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Bric JD, Miley EN, Parvataneni HK, Pulido L, Prieto HA, Gray CF, Deen JT. Outpatient total hip and knee arthroplasty - Patient expectations versus experience. J Orthop 2024; 51:109-115. [PMID: 38371352 PMCID: PMC10867624 DOI: 10.1016/j.jor.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 01/23/2024] [Accepted: 01/28/2024] [Indexed: 02/20/2024] Open
Abstract
Aims & objectives With modern advancements in surgical techniques and rapid recovery protocols, incidence of outpatient total joint arthroplasty (TJA) is increasing. Previous literature has historically focused on cost, safety, and clinical outcomes, with few studies investigating patient expectations and experiences. The aim of this study was to survey preoperative patient expectations related to outpatient TJA surgery compared with perioperative perceptions and experience. Materials & methods Prospective study of patients undergoing outpatient total hip or knee arthroplasty at a single Tertiary Academic center. Preoperative and postoperative surveys were administered during routine clinic visits. Results One hundred and six patients completed preoperative surveys; 79 completed postoperative surveys and were included in the final data analysis. Fifty (63.3 %) patients reported being aware of outpatient TJA prior to undergoing the procedure. There was no difference between preoperative anticipated pain control and postoperative perceived pain control (6.64 vs. 6.88, p = 0.77). Most postoperative patients (N = 56, 70.9 %) rated outpatient surgery as "much better" or "better" than expected. Most postoperative patients (N = 68, 86 %) would opt to have outpatient surgery again. Fifty-two (65.8 %) of postoperative patients believed outpatient surgery sped up their postoperative rehabilitation. Conclusion For most patients, the outpatient surgical experience met or exceeded expectations. Nearly 90 % of patients would prefer to have outpatient surgery in the future, further supporting the continued migration of elective arthroplasty away from inpatient sites of care.
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Affiliation(s)
- Justin D. Bric
- The Southeast Permanente Medical Group, Atlanta, GA, USA
| | - Emilie N. Miley
- Department of Orthopaedic Surgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | | | - Luis Pulido
- Florida Orthopedic Institute, Gainesville, FL, USA
| | - Hernan A. Prieto
- Department of Orthopaedic Surgery, College of Medicine, University of Florida, Gainesville, FL, USA
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Plate JF, Deen JT, Deans CF, Pour AE, Yates AJ, Sterling RS. Implementation of the New Medicare-Mandated Patient-Reported Outcomes After Joint Arthroplasty Performance Measure. J Arthroplasty 2024; 39:1136-1139. [PMID: 38278185 DOI: 10.1016/j.arth.2024.01.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/26/2023] [Accepted: 01/13/2024] [Indexed: 01/28/2024] Open
Abstract
A new mandatory hospital-level, risk-standardized performance measure for elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) based on patient-reported outcomes (THA/TKA PRO-PM) has been implemented by the Centers for Medicare & Medicaid Services (CMS). All THA and TKA in Medicare fee-for-service beneficiaries at inpatient facilities are included. The THA/TKA PRO-PM is the proportion of risk-standardized THA or TKA patients meeting or exceeding the substantial clinical benefit threshold between preoperative and postoperative outcomes measures (Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement, Knee injury and Osteoarthritis Outcome Score for Joint Replacement). This binary outcome (yes/no) is then divided by all eligible patients creating a percentage of patients reaching substantial clinical benefit. The percentile score among hospitals will be reported. Following 2 voluntary reporting periods, mandatory reporting will begin in 2025. The CMS requires 50% reporting rates; failure leads to annual payment reduction in fiscal year 2028. The CMS intends the THA/TKA PRO-PM to be a patient-centered, meaningful, and relatable measure of hospital performance reported to the public. For surgeons, this is an opportunity to collaborate with hospitals for developing and implementing a THA/TKA data collection system to avoid penalties for the hospital. Further implementation for outpatient surgery and in ambulatory surgery centers has been announced by CMS. Major resources will be needed to succeed in the expected capture rates.
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Affiliation(s)
- Johannes F Plate
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; American Association of Hip and Knee Surgeons Health Policy Fellowship Program, Rosemont, Illinois
| | - Justin T Deen
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, Florida; American Association of Hip and Knee Surgeons Health Policy Fellowship Program, Rosemont, Illinois
| | - Christopher F Deans
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska; American Association of Hip and Knee Surgeons Health Policy Fellowship Program, Rosemont, Illinois
| | - Aidin E Pour
- Department of Orthopaedics & Rehabilitation, Yale University, New Haven, Connecticut
| | - Adolph J Yates
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert S Sterling
- Department of Orthopaedic, George Washington University, Washington, District of Columbia
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Deans CF, Abdeen AR, Ricciardi BF, Deen JT, Schabel KL, Sterling RS. New CMS Merit-Based Incentive Payment System Value Pathway After Total Knee and Hip Arthroplasty: Preparing for Mandatory Reporting. J Arthroplasty 2024; 39:1131-1135. [PMID: 38278186 DOI: 10.1016/j.arth.2024.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 12/30/2023] [Accepted: 01/13/2024] [Indexed: 01/28/2024] Open
Abstract
This article discusses the implementation of a new Merit-Based Incentive Payment System Value Pathway (MVPs) applicable to elective total hip and total knee arthroplasty as created by Medicare and Medicaid Services (CMS) - the Improving Care for Lower Extremity Joint Repair MVP (MVP ID: G0058). We describe specific quality measures, surgeon-hospital collaborations, future developments with Quality Payment Program, and how lessons from early implementation will empower clinicians to participate in the refining of this MVP. The CMS has designed MVPs as a subset of measures relevant to a specialty or medical condition, in an effort to reduce the burden of reporting and improve assessment of care quality. Physicians and payors must be mindful of detrimental effects these measures in their current form may have on surgeons, institutions, and patients, including disincentivizing care for sicker or more vulnerable populations, and increased administrative costs. Early voluntary participation is crucial to gain valuable experience for the orthopedic community and in an effort to work alongside CMS to maximize care while minimizing cost for patients and burden for providers.
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Affiliation(s)
- Christopher F Deans
- Department of Orthopaedic Surgery & Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska; American Association of Hip and Knee Surgeons Health Policy Fellowship Program, Rosemont, Illinois
| | - Ayesha R Abdeen
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, Massachusetts
| | - Benjamin F Ricciardi
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York
| | | | - Kathryn L Schabel
- Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, Portland, Oregon
| | - Robert S Sterling
- Department of Orthopaedic Surgery, George Washington University, Washington, District of Columbia
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Kakalecik J, Sipavicius E, Miley EN, Horodyski M, Gray CF, Prieto HA, Parvataneni HK, Deen JT. Opioid Utilization After Primary Total Hip and Knee Arthroplasty Following Sequential Implementation of Statewide Legislation. Arthroplast Today 2024; 25:101275. [PMID: 38229868 PMCID: PMC10790000 DOI: 10.1016/j.artd.2023.101275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/21/2023] [Accepted: 10/19/2023] [Indexed: 01/18/2024] Open
Abstract
Background Following total hip arthroplasty (THA) and total knee arthroplasty (TKA), increased opioid use is associated with poor clinical outcomes. This study investigates implications of Florida legislative mandates on prescribing practices and opioid utilization following primary THA and TKA. Methods We retrospectively reviewed patients undergoing primary TKA or THA between January 1, 2018, to December 31, 2020 at our academic medical center. Three groups were identified: procedures performed prior to mandates, after seven-day prescription limit, and after mandated electronic prescribing. A multivariate analyses of variance evaluated length of stay, morphine milligram equivalents (MMEs), age, body mass index and number of prescription refills. Chi-square tests compared preoperative opioid use, readmissions, and discharge disposition. Results There were 198 patients in group one, 238 patients in group two, and 215 patients in group three (N = 651). Prior to any mandates, patients were prescribed 822.3 + 626.7 MMEs. Following a seven-day prescription limit this decreased to 465.0 + 296.0 MMEs (P < .001), which further decreased after mandated electronic prescribing (228.0 + 284.4 MMEs [P < 0.001]). Patients undergoing THA were prescribed less MME than those undergoing TKA. There was a 2.6% 90-day readmission rate, with no pain-related readmissions. Conclusions Florida legislative mandates for opioid prescription quantities and electronic prescribing have effectively reduced average MMEs prescribed following primary arthroplasty. Despite a shift towards ambulatory surgery, opioid utilization decreased without compromising patient outcomes. These findings underscore the significance of both legislative and surgical practices influencing opioid prescribing habits among orthopaedic surgeons.
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Affiliation(s)
- Jaquelyn Kakalecik
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | | | - Emilie N. Miley
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - MaryBeth Horodyski
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Chancellor F. Gray
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Hernan A. Prieto
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Hari K. Parvataneni
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Justin T. Deen
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
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Chen DQ, Parvataneni HK, Miley EN, Deen JT, Pulido LF, Prieto HA, Gray CF. Lessons Learned From the Comprehensive Care for Joint Replacement Model at an Academic Tertiary Center: The Good, the Bad, and the Ugly. J Arthroplasty 2023; 38:S54-S62. [PMID: 36781061 PMCID: PMC10839807 DOI: 10.1016/j.arth.2023.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 02/02/2023] [Accepted: 02/04/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Our institution participated in the Comprehensive Care for Joint Replacement (CJR) model from 2016 to 2020. Here we review lessons learned from a total joint arthroplasty (TJA) care redesign at a tertiary academic center amid changing: (1) CJR rules; (2) inpatient only rules; and (3) outpatient trends. METHODS Quality, financial, and patient demographic data from the years prior to and during participation in CJR were obtained from institutional and Medicare reconciled CJR performance data. RESULTS Despite an increase in true outpatients and new challenges that arose from changing inpatient-only rules, there was significant improvement in quality metrics: decreased length of stay (3.48-1.52 days, P < .001), increased home discharge rate (70.2-85.5%, P < .001), decreased readmission rate (17.7%-5.1%, P < .001), decreased complication rate (6.5%-2.0%, P < .001), and the Centers for Medicare and Medicaid Services (CMS) Composite Quality Score increased from 4.4 to 17.6. Over the five year period, CMS saved an estimated $8.3 million on 1,486 CJR cases, $7.5 million on 1,351 non-CJR cases, and $600,000 from the voluntary classification of 371 short-stay inpatients as outpatient-a total savings of $16.4 million. Despite major physician time and effort leading to marked improvements in efficiency, quality, and large cost savings for CMS, CJR participation resulted in a net penalty of $304,456 to our institution, leading to zero physician gainsharing opportunities. CONCLUSION The benefits of CJR were tempered by malalignment of incentives among payer, hospital, and physician as well as a lack of transparency. Future payment models should be refined based on the successes and challenges of CJR.
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Affiliation(s)
- Dennis Q Chen
- Department of Orthopaedic Surgery, College of Medicine, University of Florida, Gainesville, Florida
| | - Hari K Parvataneni
- Department of Orthopaedic Surgery, College of Medicine, University of Florida, Gainesville, Florida
| | - Emilie N Miley
- Department of Orthopaedic Surgery, College of Medicine, University of Florida, Gainesville, Florida
| | - Justin T Deen
- Department of Orthopaedic Surgery, College of Medicine, University of Florida, Gainesville, Florida
| | - Luis F Pulido
- Department of Orthopaedic Surgery, College of Medicine, University of Florida, Gainesville, Florida
| | - Hernan A Prieto
- Department of Orthopaedic Surgery, College of Medicine, University of Florida, Gainesville, Florida
| | - Chancellor F Gray
- Department of Orthopaedic Surgery, College of Medicine, University of Florida, Gainesville, Florida
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Silverberg AJ, Parvataneni HK, Prieto HA, Deen JT, Vasilopoulos T, Horodyski M, Gray CF. A Physician-led Care Redesign Blunts Predictors of Length of Stay after Total Hip and Knee Arthroplasty. J Surg Orthop Adv 2023; 32:97-101. [PMID: 37668645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
We questioned to what extent traditional predictors of care team burden (via increased length of stay [LOS] after total joint arthroplasty [TJA]) were able to be mitigated through alteration of the care pathway. The impact on LOS of traditional patient risk factors, as well as encounter variables, were analyzed for a consecutive set of patients undergoing surgery before and after a physician-initiated arthroplasty care pathway redesign. We analyzed the impact of these variables on LOS, discharge disposition, and 90-day readmission; separate analyses were performed pre- and post-redesign for LOS. Several patient factors (Risk Assessment and Prediction Tool, body mass index, age, insurance type, smoking) predicted longer LOS in the pre-redesign cohort; post-redesign, only ambulation on the day of surgery and anticoagulation type were predictive. The redesign also lessened the aggregate impact of the patient-specific risk factors, resulting in reduced variation in LOS. Physician leadership of care pathways can reduce the impact of factors that have portended longer LOS, thereby reducing variability in LOS and costs for disparate patient populations while driving improvements in value-based care indices. (Journal of Surgical Orthopaedic Advances 32(2):097-101, 2023).
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Affiliation(s)
- Arnold J Silverberg
- University of Florida, Department of Orthopaedics and Rehabilitation, Gainesville, Florida
| | - Hari K Parvataneni
- University of Florida, Department of Orthopaedics and Rehabilitation, Gainesville, Florida
| | - Hernan A Prieto
- University of Florida, Department of Orthopaedics and Rehabilitation, Gainesville, Florida
| | - Justin T Deen
- University of Florida, Department of Orthopaedics and Rehabilitation, Gainesville, Florida
| | - Terrie Vasilopoulos
- University of Florida, Department of Orthopaedics and Rehabilitation, Gainesville, Florida
| | - MaryBeth Horodyski
- University of Florida, Department of Orthopaedics and Rehabilitation, Gainesville, Florida
| | - Chancellor F Gray
- University of Florida, Department of Orthopaedics and Rehabilitation, Gainesville, Florida
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Baez C, Nusbickel AJ, Knapik JA, Deen JT. Periprosthetic Metastatic Lung Carcinoma About a Total Knee Arthroplasty: A Case Report. JBJS Case Connect 2022; 12:01709767-202212000-00022. [PMID: 36820901 DOI: 10.2106/jbjs.cc.22.00350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 09/11/2022] [Indexed: 02/24/2023]
Abstract
CASE A 64-year-old man presented with unrelenting left knee pain and an unremarkable radiograph 4 months after revision total knee arthroplasty (TKA). Pain persisted, despite conservative management, and repeat imaging demonstrated significant lysis of the left medial tibial condyle. A biopsy demonstrated metastatic squamous cell carcinoma of the lung. Management with excision and curettage of the tibial lesion was followed by palliative radiotherapy and chemotherapy until the patient died 7 months later. CONCLUSION This case highlights metastasis as an etiology for persistent TKA pain in a patient with significant risk factors.
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Affiliation(s)
- Catalina Baez
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, Florida
| | - Alex J Nusbickel
- Department of Medicine, University of Florida, Gainesville, Florida
| | - Jacquelyn A Knapik
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - Justin T Deen
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, Florida
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Gibon E, Vasilopoulos T, Sipavicius E, Deen JT, Prieto HA, Gray CF, Parvataneni HK, Pulido L. Surgical Management of Tibial Bone Loss in Revision Total Knee Arthroplasty: Clinical Outcomes and Radiographic Analysis of Tantalum Cones, Titanium Cones and Titanium Sleeves. Iowa Orthop J 2022; 42:145-153. [PMID: 35821926 PMCID: PMC9210416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND The use of metaphyseal cones and sleeves has improved the ability to manage tibial bone loss in revision total knee arthroplasty (TKA). The purpose of this study was to compare the outcomes of three systems used for tibial metaphyseal reconstruction in revision TKA. METHODS We performed a retrospective review of a consecutive series of 723 revision TKAs, including 145 (20%) knee revisions using tibial cones or sleeves. We compared porous tantalum (TM) cones, titanium (Ti) cones and titanium sleeves. The mean follow-up was 2.5 years. RESULTS The rate of revision for any reason was similar among all groups. Revision-free survival rates were similar among all systems studied at a mean follow-up of 2.5 years (TM cones 93%, Ti cones 94%, titanium sleeves 89%). Ti cones had a lower complication rate (6%) compared to TM cones (24%) and sleeves (29%). TM cones (15%) and titanium sleeves (13%) had higher reoperation rates (for any cause) than Ti cones (2%). Radiographic loosening was higher for sleeves (11%) than TM and Ti cones (2%). CONCLUSION Metaphyseal reconstruction for tibial bone loss in revision TKA using tantalum cones, titanium cones and titanium sleeves showed successful and comparable early clinical outcomes at a mean follow-up of 2.5 years with higher rates of radiographic loosening for titanium sleeves. Level of Evidence: III.
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Affiliation(s)
- Emmanuel Gibon
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida, Gainesville, Florida, USA
| | - Terrie Vasilopoulos
- Department of Anesthesiology, University of Florida, Gainesville, Florida, USA
| | - Edvinas Sipavicius
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida, Gainesville, Florida, USA
| | - Justin T. Deen
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida, Gainesville, Florida, USA
| | - Hernan A. Prieto
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida, Gainesville, Florida, USA
| | - Chancellor F. Gray
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida, Gainesville, Florida, USA
| | - Hari K. Parvataneni
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida, Gainesville, Florida, USA
| | - Luis Pulido
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida, Gainesville, Florida, USA
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Prieto HA, Deen JT, Gibon EF, Gordon K, Gray CF, Parvataneni HK. A Learner-Centered Education Strategy: Optimizing an Interactive and Multimodal Learning Format in Orthopaedic Hip & Knee Arthroplasty. J Surg Educ 2021; 78:1052-1057. [PMID: 33160943 DOI: 10.1016/j.jsurg.2020.10.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/23/2020] [Accepted: 10/20/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE The Accreditation Council for Graduate Medical Education (ACGME) and The American Board of Orthopaedic Surgery proposed The Orthopaedic Surgery Milestone Project. Training residency and fellowship programs have evolved accordingly adjusting academic curriculums. A new comprehensive Learner-Centered Education Curriculum (LCEC) was designed based on critical reviews and interactive collaboration between faculty, residents, and fellows using structured interviews and iterative feedback. We aim to evaluate the results at 4 years after implementation of a new curriculum. DESIGN The new adult arthroplasty LCEC was implemented in 2015; data collected between 2015 and 2019 was retrospectively reviewed and analyzed. Our primary goal was to evaluate educational, research, and quality successes using objective and quantitative academic quality metrics including annual Orthopedic In-Training Examination scores for the Hip & Knee domain to evaluate the medical knowledge competency. SETTING This study was conducted at the Department of Orthopedic Surgery residency and fellowship program of Adult Arthroplasty and Joint Reconstruction Surgery, University of Florida (tertiary care center). PARTICIPANTS Participants include 25 learners (PGY-1 to 5, Clinical fellows) and faculty of an ACGME-accredited orthopedic surgery residency and adult arthroplasty fellowship program. RESULTS Significant improvements in academic, research and quality metrics were obtained since implementation of the LCEC: Orthopedic In-Training Examination scores for Hip & Knee domain increased from 50th to 87th percentile (P=0.042), annual learner peer-reviewed publications and research awards from none before intervention to 20 and 8 respectively (p < 0.05). Resident and fellows conference attendance improved from 81% to 99% (p = 0.0001). The ACGME resident Likert-evaluations also improved from 4.6 to 4.8. CONCLUSION This LCEC, by enhancing an interactive and active academic learning experience, positively influenced fund of knowledge, conceptual thinking, and interest in the specialty and learner attitudes. Significant and consistent improvements in academic, research, and quality metrics were obtained, while maintaining the highest resident evaluation scores in the program.
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Affiliation(s)
- Hernan A Prieto
- Investigation performed at the Department of Orthopaedic Surgery, University of Florida, Gainesville, Florida.
| | - Justin T Deen
- Investigation performed at the Department of Orthopaedic Surgery, University of Florida, Gainesville, Florida
| | - Emmanuel F Gibon
- Investigation performed at the Department of Orthopaedic Surgery, University of Florida, Gainesville, Florida
| | - Kendra Gordon
- Investigation performed at the Department of Orthopaedic Surgery, University of Florida, Gainesville, Florida
| | - Chancellor F Gray
- Investigation performed at the Department of Orthopaedic Surgery, University of Florida, Gainesville, Florida
| | - Hari K Parvataneni
- Investigation performed at the Department of Orthopaedic Surgery, University of Florida, Gainesville, Florida
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Thomas CD, Parvataneni HK, Gray CF, Deen JT, Prieto HA, Pulido LF, Elsey AR, Elwood EN, Starostik P, Gong Y, Fillingim RB, Johnson JA, Cavallari LH. A hybrid implementation-effectiveness randomized trial of CYP2D6-guided postoperative pain management. Genet Med 2021; 23:621-628. [PMID: 33420349 PMCID: PMC8525217 DOI: 10.1038/s41436-020-01050-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Cytochrome P450 2D6 (CYP2D6) genotype-guided opioid prescribing is limited. The purpose of this type 2 hybrid implementation-effectiveness trial was to evaluate the feasibility of clinically implementing CYP2D6-guided postsurgical pain management and determine that such an approach did not worsen pain control. METHODS Adults undergoing total joint arthroplasty were randomized 2:1 to genotype-guided or usual pain management. For participants in the genotype-guided arm with a CYP2D6 poor (PM), intermediate (IM), or ultrarapid (UM) metabolizer phenotype, recommendations were to avoid hydrocodone, tramadol, codeine, and oxycodone. The primary endpoints were feasibility metrics and opioid use; pain intensity was a secondary endpoint. Effectiveness outcomes were collected 2 weeks postsurgery. RESULTS Of 282 patients approached, 260 (92%) agreed to participate. In the genotype-guided arm, 20% had a high-risk (IM/PM/UM) phenotype, of whom 72% received an alternative opioid versus 0% of usual care participants (p < 0.001). In an exploratory analysis, there was less opioid consumption (200 [104-280] vs. 230 [133-350] morphine milligram equivalents; p = 0.047) and similar pain intensity (2.6 ± 0.8 vs. 2.5 ± 0.7; p = 0.638) in the genotype-guided vs. usual care arm, respectively. CONCLUSION Implementing CYP2D6 to guide postoperative pain management is feasible and may lead to lower opioid use without compromising pain control.
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Affiliation(s)
- Cameron D Thomas
- Department of Pharmacotherapy and Translation Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, FL, USA
| | - Hari K Parvataneni
- Department of Orthopaedics and Rehabilitation, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Chancellor F Gray
- Department of Orthopaedics and Rehabilitation, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Justin T Deen
- Department of Orthopaedics and Rehabilitation, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Hernan A Prieto
- Department of Orthopaedics and Rehabilitation, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Luis F Pulido
- Department of Orthopaedics and Rehabilitation, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Amanda R Elsey
- Department of Pharmacotherapy and Translation Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Erica N Elwood
- Department of Pharmacotherapy and Translation Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Petr Starostik
- Department of Pathology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Yan Gong
- Department of Pharmacotherapy and Translation Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, FL, USA
| | - Roger B Fillingim
- Department of Community Dentistry and Behavioral Science, College of Dentistry, University of Florida, Gainesville, FL, USA
| | - Julie A Johnson
- Department of Pharmacotherapy and Translation Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, FL, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translation Research, College of Pharmacy, University of Florida, Gainesville, FL, USA.
- Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, FL, USA.
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Stambough JB, Deen JT, Walton SL, Kerr JM, Zarski MJ, Yates AJ, Andrawis JP. Arthroplasty During COVID-19: Surveillance of AAHKS Members in the First Year of the Pandemic. Arthroplast Today 2021; 7:209-215. [PMID: 33521187 PMCID: PMC7831437 DOI: 10.1016/j.artd.2020.12.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 12/14/2020] [Accepted: 12/21/2020] [Indexed: 01/16/2023] Open
Abstract
Background The COVID-19 pandemic has had a severe impact on the practices of adult reconstruction surgeons, primarily due to the elective nature of hip and knee arthroplasty. Methods To capture the impact of COVID-19 on its members, the American Association of Hip and Knee Surgeons sent 6 surveys over a span of 7 months from late March until September of 2020 querying its members regarding the effects of COVID on the health and well-being of their personal, financial, and clinical practice. Results Ninety-two percent of surgeons reported a cessation of elective inpatient cases during the height of the crisis. The reduction was greatest for surgeries performed in hospital-based sites of care. Ninety-one percent reported a drop in clinic volume. At the final surveys, these numbers where 7% and 59%, respectively. In addition, there was a widespread increase in the use of telemedicine during this period. Only a small number of orthopedic practices permanently closed because of COVID-19; 68% of surgeons, however, sought federal funding to offset their loss of revenue because of the restrictions placed on elective surgeries. Finally, once elective surgeries were reinstated, most surgeons reported no restrictions with surgical cases and that they believed they were adapting to the challenges of COVID successfully. Conclusions The impact of COVID-19 in 2020 on the practice of arthroplasty resulted in nearly universal loss of volume and significant financial stress. Recovery has been consistent but incomplete for most practices. Continued monitoring of the members of American Association of Hip and Knee Surgeons will be needed in 2021 to measure the strength of the demonstrated adaptive recovery of 2020.
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Affiliation(s)
- Jeffrey B Stambough
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Justin T Deen
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Sharon L Walton
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Joshua M Kerr
- American Association of Hip and Knee Surgeons, Rosemont, IL, USA
| | - Michael J Zarski
- American Association of Hip and Knee Surgeons, Rosemont, IL, USA
| | - Adolph J Yates
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John P Andrawis
- Department of Orthopaedic Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA
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Deen JT, Stone WZ, Gray CF, Prieto HA, Iams DA, Boezaart AP, Parvataneni HK. A Simple, Personalized Opioid Stratification Pathway Dramatically Reduces Opioid Utilization. Arthroplast Today 2020; 6:731-735. [PMID: 32923559 PMCID: PMC7475051 DOI: 10.1016/j.artd.2020.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/09/2020] [Accepted: 07/09/2020] [Indexed: 11/12/2022] Open
Abstract
Orthopaedic surgeons account for the largest proportion of opioid prescriptions in the United States among surgical specialties. In total joint arthroplasty, increased opioid use has been associated with poorer clinical and functional outcomes. Despite an abundance of literature on opioid mitigation strategies, most fail to provide personalized prescriptions. Typically, most protocols prescribe the same opioid regimen regardless of patient factors or the extent of the planned procedure. We present a simple opioid stratification pathway that can be used by physicians and office staff as they prepare patients for arthroplasty. We have found this to be easy to implement, effective, and sustainable at a tertiary academic institution and allows for iterative improvements over time.
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Affiliation(s)
- Justin T Deen
- Department of Orthopedic Surgery and Rehabilitation, University of Florida College of Medicine, Gainesville, FL, USA
| | - William Z Stone
- Department of Orthopedic Surgery and Rehabilitation, University of Florida College of Medicine, Gainesville, FL, USA
| | - Chancellor F Gray
- Department of Orthopedic Surgery and Rehabilitation, University of Florida College of Medicine, Gainesville, FL, USA
| | - Hernan A Prieto
- Department of Orthopedic Surgery and Rehabilitation, University of Florida College of Medicine, Gainesville, FL, USA
| | - Dane A Iams
- Department of Orthopedic Surgery, Denver Health, Denver, CO, USA
| | - Andre P Boezaart
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Hari K Parvataneni
- Department of Orthopedic Surgery and Rehabilitation, University of Florida College of Medicine, Gainesville, FL, USA
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13
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Deen JT, Stone WZ, Gray CF, Prieto HA, Iams DA, Boezaart AP, Parvataneni HK. Revision Arthroplasty Does Not Require More Opioids Than Primaries: A Review of Prescribing Practices After Implementation of a Structured Perioperative Pain Management Strategy. J Arthroplasty 2020; 35:2173-2176. [PMID: 32482474 DOI: 10.1016/j.arth.2020.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/01/2020] [Accepted: 04/03/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND There is a growing body of literature on opioid mitigation strategies following total joint arthroplasty. However, these have almost exclusively been studied in populations undergoing primary procedures, with revision arthroplasty historically thought to be more resistant due to procedural variability and complexity. We report on opioid utilization for revision arthroplasty following implementation of a structured, standardized opioid reduction strategy. METHODS Beginning January 2015, a comprehensive multidisciplinary pain protocol was developed and applied universally to all patients undergoing hip and knee arthroplasty, including revisions, without exclusion. We performed a retrospective review of opioid prescription trends for the revision arthroplasty subgroup between January 2014 and July 2018, with the first year serving as a baseline for comparison. Inpatient and outpatient opioid prescription data, inpatient satisfaction scores, and quality metrics were also reviewed. RESULTS We identified 1273 revision arthroplasty cases in the study period. There was a significant reduction in average oral morphine equivalents utilized per procedure when comparing preintervention and postimplementation values. Overall, inpatient prescriptions decreased 24.1% and outpatient utilization decreased 62.4% over the study period. Significant reductions were seen in both the total hip (60.6%) and total knee (64.0%) subgroups. Although revision arthroplasty patients were prescribed 32.5% more oral morphine equivalents at baseline, at year 5 there was no significant difference in outpatient prescriptions between primary and revision subgroups. CONCLUSION At our institution, a standardized opioid reduction strategy has resulted in marked reduction in opioid prescriptions for revision arthroplasty patients in line with generally successful reductions for primary arthroplasty. More importantly, with this approach, revision arthroplasty patients required no more outpatient opioids than their primary counterparts. LEVEL OF EVIDENCE Level III, Retrospective cohort study.
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Affiliation(s)
- Justin T Deen
- Department of Orthopaedics and Rehabilitation, University of Florida College of Medicine, Gainesville, FL
| | - William Z Stone
- Department of Orthopaedics and Rehabilitation, University of Florida College of Medicine, Gainesville, FL
| | - Chancellor F Gray
- Department of Orthopaedics and Rehabilitation, University of Florida College of Medicine, Gainesville, FL
| | - Hernan A Prieto
- Department of Orthopaedics and Rehabilitation, University of Florida College of Medicine, Gainesville, FL
| | - Dane A Iams
- Department of Orthopedic Surgery, Denver Health, Denver, CO
| | - Andre P Boezaart
- Department of Anesthesia, University of Florida College of Medicine, Gainesville, FL
| | - Hari K Parvataneni
- Department of Orthopaedics and Rehabilitation, University of Florida College of Medicine, Gainesville, FL
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14
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Abstract
Intraprosthetic fracture of a femoral component is a rare but devastating complication after total hip arthroplasty (THA). We present the case of a 68-year-old man who presented with acute hip pain approximately 8 years after a left THA with a modern cementless, titanium femoral component. Radiographs revealed a fracture of the midportion of the neck of the stem, below the level of the trunnion. The patient underwent an isolated 1-component revision THA with a modular exchange. To our knowledge, this is the only reported case of a catastrophic failure fracture of this particular prosthesis.
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Affiliation(s)
- Emmanuel Gibon
- Division of Adult Reconstruction, Department of Orthopedics and Rehabilitation, University of Florida College of Medicine, University of Florida, Gainesville, FL, USA
| | - Justin T Deen
- Division of Adult Reconstruction, Department of Orthopedics and Rehabilitation, University of Florida College of Medicine, University of Florida, Gainesville, FL, USA
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15
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Gray CF, Prieto HA, Deen JT, Parvataneni HK. Bundled Payment "Creep": Institutional Redesign for Primary Arthroplasty Positively Affects Revision Arthroplasty. J Arthroplasty 2019; 34:206-210. [PMID: 30448324 DOI: 10.1016/j.arth.2018.10.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/02/2018] [Accepted: 10/22/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Revision total joint arthroplasty (TJA) is associated with increased readmissions, complications, and expense compared to primary TJA. Bundled payment methods have been used to improve value of care in primary TJA, but little is known of their impact in revision TJA patients. The purpose of this study is to evaluate the impact of a care redesign for a bundled payment model for primary TJA on quality metrics for revision patients, despite absence of a targeted intervention for revisions. METHODS We compared quality metrics for all revision TJA patients including readmission rate, use of post-acute care facility after discharge, length of stay, and cost, between the year leading up to the redesign and the 2 years following its implementation. Changes in the primary TJA group over the same time period were also assessed for comparison. RESULTS Despite a volume increase of 37% over the study period, readmissions declined from 8.9% to 5.8%. Use of post-acute care facilities decreased from 42% to 24%. Length of stay went from 4.84 to 3.92 days. Cost of the hospital episode declined by 5%. CONCLUSION Our health system experienced a halo effect from our bundled payment-influenced care redesign, with revision TJA patients experiencing notable improvements in several quality metrics, though not as pronounced as in the primary TJA population. These changes benefitted the patients, the health system, and the payers. We attribute these positive changes to an altered institutional mindset, resulting from an invested and aligned care team, with active physician oversight over the care episode.
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MESH Headings
- Aged
- Arthroplasty, Replacement, Hip/economics
- Arthroplasty, Replacement, Hip/standards
- Arthroplasty, Replacement, Hip/statistics & numerical data
- Arthroplasty, Replacement, Knee/economics
- Arthroplasty, Replacement, Knee/standards
- Arthroplasty, Replacement, Knee/statistics & numerical data
- Critical Pathways/economics
- Critical Pathways/standards
- Critical Pathways/statistics & numerical data
- Episode of Care
- Health Expenditures
- Hospitals
- Humans
- Middle Aged
- Patient Care Bundles/economics
- Patient Care Bundles/standards
- Patient Care Bundles/statistics & numerical data
- Patient Discharge
- Reoperation/economics
- Reoperation/standards
- Reoperation/statistics & numerical data
- Retrospective Studies
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Affiliation(s)
- Chancellor F Gray
- Department of Orthopaedics and Rehabilitation, University of Florida College of Medicine, Gainesville, FL
| | - Hernan A Prieto
- Department of Orthopaedics and Rehabilitation, University of Florida College of Medicine, Gainesville, FL
| | - Justin T Deen
- Department of Orthopaedics and Rehabilitation, University of Florida College of Medicine, Gainesville, FL
| | - Hari K Parvataneni
- Department of Orthopaedics and Rehabilitation, University of Florida College of Medicine, Gainesville, FL
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Prieto HA, Vincent HK, Deen JT, Iams DA, Parvataneni HK. Tranexamic Acid Effectively Reduces Blood Loss and Transfusion Rates during Simultaneous Bilateral Total Knee Arthroplasty. J Knee Surg 2018; 31:270-276. [PMID: 28505683 DOI: 10.1055/s-0037-1603333] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Tranexamic acid (TXA) can reduce blood loss and decrease transfusion rates after total knee arthroplasty (TKA). The purpose of our study was to evaluate the efficacy of TXA in a homogenous, consecutive cohort of patients undergoing simultaneous bilateral primary TKA. This was a retrospective study of 50 consecutive patients who underwent bilateral simultaneous primary TKA between 2011 and 2015. Of these, 20 patients received TXA and 30 patients did not receive TXA and served as the control group. Primary outcome measurements were intraoperative estimated blood loss, hemoglobin (Hb) and Hematocrit (Hct) levels on postoperative day (POD) 1 and POD2, and blood transfusion rates. Secondary outcomes included length of stay (LOS), knee flexion/extension range of motion (ROM), and postoperative complications. There was no difference between groups for preoperative Hb and Hct (all p > 0.05). The TXA group demonstrate higher Hb levels at POD1 (11.7 in TXA vs. 10.4 controls; p < 0.001) and POD2 (10.5 in TXA vs. 9.6 controls; p < 0.001), as well as higher Hct levels at POD1 (35.6 in TXA vs. 32.1 controls; p < 0.001) and POD2 (31.9 in TXA vs. 29.3 controls; p < 0.001). There was less percentage variation in Hb levels in the TXA group from preoperative to POD1 (17.7% in TXA vs. 25.7% controls; p < 0.0001) and POD2 (26.1% TXA vs. 31.8% controls; p = 0.019). Similarly, less percentage variation in Hct levels in the TXA group from presurgery to POD1 (17.0% TXA vs. 25.7% controls; p < 0.0001) and POD2 (25.0% TXA vs. 31.3% controls; p = 0.005). A total of 23.3% of patients in the control group required transfusions compared with no patients in the TXA (p = 0.044). There were no differences in LOS, knee ROM, or number of complications. No thromboembolic events occurred. TXA in bilateral simultaneous TKA effectively reduces blood loss, maintains postoperative Hb and Hct levels, and significantly decreases blood transfusion rates. The level of evidence is level III (therapeutic study).
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Affiliation(s)
- Hernan A Prieto
- Department of Orthopaedics and Rehabilitation, College of Medicine, University of Florida, Gainesville, Florida
| | - Heather K Vincent
- Department of Orthopaedics and Rehabilitation, College of Medicine, University of Florida, Gainesville, Florida
| | - Justin T Deen
- Department of Orthopaedics and Rehabilitation, College of Medicine, University of Florida, Gainesville, Florida
| | - Dane A Iams
- Department of Orthopaedics and Rehabilitation, College of Medicine, University of Florida, Gainesville, Florida
| | - Hari K Parvataneni
- Department of Orthopaedics and Rehabilitation, College of Medicine, University of Florida, Gainesville, Florida
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