed using correlation coefficients, t tests, or chi-squared tests; multivariate comparisons used linear or logistic regression. Our data showed no significant correlation between serum albumin and patients with readmission (odds ratio -0.14, P = 0.06), return to operating room (-0.07, P = 0.61), or surgical site infection (-0.08, P = 0.56). With bivariate analysis, functional status and COPD were significant for readmission (12.67, P < 0.001 and 7.83, P < 0.001, respectively) and dehiscence (30.52, P < 0.001 and 6.74, P = 0.05, respectively), while high ASA class (0.4, P = 0.01), increased age (0.1, P < 0.001), and longer time of operation (0.19, P < 0.001) were associated with longer TLOS. With multivariate analysis, functional status showed higher odds of readmission (7.42, P = 0.02) and dehiscence (20.47, P = 0.01), while COPD showed higher odds for readmission (6.65, P < 0.001) and longer TLOS (0.31, P = 0.05). High ASA class (0.42, P < 0.001) and female sex (0.32, P < 0.001) also had higher odds for longer TLOS. In summary, low albumin was not significant for readmission, return to operating room, or surgical site infection in TAA. COPD, functional status, high ASA class, longer time of operation, increased age, and female sex were all correlated with adverse outcomes in TAA.
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Affiliation(s)
- Jeffrey T Bowcutt
- John Sealy School of Medicine, The University of Texas Medical Branch, Galveston, TX
| | - Naohiro Shibuya
- The University of Texas Rio Grande Valley, School of Podiatric Medicine, Edinburg, TX
| | - Daniel C Jupiter
- Department of Biostatistics and Data Science, The University of Texas Medical Branch, Galveston, TX; Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, TX.
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Churchill JL, Paez CJ, Entezari V, Ricchetti ET, Ho JC. Understanding Medical Optimization for Patients Undergoing Shoulder Arthroplasty. Orthop Clin North Am 2023; 54:309-318. [PMID: 37271559 DOI: 10.1016/j.ocl.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Many surgeons seek to optimize their patients' comorbid conditions preoperatively to reduce postoperative complications. To effectively optimize patients before total shoulder arthroplasty, the surgeon should be familiar with recognizing and treating common medical comorbidities found in an orthopedic patient including anemia, diabetes, malnutrition, cardiovascular conditions, and history of deep venous thrombosis. Screening for depression or other mental illness should also be conducted preoperatively and managed accordingly before surgery. Preoperative opioid use and smoking have significant effects on postoperative outcomes and should be addressed before surgery.
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Affiliation(s)
- Jessica L Churchill
- Cleveland Clinic Foundation, Department of Orthopaedic Surgery, A40, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Conner J Paez
- Cleveland Clinic Foundation, Department of Orthopaedic Surgery, A40, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Vahid Entezari
- Cleveland Clinic Foundation, Department of Orthopaedic Surgery, A40, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Eric T Ricchetti
- Cleveland Clinic Foundation, Department of Orthopaedic Surgery, A40, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Jason C Ho
- Cleveland Clinic Foundation, Department of Orthopaedic Surgery, A40, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Nocon A, Fowler MJ, Tam K, Tonnessen R, Sculco T, Carli AV. Taking a Deeper Dive into Malnutrition and Revision Arthroplasty: When do Nutritionists Get Involved? J Arthroplasty 2023:S0883-5403(23)00398-4. [PMID: 37100097 DOI: 10.1016/j.arth.2023.04.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/11/2023] [Accepted: 04/13/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Perioperative malnutrition is associated with increased complications and mortality following revision total joint arthroplasty (TJA). Nutritional consultations are useful in characterizing patient nutritional status, but are inconsistently utilized post-revision TJA. We sought to describe 1) the prevalence of nutritional consultations post revision TJA, 2) determine if septic revision TJA patients needed consultations more often, and if 3) a diagnosis of 'malnutrition' from the nutritionist conferred increased readmission rates. METHODS A retrospective study of 2,697 rTJAs performed in a single institution over a 4-year period was performed. Patient demographics, reasons for revision TJA, occurrences of nutritional consultation (indicated if body mass index (BMI)<20, Malnutrition Screening Tool (MST) score > 2, or poor oral intake postoperatively), specific nutritional diagnosis (according to 2020 Electronic Nutrition Care Process Terminology (eNCPT) and 90-day readmission rates were recorded and analyzed. Rates of consultations and adjusted logistic regressions were calculated. RESULTS There were 501 patients (18.6%) who required nutritional consultations, with 55 (11.0%) of these patients receiving a 'malnutrition' diagnosis. Septic rTJA patients required significantly more nutritional consultations (P<0.01) and were significantly more likely to have 'malnutrition' (P=0.49). A diagnosis of malnutrition was associated with highest odds of all-cause readmission (Odds Ratio (OR)=3.89, P=0.01), which was even higher than undergoing a septic revision TJA. CONCLUSION Nutritional consultations occur frequently following revision TJA. Patients who receive a diagnosis of 'malnutrition' through consultation are at significantly higher risk for re-admission and require close follow-up. Future efforts are needed to further characterize these patients in order to identify as well as optimize them preoperatively.
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Affiliation(s)
- Allina Nocon
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Mia J Fowler
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Kathleen Tam
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Rebecca Tonnessen
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Thomas Sculco
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Alberto V Carli
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York.
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Llombart R, Mariscal G, Barrios C, de la Rubia Ortí JE, Llombart-Ais R. The Impact of Hypoalbuminemia on Postoperative Complications in Patients Undergoing Shoulder Arthroplasty: A Meta-Analysis. J Nutr Health Aging 2023; 27:1248-1254. [PMID: 38151876 DOI: 10.1007/s12603-023-2050-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 09/21/2023] [Indexed: 12/29/2023]
Abstract
OBJECTIVES The objective of this meta-analysis was to investigate the association between hypoalbuminemia and postoperative complications in patients undergoing shoulder arthroplasty. METHODS This meta-analysis study was registered in PROSPERO (CRD42023442466) and adhered to the PRISMA guidelines. Studies focused on shoulder arthroplasty that compared hypoalbuminemia and normal albumin levels were included. A systematic literature search was conducted in PubMed, EMBASE, Scopus, and the Cochrane Collaboration database. Seven comparative studies were included, and odds ratios with a 95% confidence interval were calculated for the dichotomous variables. A fixed-effect model was used when there was no statistical evidence of heterogeneity, and a random-effect model was used when significant heterogeneity was observed. Review Manager 5.4 software was used for data analysis. RESULTS The meta-analysis included a total of 20,290 patients from seven studies. Hypoalbuminemia was significantly associated with a higher risk of readmissions (OR 2.92, 95%CI 1.74 to 4.91), reoperations (OR 3.23, 95%CI 1.98 to 5.27), an increase in hospital stay duration (MD 1.59, 95%CI 0.86 to 2.32), and complications such as death (OR 5.75, 95% CI 2.98 to 11.08; studies = 4), thromboembolic events (OR 2.43, 95% CI 1.46 to 4.06; studies = 4), cardiac events (OR 2.78, 95% CI 1.07 to 7.24; studies = 3), pulmonary infections (OR 3.09, 95% CI 1.54 to 6.20; studies = 3), systemic infections (OR 2.19, 95% CI 1.51 to 3.16; studies = 3), and transfusions (OR 3.16, 95% CI 2.23 to 4.48; studies = 2). However, there was no significant association between hypoalbuminemia and renal complications, surgical site infections, urinary tract infections, wound problems, or cardiovascular events. CONCLUSION This meta-analysis provides strong evidence that hypoalbuminemia is associated with a higher risk of postoperative complications in patients undergoing shoulder arthroplasty.
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Affiliation(s)
- R Llombart
- Gonzalo Mariscal, Institute for Research on Musculoskeletal Disorders, School of Medicine, Valencia Catholic University, Valencia, Spain, Carrer de Quevedo, 2, 46001 València, Valencia, +34649615489, , ORCID: 0000-0002-5166-198X
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Goltz DE, Burnett RA, Levin JM, Wickman JR, Belay ES, Howell CB, Risoli TJ, Green CL, Simmons JA, Nicholson GP, Verma NN, Lassiter TE, Anakwenze OA, Garrigues GE, Klifto CS. Appropriate patient selection for outpatient shoulder arthroplasty: a risk prediction tool. J Shoulder Elbow Surg 2022; 31:235-244. [PMID: 34592411 DOI: 10.1016/j.jse.2021.08.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/15/2021] [Accepted: 08/20/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND The transition from inpatient to outpatient shoulder arthroplasty critically depends on appropriate patient selection, both to ensure safety and to counsel patients preoperatively regarding individualized risk. Cost and patient demand for same-day discharge have encouraged this transition, and a validated predictive tool may help decrease surgeon liability for complications and help select patients appropriate for same-day discharge. We hypothesized that an accurate predictive model could be created for short inpatient length of stay (discharge at least by postoperative day 1), potentially serving as a useful proxy for identifying patients appropriate for true outpatient shoulder arthroplasty. METHODS A multicenter cohort of 5410 shoulder arthroplasties (2805 anatomic and 2605 reverse shoulder arthroplasties) from 2 geographically diverse, high-volume health systems was reviewed. Short inpatient stay was the primary outcome, defined as discharge on either postoperative day 0 or 1, and 49 patient outcomes and factors including the Elixhauser Comorbidity Index, sociodemographic factors, and intraoperative parameters were examined as candidate predictors for a short stay. Factors surviving parameter selection were incorporated into a multivariable logistic regression model, which underwent internal validation using 10,000 bootstrapped samples. RESULTS In total, 2238 patients (41.4%) were discharged at least by postoperative day 1, with no difference in rates of 90-day readmission (3.5% vs. 3.3%, P = .774) between cohorts with a short length of stay and an extended length of stay (discharge after postoperative day 1). A multivariable logistic regression model demonstrated high accuracy (area under the receiver operator characteristic curve, 0.762) for discharge by postoperative day 1 and was composed of 13 variables: surgery duration, age, sex, electrolyte disorder, marital status, American Society of Anesthesiologists score, paralysis, diabetes, neurologic disease, peripheral vascular disease, pulmonary circulation disease, cardiac arrhythmia, and coagulation deficiency. The percentage cutoff maximizing sensitivity and specificity was calculated to be 47%. Internal validation showed minimal loss of accuracy after bias correction for overfitting, and the predictive model was incorporated into a freely available online tool to facilitate easy clinical use. CONCLUSIONS A risk prediction tool for short inpatient length of stay after shoulder arthroplasty reaches very good accuracy despite requiring only 13 variables and was derived from an underlying database with broad geographic diversity in the largest institutional shoulder arthroplasty cohort published to date. Short inpatient length of stay may serve as a proxy for identifying patients appropriate for same-day discharge, although perioperative care decisions should always be made on an individualized and holistic basis.
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Affiliation(s)
- Daniel E Goltz
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Robert A Burnett
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Jay M Levin
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - John R Wickman
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Elshaday S Belay
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Claire B Howell
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Thomas J Risoli
- Department of Biostatistics and Bioinformatics, Duke School of Medicine, Durham, NC, USA
| | - Cynthia L Green
- Department of Biostatistics and Bioinformatics, Duke School of Medicine, Durham, NC, USA
| | - J Alan Simmons
- Rush Research Core, Rush University Medical Center, Chicago, IL, USA
| | - Gregory P Nicholson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Nikhil N Verma
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Tally E Lassiter
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Oke A Anakwenze
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Grant E Garrigues
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Christopher S Klifto
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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