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Dean MC, Cherian NJ, Beck da Silva Etges AP, Dowley KS, LaPorte ZL, Torabian KA, Eberlin CT, Best MJ, Martin SD. Variation in the Cost of Hip Arthroscopy for Labral Pathological Conditions: A Time-Driven Activity-Based Costing Analysis. J Bone Joint Surg Am 2024:00004623-990000000-01112. [PMID: 38781316 DOI: 10.2106/jbjs.23.00500] [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: 05/25/2024]
Abstract
BACKGROUND Despite growing interest in delivering high-value orthopaedic care, the costs associated with hip arthroscopy remain poorly understood. By employing time-driven activity-based costing (TDABC), we aimed to characterize the cost composition of hip arthroscopy for labral pathological conditions and to identify factors that drive variation in cost. METHODS Using TDABC, we measured the costs of 890 outpatient hip arthroscopy procedures for labral pathological conditions across 5 surgeons at 4 surgery centers from 2015 to 2022. All patients were ≥18 years old and were treated by surgeons who each performed ≥20 surgeries during the study period. Costs were normalized to protect the confidentiality of internal hospital cost data. Descriptive analyses and multivariable linear regression were performed to identify factors underlying cost variation. RESULTS The study sample consisted of 515 women (57.9%) and 375 men (42.1%), with a mean age (and standard deviation) of 37.1 ± 12.7 years. Most of the procedures were performed in patients who were White (90.6%) or not Hispanic (93.4%). The normalized total cost of hip arthroscopy per procedure ranged from 43.4 to 203.7 (mean, 100 ± 24.2). Of the 3 phases of the care cycle, the intraoperative phase was identified as the largest generator of cost (>90%). On average, supply costs accounted for 48.8% of total costs, whereas labor costs accounted for 51.2%. A 2.5-fold variation between the 10th and 90th percentiles for total cost was attributed to supplies, which was greater than the 1.8-fold variation attributed to labor. Variation in total costs was most effectively explained by the labral management method (partial R2 = 0.332), operating surgeon (partial R2 = 0.326), osteoplasty type (partial R2 = 0.087), and surgery center (partial R2 = 0.086). Male gender (p < 0.001) and younger age (p = 0.032) were also associated with significantly increased costs. Finally, data trends revealed a shift toward labral preservation techniques over debridement during the study period (with the rate of such techniques increasing from 77.8% to 93.2%; Ptrend = 0.0039) and a strong correlation between later operative year and increased supply costs, labor costs, and operative time (p < 0.001 for each). CONCLUSIONS By applying TDABC to outpatient hip arthroscopy, we identified wide patient-to-patient cost variation that was most effectively explained by the method of labral management, the operating surgeon, the osteoplasty type, and the surgery center. Given current procedural coding trends, declining reimbursements, and rising health-care costs, these insights may enable stakeholders to design bundled payment structures that better align reimbursements with costs. LEVEL OF EVIDENCE Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Michael C Dean
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Mayo Clinic Alix School of Medicine, Rochester, Minnesota
| | - Nathan J Cherian
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Department of Orthopaedic Surgery, University of Nebraska, Omaha, Nebraska
| | - Ana Paula Beck da Silva Etges
- Avant-garde Health, Boston, Massachusetts
- National Institute of Science and Technology for Health Technology Assessment (IATS/CNPq), Porto Alegre, Brazil
- Graduate Program in Epidemiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Kieran S Dowley
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Zachary L LaPorte
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Kaveh A Torabian
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Christopher T Eberlin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Department of Orthopaedic Surgery, University of Iowa, Iowa City, Iowa
| | - Matthew J Best
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Scott D Martin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Meta F, Reuter ZC, Pan X, Krych AJ, Hevesi M. Inside-Out Anchor Placement: A Technique to Instrument Far Medial Anchors in Acetabular Labral Repair. Arthrosc Tech 2024; 13:102949. [PMID: 38835447 PMCID: PMC11144940 DOI: 10.1016/j.eats.2024.102949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/14/2024] [Indexed: 06/06/2024] Open
Abstract
Labral tears most commonly occur anteriorly between the 12- and 3-o'clock positions, with the 12-o'clock position denoted as superior and the 3-o'clock position denoted as anterior. When approaching the 3-o'clock position and beyond, suture anchor placement becomes difficult given the challenging arthroscopic trajectory and an overall thin anterior rim of cortical bone for anchor purchase, resulting in a narrow angle of safe drilling. The purpose of this technical note is to present a safe and reproducible method of suture anchor placement during acetabular labral repair approaching the 3- and 4-o'clock positions, with the 12-o'clock position representing the superior anatomic location and the 3-o'clock position representing the anterior anatomic location regardless of hip laterality. We use an inside-out anchor placement technique to place far medial anchors, which differs from the conventional techniques (e.g., outside-in technique) in which anchor placement is performed along the external margin of the acetabular labrum.
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Affiliation(s)
- Fabien Meta
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Zachary C. Reuter
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Xuankang Pan
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Aaron J. Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Mario Hevesi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
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Suarez-Ahedo C, Camacho-Galindo J, López-Reyes A, Martinez-Gómez LE, Pineda C, Domb BG. A comprehensive review of hip arthroscopy techniques and outcomes. SAGE Open Med 2024; 12:20503121231222212. [PMID: 38249944 PMCID: PMC10798066 DOI: 10.1177/20503121231222212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 12/04/2023] [Indexed: 01/23/2024] Open
Abstract
Transforming the orthopedic landscape, hip arthroscopy pioneers a minimally invasive surgical approach for diagnosing and addressing hip pathologies. With its origins dating back to Burman's 1931 cadaveric study, this groundbreaking technique gained clinical relevance in 1939 through Takagi's report. However, the 1980s marked the actual emergence of hip arthroscopy for treating a wide range of hip disorders. Now, a staple in modern orthopedics, hip arthroscopy empowers patients with previously undiagnosed and untreated hip conditions, enabling them to obtain relief and reclaim their lives. By employing a compact camera and specialized tools, surgeons expertly navigate the hip joint, performing procedures from excising loose bodies and mending labral tears to addressing femoroacetabular impingement and tackling other intricate issues. This innovative approach has dramatically elevated patients' quality of life, allowing them to embrace targeted treatments and resume daily activities without resorting to lifestyle alterations.
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Affiliation(s)
- Carlos Suarez-Ahedo
- Adult Hip and Knee Reconstruction Department, National Rehabilitation Institute of Mexico, Mexico City, Mexico
- Geriatric Science Laboratory, National Rehabilitation Institute of Mexico, Mexico City, Mexico
- American Hip Institute, Chicago, IL, USA
| | | | - Alberto López-Reyes
- Geriatric Science Laboratory, National Rehabilitation Institute of Mexico, Mexico City, Mexico
| | - Laura E Martinez-Gómez
- Geriatric Science Laboratory, National Rehabilitation Institute of Mexico, Mexico City, Mexico
| | - Carlos Pineda
- National Rehabilitation Institute of Mexico, Mexico City, Mexico
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Barnes RH, Vasileff WK. Modified Loop Suture Technique in Arthroscopic Labral Repair of the Hip. Arthrosc Tech 2023; 12:e1541-e1547. [PMID: 37780652 PMCID: PMC10533857 DOI: 10.1016/j.eats.2023.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 04/22/2023] [Indexed: 10/03/2023] Open
Abstract
Hip arthroscopy is rapidly increasing in case volume annually in the United States. However, it remains a challenging surgery with a steep learning curve. Labral repair is commonly performed to preserve the labrum rather than labral debridement or reconstruction. Many techniques have been described for labral repair. In this technical note, we describe our technique for a modified loop suture technique for arthroscopic labral repair of the hip.
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Affiliation(s)
- Ryan H. Barnes
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - W. Kelton Vasileff
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
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Chen Q, Zou J, Wang F, Qiao K, Li H, Zhang W, Tian K. Portal Selection for Suture Anchor Placement During Hip Arthroscopic Labral Repair: A Study Based on 3-Dimensional Model Reconstruction. Orthop J Sports Med 2023; 11:23259671231189729. [PMID: 37655241 PMCID: PMC10467395 DOI: 10.1177/23259671231189729] [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: 03/29/2023] [Accepted: 04/26/2023] [Indexed: 09/02/2023] Open
Abstract
Background Arthroscopic suture repair is the main treatment option for hip labral tears; however, anchor insertion and placement from arthroscopic portals is difficult. Purpose To quantitatively evaluate the safety of various arthroscopic portals for suture anchor placement during hip labral repair. Study Design Descriptive laboratory study. Methods The computed tomography scans of 20 patients with normally developed hip joints were used to create 3-dimensional models. The distances from the anchor to the articular cartilage (DAC) and from the acetabular insertion point to the cortical bone (DCB) were measured in the anterolateral portal (AL), posterolateral portal (PL), midanterior portal (MAP), medial MAP, and 3 distal anterolateral accessory portals (DALAs): DALA-proximal, DALA-middle, and DALA-distal. Labral tears were divided into anterior (4, 3, and 2 o'clock), lateral (1, 12, and 11 o'clock), and posterior (10, 9, and 8 o'clock) acetabular zones, and the Kruskal-Wallis and Mann-Whitney U test were used to compare DAC and DCB in the zones. The success rate was defined as anchors placed with DAC ≥1 mm and DCB ≥15 mm. Results The DAC was significantly smaller in the AL at 1 o'clock (0.68 ± 0.32 mm; P < .001) and 12 o'clock (0.37 ± 0.30 mm; P < .001), and in the PL at 12 o'clock (-0.35 ± 0.38 mm; P < .001) and 11 o'clock (0.60 ± 0.24 mm; P < .001). The DCB was significantly smaller in the DALA-P at 3 o'clock (8.93 ± 2.12 mm; P < .001) and 11 o'clock (9.59 ± 2.84 mm; P < .001), the MAP at 12 o'clock (13.76 ± 3.89 mm; P < .001) and 11 o'clock (0.27 ± 0.27 mm; P < .001), and the MMA at 12 o'clock (5.96 ± 2.31 mm; P < .001) and 11 o'clock (0 mm; P < .001). Success rates were high for MAP and MMA between 4 o'clock and 1 o'clock, for DALA-proximal at 12 o'clock, for AL at 11 o'clock, and for PL between 10 o'clock and 8-o'clock. Conclusion There were significant differences in the success rate of anchor placement using different portals during hip arthroscopic labral repair. Clinical Relevance MAP is recommended for labral repair between 4 o'clock and 1 o'clock, DALA-P is recommended between 2 o'clock and 12 o'clock, AL is suitable at 11 o'clock, and PL is suitable between 10 o'clock and 8 o'clock.
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Affiliation(s)
- Qi Chen
- Department of Joint and Sports Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Jiyang Zou
- Department of Joint and Sports Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Fusheng Wang
- Department of Joint and Sports Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Kai Qiao
- Department of Joint and Sports Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Cardiac and Osteochondral Tissue Engineering (COTE) Group, School of Medicine, The Chinese University of Hong Kong, Shenzhen, China
| | - Han Li
- Department of Joint and Sports Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Weiguo Zhang
- Department of Joint and Sports Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopaedic Diseases, Liaoning Province, Dalian Liaoning, China
| | - Kang Tian
- Department of Joint and Sports Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopaedic Diseases, Liaoning Province, Dalian Liaoning, China
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Ernat JJ, Comfort SM, Jildeh TR, Ruzbarsky JJ, Philippon MJ. Effect of Anchor Density on Functional Outcomes After Arthroscopic Hip Labral Repair. Am J Sports Med 2022; 50:3210-3217. [PMID: 36122359 DOI: 10.1177/03635465221121577] [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] [Indexed: 01/31/2023]
Abstract
BACKGROUND While labral repair has been widely adopted as the first line treatment for labral injury during hip arthroscopy, there is no widespread consensus on the procedural technique, including the number of anchors that should be used to avoid recurrent instability and revision surgery. PURPOSE To determine if anchor density can predict patient-reported outcomes after arthroscopic labral repair in the hip. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Patients aged 18 to 50 years who underwent primary hip arthroscopic surgery with labral repair between January 2011 and December 2016 were identified from a prospectively collected database. Exclusion criteria consisted of previous ipsilateral surgery, osteoarthritis (Tönnis grade >1), and severe cartilage defects (Outerbridge grade III/IV) or concomitant labral reconstruction, capsular reconstruction, or microfracture. Minimum 2-year patient-reported outcomes (modified Harris Hip Score [mHHS], Hip Outcome Score [HOS]-Activities of Daily Living [ADL], HOS-Sport Specific Subscale [SSS], 12-Item Short Form Health Survey [SF-12]), rates of achieving the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) for each score, revision surgery rate, and rate of conversion to total hip arthroplasty (THA) were compared based on anchor density (number of anchors per millimeter of labral tear). RESULTS A total of 634 hips (575 patients) with a mean age of 30.4 ± 9.5 years (range, 18.0-49.9 years) met inclusion criteria. The mean labral tear size was 31 ± 11 mm (range, 2-70 mm) with a median number of anchors used for labral repair of 3 (range, 1-7) and mean anchor density of 0.11 ± 0.08 anchors (range, 0.03-1.33) per millimeter of labral tear. Hips with a minimum 2-year follow-up (451/634 [71.1%]) had significant improvements on the mHHS, HOS-ADL, HOS-SSS, and SF-12 Physical Component Summary (P < .001 for all). There was no significant correlation detected between anchor density or number of anchors used and postoperative scores (correlation coefficient range, -0.05 to 0.17; P > .05 for all). The rate of revision surgery was 6.4% (28 patients), with 8 hips found to have labral tears and/or deficiency on revision. Additionally, 6 hips (1.3%) had to undergo THA at a mean of 3.6 ± 2.1 years (range, 2.0-5.5 years). CONCLUSION Anchor density did not have a correlation with postoperative outcomes, achieving the MCID or PASS, revision hip arthroscopic surgery, complications, or conversion to THA.
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Affiliation(s)
- Justin J Ernat
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | | | | | - Marc J Philippon
- Steadman Philippon Research Institute, Vail, Colorado, USA.,The Steadman Clinic, Vail, Colorado, USA
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Wirries N, Dienst M. [Labral lesions in femoroacetabular impingement syndrome: evidence-based treatment]. ORTHOPADIE (HEIDELBERG, GERMANY) 2022; 51:450-457. [PMID: 35507061 DOI: 10.1007/s00132-022-04253-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/06/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND The acetabular labrum and the adjacent rim cartilage are the primary targets of primary or secondary degeneration processes in the hip joint. Currently, femoroacetabular impingement syndrome (FAIS) is considered the main mechanical pathology leading to chondrolabral damage. The treatment options for labrum tears range from a debridement/resection, repair to augmentation or transplantation. AIM Description of surgical treatment options for pathologic changes of the acetabulare labrum and their results with a focus on FAIS. MATERIALS AND METHODS A literature search was performed on https://pubmed.ncbi.nlm.nih.gov using the following key words: hip, labrum, therapy, resection, repair, augmentation, reconstruction. RESULTS The different surgical procedures as labrum therapy reduce pain and increase the joint function. Labral repair, augmentation, and reconstruction tend to have better results compared to resection but are associated with a higher rate of postoperative intraarticular adhesions. DISCUSSION In addition to reducing pain and improving function, the goal of surgical treatment of labrum lesions should be to maintain the functions of the labrum. The labrum should be preserved, in cases of adequate tissue quality and width. In the setting of resective procedures, the resection should be limited to the unstable parts of the labrum. The results of labral augmentation and reconstruction are promising, allowing these procedures to be considered for patients with ongoing symptoms in the revision situation with labral defects or an insufficient residual labrum.
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Affiliation(s)
- Nils Wirries
- Orthopädische Klinik, Medizinische Hochschule Hannover, DIAKOVERE Annastift, Anna-von Borries Str. 1-7, 30625, Hannover, Deutschland.
| | - Michael Dienst
- Orthopädische Chirurgie München (OCM), München, Deutschland
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Christoforetti JJ, Bucci G, Nickel B, Singleton SB, McGovern RP. ‘Mini-Max’ knotless acetabular labrum repair: repair construct rationale and allocation in a consecutive case series with minimum 1-year clinical outcomes. J Hip Preserv Surg 2021; 8:261-269. [PMID: 35582690 PMCID: PMC9106284 DOI: 10.1093/jhps/hnab061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 06/08/2021] [Accepted: 07/26/2021] [Indexed: 12/01/2022] Open
Abstract
To describe the ‘mini-Max’ approach to labrum repair using non-absorbable 2.4-mm knotless
suture anchors and report objective clinical outcomes with a large single-surgeon cohort.
Level 3 retrospective case series. A retrospective review was conducted to report the use
and allocation of non-absorbable 2.4-mm knotless suture anchors during ‘mini-Max’ labral
repair from 2015 to 2018. Descriptive analysis of the labral damage severity, size and
number of anchors used to arthroscopically repair the acetabular labrum was performed.
Paired-samples t-tests were performed to evaluate whether preoperative and 1-year
follow-up patient-reported outcomes (PROs) were statistically significant. An analysis of
variance was performed comparing PROs with categorized number of labral anchors. A total
of 390 patients were queried in this study, with 330 (85%) diagnosed intraoperatively with
acetabular labral tears. A total of 245 patients (137 females and 108 males) with a mean
age of 30.1 ± 11.6 years (mean ± SD) at the time of surgery underwent ‘mini-Max’ labral
refixation. Of the 245 labral tears, 88 (35.9%) were graded as mild, 113 (46.1%) as
moderate and 44 (18.0%) as severe. Labral repairs required an average of 2.1 ± 0.67
anchors across all patients included. Forty-one repairs (16.7%) required one anchor, 139
(56.7%) required two anchors, 63 (25.7%) required three anchors and 2 (0.8%) required four
anchors. Significant improvements were reported for all PROs (P ≤ .001)
at a minimum of 1-year follow-up. Arthroscopic ‘mini-Max’ labral repair using
non-absorbable knotless suture anchors is a safe and effective technique for improving the
lives of patients suffering from symptomatic acetabular labrum tears.
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Affiliation(s)
- John J Christoforetti
- Department of Orthopedic Sports Medicine and Hip Preservation Surgery, Texas Health Orthopedic Specialist, Dallas/ Ft Worth, 5858 Main St. Suite 210, Frisco, TX 75034, USA
- Department of Orthopedic Sports Medicine and Hip Preservation Surgery, Allegheny Singer Research Institute, 4800 Friendship Ave, Pittsburgh, PA 15224, USA
| | - Gabriella Bucci
- Department of Orthopedic Sports Medicine and Hip Preservation Surgery, Texas Health Orthopedic Specialist, Dallas/ Ft Worth, 5858 Main St. Suite 210, Frisco, TX 75034, USA
| | - Beth Nickel
- Department of Orthopedic Sports Medicine and Hip Preservation Surgery, Allegheny Singer Research Institute, 4800 Friendship Ave, Pittsburgh, PA 15224, USA
| | - Steven B Singleton
- Department of Orthopedic Sports Medicine and Hip Preservation Surgery, Texas Health Orthopedic Specialist, Dallas/ Ft Worth, 5858 Main St. Suite 210, Frisco, TX 75034, USA
| | - Ryan P McGovern
- Department of Orthopedic Sports Medicine and Hip Preservation Surgery, Texas Health Orthopedic Specialist, Dallas/ Ft Worth, 5858 Main St. Suite 210, Frisco, TX 75034, USA
- Department of Orthopedic Sports Medicine and Hip Preservation Surgery, Allegheny Singer Research Institute, 4800 Friendship Ave, Pittsburgh, PA 15224, USA
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