1
|
Boddu SP, Gill VS, Haglin JM, Brinkman JC, Deckey DG, Bingham JS. Lower Income and Nonheterosexual Orientation Are Associated With Poor Access to Care in Patients With Knee Osteoarthritis. Arthroplast Today 2024; 27:101353. [PMID: 38774403 PMCID: PMC11106826 DOI: 10.1016/j.artd.2024.101353] [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: 10/19/2023] [Revised: 01/20/2024] [Accepted: 02/14/2024] [Indexed: 05/24/2024] Open
Abstract
Background Social determinants of health are implicated in the experience of knee osteoarthritis, a key component of which is access to care and healthcare utilization. The objective of this study was to describe difficulties in access to care and healthcare utilization in the United States knee osteoarthritis population. Methods The publicly available All of Us Database was utilized to conduct a retrospective cohort study. Patients with a diagnosis of knee osteoarthritis were included and matched to a control group who did not have knee osteoarthritis. The association of knee osteoarthritis and patient-specific demographic features with self-reported domains of access to care was analyzed. Results Among 15,718 patients with knee osteoarthritis, 27.6% reported delayed care (n = 4343), 25.6% reported inability to afford care (n = 4015), 12.8% reported skipped medications (n = 2011), and 1.6% reported not seeing a healthcare provider in over 1 year (n = 247). Patients with knee osteoarthritis were more likely to be unable to afford care (odds ratio 1.21, P < .001) or skip medications (odds ratio 1.12, P = .004) in comparison to matched patients without knee osteoarthritis. Among the knee osteoarthritis cohort, low income and nonheterosexual orientation were both associated with increased rates of delayed care and an inability to afford care. Conclusions Patients with knee osteoarthritis report significant challenges with delayed care, affordability of care, and medication adherence. Among patients with knee osteoarthritis, patients who are younger age, female sex, low-income, low-education, nonheterosexual orientation, or have poor physical and mental health are at increased risk of having decreased access to treatment.
Collapse
Affiliation(s)
- Sayi P. Boddu
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | - Vikram S. Gill
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | - Jack M. Haglin
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | | | - David G. Deckey
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | | |
Collapse
|
2
|
Haglin JM, Brinkman JC, Austin RP, Deckey DG, Christopher ZK, Spangehl MJ, Bingham JS. Risk Versus Reward - Hospitals Incentivized More than Surgeons to Care for Riskier Arthroplasty Patients. J Arthroplasty 2024:S0883-5403(24)00439-X. [PMID: 38735550 DOI: 10.1016/j.arth.2024.05.006] [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: 01/11/2024] [Revised: 05/01/2024] [Accepted: 05/02/2024] [Indexed: 05/14/2024] Open
Abstract
PURPOSE The purpose of this study was to assess the relationship between risk and reimbursement for both surgeons and hospitals among Medicare patients undergoing primary total joint arthroplasty (TJA). METHODS The "2021-Medicare-Physician-and-Other-Provider" and "2021-Medicare-Inpatient-Hospitals" files were utilized. Patient comorbidity profiles were collected, including the mean patient-hierarchal-condition-category (HCC) risk score, which is a standardized metric accounting for comorbidities. Surgeon data included all primary TJA procedures (inpatient and outpatient) billed to Medicare in 2021, while hospital data included all inpatient episodes of primary TJA billed to Medicare in 2021. Surgeon and hospital reimbursements were collected. All episodes were split into a "sicker-cohort" with an HCC risk score of 1.5 or greater and a "healthier-cohort" with HCC risk scores less than 1.5. Variables were compared across cohorts. RESULTS In 2021, 386,355 primary total hip and knee arthroplasty procedures were billed to Medicare and were included. The mean surgeon reimbursement among the sicker cohort was $1,021.91, which was less than for the healthier cohort of $1,060.13 (P < 0.001). Meanwhile, for the hospital analysis, 112,012 Medicare patients were admitted as inpatients for primary TJA in 2021 and included. The mean reimbursement to hospitals was significantly greater for the sicker cohort at $13,950.66, compared to the healthier cohort of $8,430.46. For both the surgeon and hospital analyses, the sicker patient cohorts had a significantly higher rate of all comorbidities assessed (P < 0.001). CONCLUSION This study demonstrates that mean surgeon reimbursement was lower for primary TJA among sicker patients in comparison to their healthier counterparts, while hospital reimbursement was higher for sicker patients. This represents a discrepancy in the incentivization of care for complex patients, as hospitals receive increased remuneration for taking on extra risk, while surgeons get paid less on average for performing TJA on sicker patients. Such data should inform future policy to assure continued access to arthroplasty care among complex patients.
Collapse
Affiliation(s)
- Jack M Haglin
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ.
| | | | - Roman P Austin
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ
| | - David G Deckey
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ
| | | | | | | |
Collapse
|
3
|
Hinckley NB, Boone AR, Deckey DG, Lai C, Hassebrock JD, Dodoo CA, Renfree KJ. Evaluating the Need for Simultaneous Carpal Tunnel Release With Forearm Fasciotomy. J Hand Surg Am 2024; 49:423-430. [PMID: 38372690 DOI: 10.1016/j.jhsa.2024.01.004] [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: 07/10/2023] [Revised: 01/01/2024] [Accepted: 01/16/2024] [Indexed: 02/20/2024]
Abstract
PURPOSE The need to include simultaneous carpal tunnel release (sCTR) with forearm fasciotomy for acute compartment syndrome (ACS) or after vascular repair is unclear. We hypothesized that sCTR is more common when: 1) fasciotomies are performed by orthopedic or plastic surgeons, rather than general or vascular surgeons; 2) ACS occurred because of crush, blunt trauma, or fractures rather than vascular/reperfusion injuries; 3) elevated compartment pressures were documented. We also sought to determine the incidence of delayed CTR when not performed simultaneously. METHODS Retrospective chart review identified patients who underwent forearm fasciotomy for ACS or vascular injury over a period of 10 years. Patient demographics, mechanism of ACS or indication for fasciotomy, surgeon subspecialty, compartment pressure measurements, inclusion of sCTR, complications, reoperations, and timing and method of definitive closure were analyzed. Logistic regression modeling was used to analyze predictors associated with delayed CTR. RESULTS Fasciotomies were performed in 166 patients by orthopedic (63%), plastic (28%), and general/vascular (9%) surgeons. Orthopedic and plastic surgeons more frequently performed sCTR (67% and 63%, respectively). A total of 107 (65%) patients had sCTR. Fasciotomies for vascular/reperfusion injury were more likely to include sCTR (44%) compared with other mechanisms. If not performed simultaneously, 11 (19%) required delayed CTR at a median of 42 days. ACS secondary to fracture had the highest rate of delayed CTR (35%), and the necessity of late CTR for fractures was not supported by the logistic regression model. Residual hand paresthesias were less frequent in the sCTR group (6.5% vs 20%). Overall complication rates were similar in both groups (63% sCTR vs 70% without sCTR). CONCLUSION When sCTR is excluded during forearm fasciotomy, 19% of patients required delayed CTR. This rate was higher (35%) when ACS was associated with fractures. Simultaneous CTR with forearm fasciotomy may decrease the incidence of residual hand paresthesias and the need for a delayed CTR. TYPE OF STUDY/LEVEL OF EVIDENCE Prognosis IV.
Collapse
Affiliation(s)
| | - Andrew R Boone
- Department of Orthopaedic Surgery, Howard University Hospital, Washington, DC
| | - David G Deckey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Cara Lai
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | | | | | - Kevin J Renfree
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ.
| |
Collapse
|
4
|
Deckey DG, Boddu SP, Verhey JT, Doxey SA, Spangehl MJ, Clarke HD, Bingham JS. Clostridium difficile Infection Prior to Total Hip Arthroplasty Independently Increases the Risk of Periprosthetic Joint Infection. J Arthroplasty 2024:S0883-5403(24)00274-2. [PMID: 38548233 DOI: 10.1016/j.arth.2024.03.058] [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: 11/20/2023] [Revised: 03/18/2024] [Accepted: 03/20/2024] [Indexed: 04/23/2024] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) following total hip arthroplasty (THA) is associated with major morbidity. There may be a link between the gut microbiome and an individual's overall immune system. A Clostridium difficile (C. difficile) infection portends poor gut microbiome health and has been previously associated with increased 90-day complication rates in total joint arthroplasty (TJA). The purpose of this study was to determine the effect of a previous history of C. difficile infection within 2 years of undergoing THA on PJI within 2 years postoperatively. METHODS Patients undergoing THA from 2010 to 2021 were identified in a patient claims database (n = 770,075). Patients who had active records 2 years before and after THA as well as a history of C. difficile infection within 2 years prior to THA (n = 1,836) were included and propensity matched to a control group using age, sex, and Elixhauser comorbidity index. The primary outcome was the 2-year incidence of postoperative PJI. The exposed C. difficile infection cohort was stratified into 4 groups based on the time proximity of the C. difficile infection. Chi-square tests and logistic regressions were used to compare the groups. RESULTS A C. difficile infection anytime within 2 years prior to total hip arthroplasty was independently associated with higher odds of PJI (OR [odds ratio]: 1.49 [95% CI (confidence interval) 1.09 to 2.02, P = .014]). Proximity of C. difficile infection to arthroplasty was associated with increased risk of PJI (infection 0 to 3 months before THA: OR 2.01 [95% CI 1.23 to 3.20], infection 3 to 6 months before THA: OR 1.84 [95% CI 1.06 to 3.04], infection 6 to 12 months before THA: OR 1.10 [95% CI 0.65 to 1.77], infection 1 to 2 years before THA: OR 1.40 [95% CI 0.94 to 2.06]). CONCLUSIONS A C. difficile infection prior to THA is an independent risk factor for PJI. Proximity of C. difficile infection is associated with increased risk of PJI. Future investigations should evaluate how to adequately optimize patients prior to THA and pursue strategies to determine appropriate timing for proceeding with THA.
Collapse
Affiliation(s)
- David G Deckey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Sayi P Boddu
- Alix School of Medicine, Mayo Clinic, Scottsdale, Arizona
| | - Jens T Verhey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Stephen A Doxey
- Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington, Minnesota
| | - Mark J Spangehl
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Henry D Clarke
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Joshua S Bingham
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| |
Collapse
|
5
|
Dossett HG, Deckey DG, Clarke HD, Spangehl MJ. Individualizing a Total Knee Arthroplasty with Three-Dimensional Planning. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202403000-00010. [PMID: 38478756 PMCID: PMC10923344 DOI: 10.5435/jaaosglobal-d-24-00023] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 01/20/2024] [Indexed: 03/17/2024]
Abstract
Total knee arthroplasty (TKA) is evolving from mechanical alignment to more individualized alignment options in an attempt to improve patient satisfaction. Thirteen-year survival of kinematically aligned prostheses has recently been shown to be similar to mechanically aligned TKA, allaying concerns of long-term failure of this newer individualized technique. There is a complex inter-relationship of three-dimensional knee and limb alignment for a TKA. This article will review planning parameters necessary to individualize each knee, along with a discussion of how these parameters are related in three dimensions. Future use of computer software and machine learning has the potential to identify the ideal surgical plan for each patient. In the meantime, the material presented here can assist surgeons as newer individual alignment planning becomes a reality.
Collapse
Affiliation(s)
- Harold Gene Dossett
- From the Department of Orthopaedics and, Phoenix Veterans Affairs Health Care System, Phoenix, AZ (Dr. Dossett), and the Department of Orthopaedics, Mayo Clinic, Phoenix, AZ (Dr. Deckey, Dr. Clarke, and Dr. Spangehl)
| | - David G. Deckey
- From the Department of Orthopaedics and, Phoenix Veterans Affairs Health Care System, Phoenix, AZ (Dr. Dossett), and the Department of Orthopaedics, Mayo Clinic, Phoenix, AZ (Dr. Deckey, Dr. Clarke, and Dr. Spangehl)
| | - Henry D. Clarke
- From the Department of Orthopaedics and, Phoenix Veterans Affairs Health Care System, Phoenix, AZ (Dr. Dossett), and the Department of Orthopaedics, Mayo Clinic, Phoenix, AZ (Dr. Deckey, Dr. Clarke, and Dr. Spangehl)
| | - Mark J. Spangehl
- From the Department of Orthopaedics and, Phoenix Veterans Affairs Health Care System, Phoenix, AZ (Dr. Dossett), and the Department of Orthopaedics, Mayo Clinic, Phoenix, AZ (Dr. Deckey, Dr. Clarke, and Dr. Spangehl)
| |
Collapse
|
6
|
Deckey DG, Boddu SP, Christopher ZK, Spangehl MJ, Clarke HD, Gililland JM, Bingham JS. Rheumatoid Arthritis Is Not a Contraindication to Unicompartmental Knee Arthroplasty. J Arthroplasty 2024:S0883-5403(24)00187-6. [PMID: 38428692 DOI: 10.1016/j.arth.2024.02.067] [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: 10/12/2023] [Revised: 02/16/2024] [Accepted: 02/21/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND Rheumatoid arthritis (RA) has historically been considered a contraindication for unicompartmental knee arthroplasty (UKA). However, the widespread use of disease-modifying antirheumatic drugs has substantially improved the management of RA and prevented disease progression. The objective of this study was to ascertain whether RA impacts UKA revision-free survivorship. METHODS Patients undergoing UKA from 2010 to 2021 were identified in an administrative claims database (n = 105,937) using Current Procedural Terminology code 27446. All patients who underwent UKA who had a diagnosis of RA with a minimum of 2-year follow-up (n = 1,422) were propensity score matched based on age, sex, and Elixhauser Comorbidity Index to those who did not have RA (n = 1,422). Laterality was identified using the 10th Revision of International Classification of Diseases codes. The primary outcome was ipsilateral revision to total knee arthroplasty (TKA) within 2 years, and the secondary outcome was ipsilateral revision at any time. RESULTS Among the 1,422 patients who had a UKA and a diagnosis of RA, 37 patients (2.6%) underwent conversion to TKA within 2 years, and 48 patients (3.4%) underwent conversion to TKA at any point. In comparison, 28 patients (2.0%) in the propensity-matched control group underwent conversion to TKA within 2 years, and 40 patients (2.8%) underwent conversion to TKA at any point. Statistical analysis revealed no significant difference in conversion to TKA between patients who had and did not have RA, either within 2 years (P = .31) or anytime (P = .45). CONCLUSIONS Patients who had RA and underwent UKA did not have an increased risk of revision to TKA compared to those who did not have RA. This may indicate that modern management of RA could allow for expanded UKA indications for RA patients.
Collapse
Affiliation(s)
- David G Deckey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Sayi P Boddu
- Alix School of Medicine, Mayo Clinic, Scottsdale, Arizona
| | - Zachary K Christopher
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona; Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Mark J Spangehl
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Henry D Clarke
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Jeremy M Gililland
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Joshua S Bingham
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| |
Collapse
|
7
|
Llanes AC, Deckey DG, Zhang N, Curley KL, Curley ND, Chhabra A, Neal MT. Lower-Extremity Injuries Predominate in American High School Tennis Players. Arthrosc Sports Med Rehabil 2023; 5:100811. [PMID: 37881190 PMCID: PMC10594564 DOI: 10.1016/j.asmr.2023.100811] [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: 05/22/2023] [Accepted: 08/20/2023] [Indexed: 10/27/2023] Open
Abstract
Purpose To describe injury epidemiology in U.S. adolescent tennis players between 2014 and 2018 via the High School Reporting Information Online (HS RIO) database. Methods The HS RIO database was queried for injury data on high school tennis players as reported by athletic trainers between 2014 and 2018. Injuries were analyzed according to athlete demographics, injury type, location, and context. Variables of interest between male and female athletes were compared using Pearson χ2 test or Fisher exact test. Results In total, 176 injuries in high school tennis players between 2014 and 2018 were identified in the HS RIO database. Overall, 25.6% (45/176) occurred in the ankle, 12.5% (22/176) in the knee, and 9.7% (17/176) in the wrist. The most common types of injuries were ligament sprains and muscle strains at 35.2% (62/176) and 17.6% (31/176) of injuries, respectively. Although most injuries were unrelated to contact, such as overuse and heat exertion or stroke, 28.7% (47/176) of injuries were the result of rotation around a planted foot/inversion of the foot. We found no difference in injury patterns between male and female high school tennis athletes. Conclusions We found no difference in injury patterns between male and female U.S. high school tennis athletes. The ankles, knees, and wrists were the most commonly injured areas in this population. The most common types of injuries were ligament sprains and muscle strains. Although many injuries were new, athletes rarely required surgery and returned to play. Finally, we found no difference in injury patterns between male and female high school tennis athletes. Clinical Relevance The epidemiology of injuries among high school tennis players is poorly understood. The information from this study will help us to understand these injuries and how we may be able to better prevent them.
Collapse
Affiliation(s)
- Aaron C. Llanes
- University of Arizona College of Medicine, Phoenix, Arizona, U.S.A
| | - David G. Deckey
- Department of Orthopaedic Surgery, Mayo Clinic Hospital, Phoenix, Arizona, U.S.A
| | - Nan Zhang
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, Arizona, U.S.A
| | - Kara L. Curley
- Department of Neurologic Surgery, Mayo Clinic Hospital, Phoenix, Arizona, U.S.A
| | | | - Anikar Chhabra
- Department of Orthopaedic Surgery, Mayo Clinic Hospital, Phoenix, Arizona, U.S.A
| | - Matthew T. Neal
- Department of Neurosurgery and Spine, Roper St. Francis, Charleston, South Carolina, U.S.A
| |
Collapse
|
8
|
Pollock JR, Doan MK, Moore ML, Haglin JM, Arthur JR, Deckey DG, Patel KA, Bingham JS. Large Variation in Listed Chargemaster Price for Total Joint Arthroplasty Among Top Orthopaedic Hospitals in the United States. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202309000-00006. [PMID: 37678834 PMCID: PMC10489520 DOI: 10.5435/jaaosglobal-d-23-00052] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/19/2023] [Accepted: 07/10/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Chargemasters are lists of all services offered by a hospital and their associated cost. This study analyzes chargemaster data to determine price differences among different hospitals for total joint arthroplasty. METHODS In May 2020, the chargemaster data for highly rated orthopaedic hospitals were accessed, and the diagnostic-related group (DRG) codes related to primary and revision total joint arthroplasty were analyzed (DRGs 466, 467, 468, 469, and 470). The prices listed for each hospital were averaged, and descriptive statistics were calculated. Furthermore, Medicare reimbursement was collected. A subanalysis was performed to determine relationships between geographic and demographic information. RESULTS The median price for a major hip or knee joint arthroplasty without complications was $68,016 (range: $39,927 to $195,264). The median price of a revision of hip or knee arthroplasty without complications was $90,966 (range: $58,967 to $247,715). The cost of living in the city in which the hospitals are located was weakly correlated with procedure pricing, whereas the median income had no notable relationship to chargemaster pricing. CONCLUSION The published cost of DRG codes in arthroplasty is widely variable among the top 20 US orthopaedic hospitals, with little correlation to the cost of living or median income of the area.
Collapse
Affiliation(s)
- Jordan R Pollock
- From the Mayo Clinic Alix School of Medicine, Scottsdale, AZ (Pollock, Doan, Dr. Moore, and Dr. Haglin), and the Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ (Dr. Arthur, Dr. Deckey, Dr. Patel, and Dr. Bingham)
| | | | | | | | | | | | | | | |
Collapse
|
9
|
Saxena A, Danoff JR, Deckey DG, Barrett TJ, Bullock MW, Sonn KA, Freccero DM, North T, Fischer SJ, Adigweme OO, Robinson K, Stronach BM. American Association of Hip and Knee Surgeons Patient Education and Public Relations Committee Update and Report. J Arthroplasty 2023; 38:1632-1635. [PMID: 37573080 DOI: 10.1016/j.arth.2023.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/14/2023] Open
Affiliation(s)
- Arjun Saxena
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jonathan R Danoff
- Department of Orthopaedic Surgery, Northwell Health, Great Neck, New York
| | - David G Deckey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Thomas J Barrett
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Matthew W Bullock
- Department of Orthopaedic Surgery, Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia
| | - Kevin A Sonn
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Trevor North
- Department of Orthopaedic Surgery, Henry Ford Health, Detroit, Michigan
| | | | | | - Kenneth Robinson
- Communications Manager, American Association of Hip and Knee Surgeons, Rosemont, Illinois
| | - Benjamin M Stronach
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences
| |
Collapse
|
10
|
Haglin JM, Brinkman JC, Moore ML, Deckey DG, Christopher ZK, Tummala SV, Spangehl MJ, Bingham JS. The Current Relationship Between Surgeon Reimbursement and Patient Complexity in Arthroplasty-A Risk-Payment Analysis of All Primary Joint Replacements Billed to Medicare in 2019. J Arthroplasty 2023; 38:S50-S53. [PMID: 36828053 DOI: 10.1016/j.arth.2023.02.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 10/14/2022] [Revised: 02/13/2023] [Accepted: 02/15/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND The purpose of this study was to assess surgeon reimbursement among total joint arthroplasty (TJA) patients who had differing risk profiles within the Medicare population. METHODS The "2019 Medicare Physician and Other Provider" file was utilized. In 2019, 441,584 primary total hip and knee arthroplasty procedures were billed to Medicare Part B. All episodes were included. Patient demographics and comorbidity profiles were collected for all patients. Additionally, mean patient hierarchal condition category (HCC) risk scores and physician reimbursements were collected. All procedure episodes were split into 2 cohorts; those with an HCC risk score of 1.5 or greater, and those with patient HCC risk scores less than 1.5. Variables were averaged for each cohort and compared. RESULTS The mean reimbursement across all procedures was $1,068.03. For the sicker patient cohort with a mean HCC risk score of 1.5 or greater, there was a significantly higher rate of all comorbidities compared to the cohort with HCC risk score under 1.5. The mean payment across the sicker cohort was $1,059.21, while the mean payment among the cohort with HCC risk score under 1.5 was 1,073.32 (P = .032). CONCLUSION This study demonstrates that for Medicare patients undergoing primary TJA in 2019, the mean surgeon reimbursement was lower for primary TJA among sick patients in comparison to their healthier counterparts, although it is difficult to ascertain the impact of this discrepancy. As alternative payment models continue to undergo evaluation and development, these data will be important for the potential advancement of more equitable reimbursement models in arthroplasty care, specifically regarding surgeon reimbursement and possible risk adjustment within such models.
Collapse
Affiliation(s)
- Jack M Haglin
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona
| | | | - Michael L Moore
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona
| | - David G Deckey
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona
| | | | | | - Mark J Spangehl
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona
| | | |
Collapse
|
11
|
Deckey DG, Lin E, Gerhart CR, Brinkman JC, Patel KA, Bingham JS. Decoding the Signals: An Analysis of Preference Signaling in the 2023 Orthopaedic Surgery Residency Match. JB JS Open Access 2023; 8:e23.00052. [PMID: 37662882 PMCID: PMC10468107 DOI: 10.2106/jbjs.oa.23.00052] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023] Open
Abstract
Background While previously used in other specialties, the preference signaling program (PSP) was implemented in the 2022 to 2023 orthopaedic surgery residency application process for the first time. The PSP allowed for 30 signaling tokens to be sent by applicants to programs of their choice to indicate particular interest in a program. It remains unknown how the PSP affects applicants and programs in the orthopaedic surgery residency match. Thus, this study's purpose was to assess the utility of preference signaling within the orthopaedic surgery residency application process in its inaugural year of use. Methods An anonymous electronic survey was emailed to all orthopaedic surgery residency applicants who applied to the authors' institution during the 2022 to 2023 application cycle. The survey was sent after match lists were submitted and closed before the release of match results. The survey collected information regarding applicant demographics, preference signaling habits, and attitude toward preference signaling. Results The survey was completed by 101 applicants. Applicants applied to a mean of 90 programs (range: 10-197) and received an average of 12 interview invitations (range: 0-39). Applicants almost uniformly used all 30 signals, with nearly two-thirds signaling their home programs (65%, 49/76), and nearly all applicants sending signals to programs at which they performed away rotations (95.7%, 88/92). Applicants received a mean of 9 invitations from programs they signaled, compared with 2 invitations from programs they did not signal. Applicants were significantly more likely to receive an interview invite at a program they signaled than one they did not (p < 0.01). Overall, 57% of applicants (57/101) found the PSP to be helpful, whereas 28% (28/101) found it to be unhelpful, and 16% (16/101) had a neutral opinion. Conclusions This study reports that the PSP in the 2022 to 2023 orthopaedic surgery match was an effective method of expressing interest in a program because applicants were significantly more likely to receive interview invites to signaled programs. More than half of respondents felt PSP to be helpful; however, the effect on application numbers is still unclear. Level of Evidence III.
Collapse
Affiliation(s)
- David G. Deckey
- Department of Orthopedics, Mayo Clinic Arizona, Phoenix, Arizona
| | - Eugenia Lin
- Department of Orthopedics, Mayo Clinic Arizona, Phoenix, Arizona
| | - Coltin R.B. Gerhart
- Anne Burnett Marion School of Medicine at Texas Christian University, Fort Worth, Texas
| | | | - Karan A. Patel
- Department of Orthopedics, Mayo Clinic Arizona, Phoenix, Arizona
| | | |
Collapse
|
12
|
Haglin JM, Hinckley NB, Moore ML, Deckey DG, Lai CH, Renfree KJ. Long-term Trends in Open vs Endoscopic Carpal Tunnel Release Among the Medicare Population in the United States. Hand (N Y) 2023:15589447231168977. [PMID: 37148177 DOI: 10.1177/15589447231168977] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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] [Indexed: 05/08/2023]
Abstract
BACKGROUND Carpal tunnel release (CTR) surgery is the most common surgery billed to Medicare by hand surgeons. As such, the purpose of this study was to evaluate trends for CTR surgeries billed to Medicare from 2000 to 2020. METHODS The publicly available Medicare Part B National Summary File from 2000 to 2020 was queried. For both open carpal tunnel release (OCTR) and endoscopic carpal tunnel release (ECTR), the number of procedures and total Medicare reimbursement were extracted. For year 2020, the specialty of the performing surgeon was recorded. Descriptive statistics were reported. RESULTS A total of 3 429 471 CTR surgeries were performed in the Medicare population from 2000 to 2020. For these procedures, Medicare paid surgeons over $1.23 billion. During this period, there was a 101.8% increase in annual CTR procedures (91 130 in 2000, 183 911 in 2020). Further, annual volume of ECTR increased by 456.2%, and accounted for an increasing percentage of total CTR procedures (9.1% in 2012, 25.2% in 2020). The average adjusted Medicare reimbursement per procedure decreased by 1.5% for OCTR, and decreased by 11.6% for ECTR. In 2020, orthopedic surgeons performed 85.1% of CTR procedures. CONCLUSIONS The volume of CTR surgeries among the Medicare population has increased from 2000 to 2020, and ECTR is accounting for a growing proportion of surgeries. When adjusted for inflation, average reimbursement has decreased, with a greater decrease among ECTR. Orthopedic surgeons perform most of such surgeries. These trends are important to assure adequate resource allocation as treating carpal tunnel becomes more common among the aging Medicare population.
Collapse
|
13
|
Deckey DG, Christopher ZK, Bingham JS, Spangehl MJ. Principles of mechanical and chemical debridement with implant retention. Arthroplasty 2023; 5:16. [PMID: 37020248 PMCID: PMC10077701 DOI: 10.1186/s42836-023-00170-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 01/17/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is one of the most common causes of early revision for total hip and knee arthroplasty. Mechanical and chemical debridement typically referred to as debridement, antibiotics, and implant retention (DAIR) can be a successful technique to eradicate PJI in acute postoperative or acute hematogenous infections. This review will focus specifically on the indications, techniques, and outcomes of DAIR. DISCUSSION The success of mechanical and chemical debridement, or a DAIR operation, is reliant on a combination of appropriate patient selection and meticulous technique. There are many technical considerations to take into consideration. One of the most important factors in the success of the DAIR procedure is the adequacy of mechanical debridement. Techniques are surgeon-specific and perhaps contribute to the large variability in the literature on the success of DAIR. Factors that have been shown to be associated with success include the exchange of modular components, performing the procedure within seven days or less of symptom onset, and possibly adjunctive rifampin or fluoroquinolone therapy, though this remains controversial. Factors that have been associated with failure include rheumatoid arthritis, age greater than 80 years, male sex, chronic renal failure, liver cirrhosis, and chronic obstructive pulmonary disease. CONCLUSIONS DAIR is an effective treatment option for the management of an acute postoperative or hematogenous PJI in the appropriately selected patient with well-fixed implants.
Collapse
Affiliation(s)
- David G Deckey
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ, 85054, USA
| | | | - Joshua S Bingham
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Mark J Spangehl
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ, 85054, USA.
| |
Collapse
|
14
|
Deckey DG, Verhey JT, Christopher ZK, Gerhart CRB, Clarke HD, Spangehl MJ, Bingham JS. Discordance Abounds in Minimum Clinically Important Differences in THA: A Systematic Review. Clin Orthop Relat Res 2023; 481:702-714. [PMID: 36398323 PMCID: PMC10013655 DOI: 10.1097/corr.0000000000002434] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 09/08/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND The minimum clinically important difference (MCID) is intended to detect a change in a patient-reported outcome measure (PROM) large enough for a patient to appreciate. Their growing use in orthopaedic research stems from the necessity to identify a metric, other than the p value, to better assess the effect size of an outcome. Yet, given that MCIDs are population-specific and that there are multiple calculation methods, there is concern about inconsistencies. Given the increasing use of MCIDs in total hip arthroplasty (THA) research, a systematic review of calculated MCID values and their respective ranges, as well as an assessment of their applications, is important to guide and encourage their use as a critical measure of effect size in THA outcomes research. QUESTIONS/PURPOSES We systematically reviewed MCID calculations and reporting in current THA research to answer the following: (1) What are the most-reported PROM MCIDs in THA, and what is their range of values? (2) What proportion of studies report anchor-based versus distribution-based MCID values? (3) What are the most common methods by which anchor-based MCID values are derived? (4) What are the most common derivation methods for distribution-based MCID values? (5) How do the reported medians and corresponding ranges compare between calculation methods for each PROM? METHODS The EMBASE, MEDLINE, and PubMed databases were systematically reviewed from inception through March 2022 for THA studies reporting an MCID value for any PROMs. Two independent authors reviewed articles for inclusion. All articles calculating new PROM MCID scores after primary THA were included for data extraction and analysis. MCID values for each PROM, MCID calculation method, number of patients, and study demographics were extracted from each article. In total, 30 articles were included. There were 45 unique PROMs for which 242 MCIDs were reported. These studies had a total of 1,000,874 patients with a median age of 64 years and median BMI of 28.7 kg/m 2 . Women made up 55% of patients in the total study population, and the median follow-up period was 12 months (range 0 to 77 months). The overall risk of bias was assessed as moderate using the modified Methodological Index for Nonrandomized Studies criteria for comparative studies (the mean score for comparative papers in this review was 18 of 24, with higher scores representing better study quality) and noncomparative studies (for these, the mean score was 10 of a possible 16 points, with higher scores representing higher study quality). Calculated values were classified as anchor-based, distribution-based, or not reported. MCID values for each PROM, MCID calculation method, number of patients, and study demographics were extracted from each study. Anchor-based and distribution-based MCIDs were compared for each unique PROM using a Wilcoxon rank sum test, given the non-normal distribution of values. RESULTS The Oxford Hip Score (OHS) and the Hip Injury and Osteoarthritis Score (HOOS) Pain and Quality of Life subscore MCIDs were the most frequently reported, comprising 12% (29 of 242), 8% (20 of 242), and 8% (20 of 242), respectively. The EuroQol VAS (EQ-VAS) was the next-most frequently reported (7% [17 of 242]) followed by the EuroQol 5D (EQ-5D) (7% [16 of 242]). The median anchor-based value for the OHS was 9 (IQR 8 to 11), while the median distribution-based value was 6 (IQR 5 to 6). The median anchor-based MCID values for HOOS Pain and Quality of Life were 33 (IQR 28 to 35) and 25 (14 to 27), respectively; the median distribution-based values were 10 (IQR 9 to 10) and 13 (IQR 10 to 14), respectively. Thirty percent (nine of 30) of studies used an anchor-based method to calculate a new MCID, while 40% (12 of 30) used a distribution-based technique. Thirty percent of studies (nine of 30) calculated MCID values using both methods. For studies reporting an anchor-based calculation method, a question assessing pain relief, satisfaction, or quality of life on a five-point Likert scale was the most commonly used anchor (30% [eight of 27]), followed by a receiver operating characteristic curve estimation (22% [six of 27]). For studies using distribution-based calculations, the most common method was one-half the standard deviation of the difference between preoperative and postoperative PROM scores (46% [12 of 26]). Most reported median MCID values (nine of 14) did not differ by calculation method for each unique PROM (p > 0.05). The OHS, HOOS JR, and HOOS Function, Symptoms, and Activities of Daily Living subscores all varied by calculation method, because each anchor-based value was larger than its respective distribution-based value. CONCLUSION We found that MCIDs do not vary very much by calculation method across most outcome measurement tools. Additionally, there are consistencies in MCID calculation methods, because most authors used an anchor question with a Likert scale for the anchor-based approach or used one-half the standard deviation of preoperative and postoperative PROM score differences for the distribution-based approach. For some of the most frequently reported MCIDs, however, anchor-based values tend to be larger than distribution-based values for their respective PROMs. CLINICAL RELEVANCE We recommend using a 9-point increase as the MCID for the OHS, consistent with the median reported anchor-based value derived from several high-quality studies with large patient groups that used anchor-based approaches for MCID calculations, which we believe are most appropriate for most applications in clinical research. Likewise, we recommend using the anchor-based 33-point and 25-point MCIDs for the HOOS Pain and Quality of Life subscores, respectively. We encourage using anchor-based MCID values of WOMAC Pain, Function, and Stiffness subscores, which were 29, 26, and 30, respectively.
Collapse
Affiliation(s)
- David G. Deckey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Jens T. Verhey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | | | | | - Henry D. Clarke
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Mark J. Spangehl
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Joshua S. Bingham
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| |
Collapse
|
15
|
Deckey DG, Verhey JT, Gerhart CRB, Christopher ZK, Spangehl MJ, Clarke HD, Bingham JS. Reply to the Letter to the Editor: There are Considerable Inconsistencies Among Minimum Clinically Important Differences in TKA: A Systematic Review. Clin Orthop Relat Res 2023; 481:843-844. [PMID: 36827490 PMCID: PMC10013672 DOI: 10.1097/corr.0000000000002592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 01/23/2023] [Indexed: 02/26/2023]
Affiliation(s)
- David G. Deckey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Jens T. Verhey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | | | | | - Mark J. Spangehl
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Henry D. Clarke
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Joshua S. Bingham
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| |
Collapse
|
16
|
Moore ML, Deckey DG, Pollock JR, Smith JRH, Tokish JM, Neal MT. The Effect of Amniotic Tissue on Spinal Interventions: A Systematic Review. Int J Spine Surg 2023; 17:32-42. [PMID: 36253081 PMCID: PMC10025852 DOI: 10.14444/8380] [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] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Amniotic membrane tissue has been thought to potentiate healing in many soft tissue conditions. Specifically, recent studies have shown its therapeutic potential for treatment in the setting of spinal pathologies. The purpose of this study is to thoroughly review the existing scientific literature and evidence concerning the clinical use of amniotic membrane-derived biologic agents on postoperative outcomes following spinal surgery. METHODS A systematic review was conducted following preferred reporting items for systematic reviews and meta-analyses guidelines using PubMed, Embase, and Cochrane databases up to December 2020 to identify animal and clinical studies examining the therapeutic potential for amniotic membrane tissue in the setting of spinal pathologies (including disc herniation, prevention of epidural fibrosis, and spinal fusion). Studies were broken down into 2 categories: experimental model type and the type of amnion product being analyzed. RESULTS A total of 12 studies (4 clinical studies and 8 studies utilizing animal models) met inclusion criteria. Additionally, the major types of amnion product were divided into cryopreserved/freeze-dried amniotic membrane, human amniotic fluid, human amniotic membrane, cross-linked amniotic membrane, and amnion-derived epithelial cells. While heterogeneity of study design precludes definitive specific results reporting, most studies showed positive benefits on healing/outcomes with amniotic augmentation. Specifically, amnion products have shown promising effects in reducing epidural adhesions and scar tissue after spine surgery, improving spinal fusion rate and postoperative pain scores, and promoting better functional outcomes after spine surgery. CONCLUSIONS A review of the limited number of reported studies revealed a wide variety of amniotic membrane preparations, treatment regimens, and indications, which limit definitive conclusions. To date, while there is no definitive clinical proof that amniotic tissues enhance tissue repair or regeneration, the aggregate results demonstrate promising basic science and outcomes potential in spinal surgery. Further study is warranted to determine whether this application is appropriate in the clinical setting. CLINICAL RELEVANCE This systematic review provides a summary of the existing literature regarding the use of amniotic membrane preparations, treatment regimens, and indications within spinal surgery. With the growing popularity and utilization of biologic agents such as amniotic membrane-derived products in orthopedic and neurologic surgery, this systematic review gives physicians a concise summary on the outcomes and indications associated with amniotic membrane products. LEVEL OF EVIDENCE: 4
Collapse
Affiliation(s)
- M Lane Moore
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - David G Deckey
- Department of Orthopaedics, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Jordan R Pollock
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | | | - John M Tokish
- Department of Orthopaedics, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Matthew T Neal
- Department of Neurosurgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| |
Collapse
|
17
|
Deckey DG, Verhey JT, Gerhart CRB, Christopher ZK, Spangehl MJ, Clarke HD, Bingham JS. There are Considerable Inconsistencies Among Minimum Clinically Important Differences in TKA: A Systematic Review. Clin Orthop Relat Res 2023; 481:63-80. [PMID: 36200846 PMCID: PMC9750659 DOI: 10.1097/corr.0000000000002440] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 09/12/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Patient-reported outcome measures (PROMs) are frequently used to assess the impact of total knee arthroplasty (TKA) on patients. However, mere statistical comparison of PROMs is not sufficient to assess the value of TKA to the patient, especially given the risk profile of arthroplasty. Evaluation of treatment effect sizes is important to support the use of an intervention; this is often quantified with the minimum clinically important difference (MCID). MCIDs are unique to specific PROMs, as they vary by calculation methodology and study population. Therefore, a systematic review of calculated MCID values, their respective ranges, and assessment of their applications is important to guide and encourage their use as a critical measure of effect size in TKA outcomes research. QUESTIONS/PURPOSES In this systematic review of MCID calculations and reporting in primary TKA, we asked: (1) What are the most frequently reported PROM MCIDs and their reported ranges in TKA? (2) What proportion of studies report distribution- versus anchor-based MCID values? (3) What are the most common methods by which these MCID values are derived for anchor-based values? (4) What are the most common derivation methods for distribution-based values? (5) How do the reported medians and corresponding interquartile ranges (IQR) compare between calculation methods for each PROM? METHODS Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review was conducted using the PubMed, EMBASE, and MEDLINE databases from inception through March 2022 for TKA articles reporting an MCID value for any PROMs. Two independent reviewers screened articles for eligibility, including any article that calculated new MCID values for PROMs after primary TKA, and extracted these data for analysis. Overall, 576 articles were identified, 38 of which were included in the final analysis. These studies had a total of 710,128 patients with a median age of 67.7 years and median BMI of 30.9 kg/m 2 . Women made up more than 50% of patients in most studies, and the median follow-up period was 17 months (range 0.25 to 72 months). The overall risk of bias was assessed as moderate using the Jadad criteria for one randomized controlled trial (3 of 5 ideal global score) and the modified Methodological Index for Non-randomized Studies criteria for comparative studies (mean 17.2 ± 1.8) and noncomparative studies (mean 9.6 ± 1.3). There were 49 unique PROMs for which 233 MCIDs were reported. Calculated values were classified as anchor-based, distribution-based, or not reported. MCID values for each PROM, MCID calculation method, number of patients, and study demographics were extracted from each study. Anchor-based and distribution-based MCIDs were compared for each unique PROM using a Wilcoxon rank sum test given non-normal distribution of values. RESULTS The WOMAC Function and Pain subscores were the most frequently reported MCID value, comprising 9% (22 of 233) and 9% (22 of 233), respectively. The composite Oxford Knee Score (OKS) was the next most frequently reported (9% [21 of 233]), followed by the WOMAC composite score (6% [13 of 233]). The median anchor-based values for WOMAC Function and Pain subscores were 23 (IQR 16 to 33) and 25 (IQR 14 to 31), while the median distribution-based values were 11 (IQR 10.8 to 11) and 22 (IQR 17 to 23), respectively. The median anchor-based MCID value for the OKS was 6 (IQR 4 to 7), while the distribution-based value was 7 (IQR 5 to 10). Thirty-nine percent (15 of 38) used an anchor-based method to calculate a new MCID, while 32% (12 of 38) used a distribution-based technique. Twenty-nine percent of studies (11 of 38) calculated MCID values using both methods. For studies reporting an anchor-based calculation method, a question assessing patient satisfaction, pain relief, or quality of life along a five-point Likert scale was the most commonly used anchor (40% [16 of 40]), followed by a receiver operating characteristic curve estimation (25% [10 of 40]). For studies using distribution-based calculations, all articles used a measure of study population variance in their derivation of the MCID, with the most common method reported as one-half the standard deviation of the difference between preoperative and postoperative PROM scores (45% [14 of 31]). Most reported median MCID values (15 of 19) did not differ by calculation method for each unique PROM (p > 0.05) apart from the WOMAC Function component score and the Knee Injury and Osteoarthritis Outcome Score Pain and Activities of Daily Living subscores. CONCLUSION Despite variability of MCIDs for each PROM, there is consistency in the methodology by which MCID values have been derived in published studies. Additionally, there is a consensus about MCID values regardless of calculation method across most of the PROMs we evaluated. CLINICAL RELEVANCE Given their importance to treatment selection and patient safety, authors and journals should report MCID values with greater consistency. We recommend using a 7-point increase as the MCID for the OKS, consistent with the median reported anchor-based value derived from several high-quality studies with large patient groups that used anchor-based approaches for MCID calculation, which we believe are most appropriate for most applications in clinical research. Likewise, we recommend using a 10-point to 15-point increase for the MCID of composite WOMAC, as the median value was 12 (IQR 10 to 17) with no difference between calculation methods. We recommend use of median reported values for WOMAC function and pain subscores: 21 (IQR 15 to 33) and 23 (IQR 13 to 29), respectively.
Collapse
Affiliation(s)
- David G. Deckey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Jens T. Verhey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | | | | | - Mark J. Spangehl
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Henry D. Clarke
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Joshua S. Bingham
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| |
Collapse
|
18
|
Fuller CC, Deckey DG, Brinkman JC, Tummala SV, Lu PG, Mishra N, Bingham JS. General Surgery Residency Applicants' Perspective on Social Media as a Recruiting Tool. J Surg Educ 2022; 79:1334-1341. [PMID: 35739022 DOI: 10.1016/j.jsurg.2022.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 02/07/2022] [Revised: 05/11/2022] [Accepted: 06/06/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE General surgery residency programs have increased their social media presence to educate and recruit prospective residents. This study aims to understand the impact of general surgery residency program social media on the 2020-2021 applicants' evaluation of prospective programs, particularly during the COVID-19 pandemic. DESIGN An optional 20-item online survey regarding specialty choice, sub-internship rotation completion, social media resource use, social media impact, and general demographic information. SETTING Large academic medical center, United States. PARTICIPANTS A total of 1191 Participants to our general surgery residency program were sent a survey. Six hundred thirteen completed the survey. RESULTS Surveys were sent to all general surgery residency applicants of a single program (1,191) and 613 (51.4%) responded. Overall, social media resources use included official residency program website (92.4%), Doximity (36.5%), and Twitter (35.6%). The most frequently relied upon resources by applicants were the official residency program website (64.9%) Twitter (10.9%) and Instagram (10.8%). Most respondents agreed that social media was an effective means to inform applicants (70.9%) and that it positively impacted their perception of the program (62.6%). The most commonly cited benefits were helping the program exhibit its culture and comradery among residents, faculty, and staff (79.2%), with posts of social events and camaraderie as being the most helpful in learning about residency programs. Of all applicants, 71.3% noted that social media had a significant impact on perceptions of programs during the application cycles that were limited by COVID-19 safety and travel restrictions. However, most applicants disagree with (35.3%) or are neutral toward (32.1%) the statement that social media will have less of an impact on future cycles not limited by COVID-19. CONCLUSION During the 2020-2021 application cycle, the majority of applicants utilized social media to inform and educate themselves about the general surgery programs they applied to. Residency-based social media had a positive impact on the majority of applicants, especially in terms of allowing a program to demonstrate its culture and camaraderie. Investing time and resources into residency social media accounts appears to be a meaningful pursuit for general surgery programs and is an important aspect in today's recruitment effort.
Collapse
Affiliation(s)
- Carson C Fuller
- Department of Surgery, University of Washington, Seattle, Washington
| | - David G Deckey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona.
| | - Joseph C Brinkman
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Sailesh V Tummala
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Patricia G Lu
- Department of General Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Nitin Mishra
- Department of General Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Joshua S Bingham
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| |
Collapse
|
19
|
Bingham JS, Hinckley NB, Deckey DG, Hines J, Spangehl MJ. Primary Tritanium acetabular components have increased rates of radiolucency associated with inferior clinical outcomes at short-term follow-up. Hip Int 2022; 32:724-729. [PMID: 33566724 DOI: 10.1177/1120700020988723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Cementless fixation is the standard for acetabular fixation in primary total hip arthroplasty (THA). There are various surface finishes thought to improve osteointegration, although literature regarding the long-term survival of some of these surfaces is limited. Regardless of design, primary stability is essential to allow for osteointegration. Previous studies have suggested an increased rate of radiolucency and compromised short-term functional outcomes using the Tritanium primary acetabular component (Stryker, Mahwah, NJ). The purpose of this study was to compare the primary Tritanium acetabular component to another contemporary acetabular component as a control group with an established clinical record. METHODS 444 consecutive, primary THAs performed by a single surgeon from 2008 to 2012 were reviewed. Patients were included if they had a minimum 1-year follow-up. Implant survivorship and modified Harris Hip Scores (mHHS) were recorded for all patients at final follow-up. Radiographs were evaluated by 2 surgeons at 6 weeks, 1 year, and the most recent follow-up for evidence of radiolucency and migration. Components were considered to have evidence of radiographic lucency if they had radiolucency in 2 or more DeLee zones. RESULTS 198 patients met criteria for inclusion (96 Pinnacle, 102 Tritanium). Average follow-up was 28 (12-72) months. At final follow-up 6.2% of the Pinnacle cups and 29.4% of the Tritanium cups had radiographic evidence of loosening (p < 0.01). The average mHHS for the Tritanium group was 83.1, and 88.4 for the Pinnacle group (p < 0.01). Radiographic evidence of loosening also correlated with a lower mHHS: 75.5 versus 86.4 (p < 0.01). In patients that received Tritanium cups without screw fixation 44.6% showed radiographic evidence of loosening versus 8% that received screw fixation (p < 0.01). In total, 6 patients in the Tritanium group required revision for aseptic loosening of the acetabular component. CONCLUSIONS The 30% rate of radiographic loosening in the Tritanium group was significantly higher than the Pinnacle group and correlated with an inferior clinical outcome. Interestingly the use of screw augmentation was protective against radiographic evidence of loosening. This suggests that the Tritanium component may be prone to fibrous in-growth because of inadequate primary stability.
Collapse
Affiliation(s)
- Joshua S Bingham
- Department of Orthopaedics, Mayo Clinic Arizona, Phoenix, AZ, USA
| | | | - David G Deckey
- Department of Orthopaedics, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Jeremy Hines
- Department of Orthopaedics, Mayo Clinic Rochester, Rochester, MN, USA
| | - Mark J Spangehl
- Department of Orthopaedics, Mayo Clinic Arizona, Phoenix, AZ, USA
| |
Collapse
|
20
|
Deckey DG, Rosenow CS, Lai C, Christopher ZK, Verhey JT, Schwartz AJ, Bingham JS. Abnormal Spinopelvic Motion and Spine Deformity are Associated With Native Femoral Retroversion in the Setting of Total Hip Arthroplasty. Arthroplast Today 2022; 17:150-154. [PMID: 36158464 PMCID: PMC9493293 DOI: 10.1016/j.artd.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/28/2022] [Accepted: 08/10/2022] [Indexed: 11/16/2022] Open
Abstract
Background The effect of spinopelvic pathology on femoral version is unclear. This study investigated variability in native femoral anteversion in patients undergoing total hip arthroplasty (THA) and its relationship to the patient’s underlying spinopelvic pattern. Methods A retrospective chart review was performed to include in the study all patients undergoing robot-assisted THA over a 3-year period. Native femoral version was measured for each patient using a preoperative computed tomography scan and categorized as excessive, normal, or retroverted. Additionally, a subset analysis was performed for all patients with sit-to-stand dynamic pelvic radiographs available, and cases were classified by spinopelvic pattern. Results A total of 119 patients were included in the study with a mean age of 68.6 years; 61 (51%) were female. The median femoral anteversion for the entire study group was 6.0° (−32° to 40°, interquartile range 13.5°). Eleven patients (9.2%) had excessive femoral anteversion, 54 of the 119 (45.4%) had normal femoral version, and 54 of the 119 (45.4%) had native retroversion. Forty-two patients (35.3%) had sit-to-stand radiographs available and were subclassified by femoral version type and spinopelvic parameters. Welch’s analysis of variance demonstrated a significant difference in femoral version among spinopelvic patterns (F = 7.826, P = .003), with Games-Howell post hoc analysis showing increased retroversion in deformity-stiff patients compared to deformity-normal mobility patients (P = .003). Conclusions This study demonstrates that native femoral retroversion is present in a significant number of patients undergoing THA and is more common in patients with stiff spine deformities. Based on this observation, currently available spinopelvic classification systems should be modified to account for native femoral version.
Collapse
|
21
|
Deckey DG, Verhey J, Haglin J, Carlson A, Kile TA, Hinckley N. Treatment of Moderate to Severe Hallux Valgus without Osteotomy or Arthrodesis. Foot & Ankle Orthopaedics 2022. [DOI: 10.1177/2473011421s00648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Category: Bunion Introduction/Purpose: Hallux valgus is a multi-planar deformity that has historically required osteotomies to correct a soft tissue deficiency. We present a novel technique for the treatment of moderate to severe hallux valgus and subsequent radiographic results of a method to correct the intermetatarsal abnormality without utilizing osteotomies or arthrodesis. Methods: One hundred and thirty-six patients undergoing primary metatarsal re-alignment with modified McBride for moderate to severe hallux valgus were included. After each patient underwent standard distal soft tissue procedure via modified McBride bunionectomy, the first metatarsal was manually reduced and brought parallel to the second. It was then held temporarily with a K-wire and position assessed to ensure the first and second metatarsal heads are in the same transverse plane to prevent relative plantar or dorsiflexion of the first ray. A bioabsorbable screw was then placed obliquely from the base of the first into the bases of the second and third metatarsals. Patients were assessed pre-operatively, at 2 weeks, 6 weeks, and 3 months for early clinical outcome, complications, and radiographic evaluation. The hallux valgus angle (HVA) and intermetatarsal angle (IMA) were recorded and used to monitor any progression or change over time. Results: This procedure allows for significant correction of moderate and severe hallux valgus deformities with little radiographic evidence of loss of reduction in early clinical follow-up. One and two-year follow-up was included for patients where available. Pre-operative assessment of HVA and IMA were 32.3° (95% CI: 31.1-33.5) and 14.8° (95% CI: 14.2-15.3), respectively. Post- operative HVA was significantly improved at 2 weeks (10.4°), 6 weeks (11.1°), and 3 months (12.1°). IMA was improved at 2 weeks (6.0°), 6 weeks (6.8°) and 3 months (7.8°). One (48 patients) and two-year follow-up (20 patients) show maintenance of correction of both HVA (1yr: 12.7°, 2yr: 10.8°) and IMA (1yr: 7.9°, 2yr: 8.0°). Complications were few including iatrogenic hallux varus (2/136, 1.4%), peri-implant fractures at the second metatarsal base (3/136, 2.2%), and valgus relapse, which was the only complication requiring re-operation (3/136, 2.2%). Conclusion: When combined with modified McBride bunionectomy, this proximal metatarsal realignment procedure provides a simple and effective method for the treatment of moderate to severe hallux valgus deformities. Additionally, there is minimal radiographic evidence of loss of reduction over time. This procedure is simple to perform, easy to learn, and does not 'burn any bridges' with regards to future surgery.
Collapse
|
22
|
Moore ML, Brinkman JC, Pollock JR, Deckey DG, Makovicka JL, Bingham JS. Patients are Most Interested in Which Hip Arthroplasty Approach? A 15-year Google Trends Analysis. Arthroplast Today 2022; 17:192-197. [PMID: 36254208 PMCID: PMC9568677 DOI: 10.1016/j.artd.2022.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/25/2022] [Accepted: 07/27/2022] [Indexed: 11/17/2022] Open
Abstract
Background Methods Results Conclusions
Collapse
Affiliation(s)
- M. Lane Moore
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ USA
| | - Joseph C. Brinkman
- Mayo Clinic Department of Orthopedic Surgery, Phoenix, AZ, USA
- Corresponding author. Mayo Clinic Department of Orthopedic Surgery, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA. Tel.: +1 480 301 9506.
| | | | - David G. Deckey
- Mayo Clinic Department of Orthopedic Surgery, Phoenix, AZ, USA
| | | | | |
Collapse
|
23
|
Verhey JT, Deckey DG, Tummala S, Hassebrock JD, Dulle D, Long JR, Miller MD, Chhabra A. A novel meniscofemoral ligament variant intra-substance to the PCL. Knee Surg Sports Traumatol Arthrosc 2022; 30:2277-2280. [PMID: 34734309 DOI: 10.1007/s00167-021-06791-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 08/16/2021] [Accepted: 10/25/2021] [Indexed: 11/25/2022]
Abstract
While much detail is known about each anatomic structure of the knee and its contributory effect on biomechanics, our understanding is still evolving. In particular, the function of the meniscofemoral ligaments and their anatomical variants have yet to be fully described. In this report, a never-before-described anatomical meniscofemoral ligament variant intra-substance to the PCL is presented. Arthroscopists should be aware of the novel variant as a growing number of studies have demonstrated the biomechanical importance of the meniscofemoral ligaments in protecting the lateral meniscus and supporting the function of the PCL.Level of Evidence: IV.
Collapse
Affiliation(s)
- Jens T Verhey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA.
| | - David G Deckey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Sailesh Tummala
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Jeffrey D Hassebrock
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Donald Dulle
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Jeremiah R Long
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Mark D Miller
- Department of Orthopaedic Surgery, University of Virginia Medical Center, Chartlottesville, VA, USA
| | - Anikar Chhabra
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| |
Collapse
|
24
|
Deckey DG, Verhey JT, Rosenow CS, Doan MK, McQuivey KS, Joseph AM, Schwartz AJ, Clarke HD, Bingham JS. Robotic-Assisted Total Knee Arthroplasty Allows for Trainee Involvement and Teaching Without Lengthening Operative Time. J Arthroplasty 2022; 37:S201-S206. [PMID: 35184933 DOI: 10.1016/j.arth.2021.12.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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: 08/04/2021] [Revised: 12/11/2021] [Accepted: 12/20/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Robot-assisted total knee arthroplasty (RA-TKA) is more accurate than mechanical total knee arthroplasty (M-TKA) and can provide real-time feedback about alignment and soft-tissue balancing that may be helpful in trainee education. However, both robotic-assist and trainee involvement potentially increase the surgical time. This study sought to evaluate whether RA-TKA procedures were longer than M-TKA procedures and whether trainee participation added additional surgical time. METHODS This retrospective cohort study reviewed 220 consecutive primary TKAs (110 M-TKA and 110 RA-TKA) performed by an orthopedic trainee under supervision or performed by the consultant surgeon with an assistant present. For M-TKAs, a measured resection technique was used. For all RA-TKAs, the MAKO robotic system (Stryker, USA) was used. Tourniquet time was measured from inflation immediately prior to skin incision to deflation after placement of the final polyethylene insert. Procedures performed by a consulting surgeon with a surgical assist were used as controls for procedures performed by the trainee. In trainee-conducted procedures, the trainee is responsible for performing all critical aspects of the procedure while the consulting surgeon provides supervision and acts as first assist. RESULTS 103 M-TKA and 96 RA-TKA were included. Tourniquet time was significantly longer for RA-TKAs vs M-TKAs (100 vs 89 minutes, P < .0001). However, there were no significant differences in tourniquet times between surgery performed by a trainee vs the consulting surgeon with surgical assist for either M-TKA (P = .3452) or RA-TKA (P = .6724). CONCLUSIONS While RA-TKA takes longer, orthopedic trainees do not add additional time. Trainees at all stages of postgraduate learning can be educated in the use of robotic technology and potentially benefit from real-time feedback without further compromising surgical efficiency or increasing patient risk.
Collapse
Affiliation(s)
- David G Deckey
- Department of Orthopedics, Mayo Clinic in Arizona, Phoenix, AZ
| | - Jens T Verhey
- Alix School of Medicine of Mayo Clinic in Arizona, Scottsdale, AZ
| | | | - Matthew K Doan
- Alix School of Medicine of Mayo Clinic in Arizona, Scottsdale, AZ
| | - Kade S McQuivey
- Department of Orthopedics, Mayo Clinic in Arizona, Phoenix, AZ
| | - Anna M Joseph
- Division of Clinical Trials and Biostatistics, Mayo Clinic in Arizona, Scottsdale, AZ
| | - Adam J Schwartz
- Department of Orthopedics, Mayo Clinic in Arizona, Phoenix, AZ; Alix School of Medicine of Mayo Clinic in Arizona, Scottsdale, AZ
| | - Henry D Clarke
- Department of Orthopedics, Mayo Clinic in Arizona, Phoenix, AZ; Alix School of Medicine of Mayo Clinic in Arizona, Scottsdale, AZ
| | - Joshua S Bingham
- Department of Orthopedics, Mayo Clinic in Arizona, Phoenix, AZ; Alix School of Medicine of Mayo Clinic in Arizona, Scottsdale, AZ
| |
Collapse
|
25
|
Deckey DG, Doan M, Hassebrock JD, Patel KA, Economopoulos K, Tokish JM, Bingham JS, Chhabra A. Prevalence of Cannabinoid (CBD) Use in Orthopaedic Sports Medicine Patients. Orthop J Sports Med 2022; 10:23259671221087629. [PMID: 35400139 PMCID: PMC8988677 DOI: 10.1177/23259671221087629] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/21/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Although there is some evidence that cannabinoid (CBD) products may provide a therapeutic effect for musculoskeletal pain, little is known about the usage patterns or their prevalence of use in orthopaedic sports medicine patients. Purpose: To report the prevalence and perceived self-efficacy of CBD products in patients evaluated in an orthopaedic sports medicine clinic. Study Design: Descriptive epidemiology study. Level of evidence, 2. Methods: The study population consisted of new patients who visited an orthopaedic surgery sports medicine clinic at a large academic center for consultation with a surgeon between August 2020 and March 2021. All patients were asked to complete a survey that assessed perceived pain and effectiveness of CBD products and other nonsurgical treatment modalities using the Single Assessment Numeric Evaluation score (range, 0-100) and the Numeric Pain Rating Scale (NRS). Descriptive factors were collected via chart review. Descriptive statistics were used to characterize the data. Results: Overall, 823 patients completed the survey (45.4% female; mean age, 51 years [range, 18-87 years]; mean body mass index, 28.9 [range, 17.2-58.4]). Body areas involved included 285 shoulders, 44 elbows, 76 hips, 276 knees, 58 ankles, and 77 other. Of these patients, 19% (152/823) endorsed the use of CBD products before their initial evaluation. The mean NRS for pain was significantly different between non-CBD users and CBD users (5.6 vs 6.1; P = .029). CBD users were significantly more likely to have tried other nonoperative modalities compared with nonusers, including nonsteroidal anti-inflammatory drugs (79.6% vs 69.8%; P = .032), bracing (44.7% vs 34.6%; P = .024), steroid injections (38.8% vs 21.6%; P < .001), and physical therapy (54% vs 36.1%; P < .001). In addition, 30.9% of CBD utilizers reported marijuana use compared with 2.8% of non-CBD users ( P < .001) for management of their pain. Conclusion: In the current study, 19% of patients had used CBD products to manage joint-related issues. Sports medicine providers should be aware of this high incidence of usage and the potential interactions CBD products may have with other treatment modalities. Further studies are needed to assess the effectiveness of CBD as a therapeutic agent and the specific interactions it has with other drugs and other forms of treatment.
Collapse
Affiliation(s)
- David G. Deckey
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Matthew Doan
- Alix School of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | | | - Karan A. Patel
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
- Alix School of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Kostas Economopoulos
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
- Alix School of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - John M. Tokish
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
- Alix School of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Joshua S. Bingham
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
- Alix School of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Anikar Chhabra
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
- Alix School of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| |
Collapse
|
26
|
Pollock JR, Moore ML, Haglin JM, LeBlanc MP, Rosenow CS, Makovicka JL, Deckey DG, Hassebrock JD, Bingham JS, Patel KA. Between 2000 and 2020, Reimbursement for Orthopaedic Foot and Ankle Surgery Decreased by 30%. Arthrosc Sports Med Rehabil 2022; 4:e553-e558. [PMID: 35494293 PMCID: PMC9042755 DOI: 10.1016/j.asmr.2021.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 11/11/2021] [Indexed: 11/27/2022] Open
Abstract
Purpose To examine and analyze Medicare reimbursement rates from 2000 to 2020 for orthopaedic foot and ankle procedures. Methods The 20 most used orthopaedic foot and ankle surgical procedures were gathered from the Centers for Medicare & Medicaid Services website using the Medicare Provider Utilization and Payment Data Public Use File 2017. The reimbursement data for each code were gathered from The Physician Fee Schedule Look-Up Tool from Centers for Medicare & Medicaid Services. The reimbursement values were adjusted for inflation to 2020 U.S. dollars using the consumer price index. Results The average inflation-adjusted reimbursement for included procedures decreased by 30% from 2000 to 2020. The greatest mean decreases were observed for “correction of hallux valgus” (–47%) and “partial excision of foot bone” (–41%). The procedures with the smallest mean decreases were observed in “treatment of “Amputation of toe” (–19%) and “closed treatment of metatarsal fracture” (–7%). Conclusions From 2000 to 2020, Inflation-adjusted Medicare reimbursement for foot and ankle surgery decreased by 30%. Level of Evidence IV; economic analysis.
Collapse
Affiliation(s)
| | - M. Lane Moore
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona, U.S.A
| | - Jack M. Haglin
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona, U.S.A
| | | | | | | | - David G. Deckey
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, U.S.A
| | | | - Joshua S. Bingham
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, U.S.A
| | - Karan A. Patel
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, U.S.A
- Address correspondence to Karan A. Patel, M.D., Department of Orthopedic Surgery, Mayo Clinic, 5779 E. Mayo Blvd., Phoenix, AZ 85054.
| |
Collapse
|
27
|
Smith JF, Moore ML, Pollock JR, Haglin JM, LeBlanc MP, Deckey DG, Arthur JR, Chhabra A. National and geographic trends in Medicare reimbursement rates for orthopedic shoulder and upper extremity surgery from 2000 to 2020. J Shoulder Elbow Surg 2022; 31:860-867. [PMID: 34619346 DOI: 10.1016/j.jse.2021.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 02/16/2021] [Revised: 09/03/2021] [Accepted: 09/06/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is a paucity of information regarding financial trends in orthopedic upper extremity surgery. If progress is to be made in advancing agreeable reimbursement models, a more comprehensive understanding of these trends is needed. The purpose of this study was to assess national and geographic trends in Medicare reimbursement rates for shoulder and elbow surgical procedures over the past 2 decades. METHODS The 10 most billed Common Procedural Terminology (CPT) codes for both orthopedic shoulder surgery and elbow/upper arm surgery were determined. Medicare reimbursement data for these CPT codes were compiled between 2000 and 2020 and adjusted for inflation. The percentage change for each procedure and the average change in reimbursement each year were analyzed. Data from 2000, 2010, and 2020 were organized by state. The total percent change in physician fee and the percent change per year were tabulated for each CPT code using inflation-adjusted data and averaged by state. RESULTS From 2000 to 2020, when corrected for inflation, shoulder and elbow procedures decreased on average by 29.3% and 24.5%, respectively. Shoulder procedures experienced a greater numerical yet statistically insignificant decline in mean reimbursement percent decrease (P = .16), average percent decrease per year (P = .11), a more negative compound annual growth rate (P = .14), and a greater R-squared value as compared with elbow and upper arm procedures. For shoulder procedures, the average percent difference in inflation-adjusted Medicare reimbursement rates from 2000 to 2020 varied from -22.6% in Alaska to -34.1% in Michigan; division data varied from -27.8% in the Mountain Division to -31.2% in the East North Central Division; and region data varied from -28.3% in the West to -30.5% in the Northeast. For elbow and upper arm procedures, the average percent difference in inflation-adjusted Medicare reimbursement rates from 2000 to 2020 varied from -17.6% in Alaska to -29.8% in Michigan; division data varied from -23.0% in the Mountain Division to -26.7% in the East North Central Division; and region data varied from -23.5% in the West to -25.7% in the Northeast. DISCUSSION Inflation-adjusted Medicare reimbursement in upper extremity surgery has decreased markedly between 2000 and 2020. The degree of decrease varies geographically. If access to quality and sustainable surgical orthopedic care is to persist in the United States, increased awareness of these trends is important. The trends identified in this study can serve to customize regional health care policymaking.
Collapse
Affiliation(s)
- Jacob F Smith
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ, USA.
| | - M Lane Moore
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Jordan R Pollock
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Jack M Haglin
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Matthew P LeBlanc
- McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - David G Deckey
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | | | - Anikar Chhabra
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ, USA; Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| |
Collapse
|
28
|
Christopher ZK, Deckey DG, Pollock JR, Spangehl MJ. Antiseptic Irrigation Solutions Used in Total Joint Arthroplasty: A Critical Analysis Review. JBJS Rev 2022; 10:01874474-202203000-00005. [PMID: 35231016 DOI: 10.2106/jbjs.rvw.21.00225] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» There are limited data that directly compare the efficacy of antiseptic irrigation solutions used for the prevention and treatment of periprosthetic joint infections in orthopaedic procedures; there is a notable lack of prospective data. » For prevention of periprosthetic joint infections, the strongest evidence supports the use of low-pressure povidone-iodine. » For the treatment of periprosthetic joint infections, delivering multiple solutions sequentially may be beneficial.
Collapse
|
29
|
Hinckley NB, Hassebrock JD, Karsen PJ, Deckey DG, Fernandez A, Kile TA, Drakos MC, Patel KA. Talus Visualization in Ankle Fractures: How Much Are We Really Seeing? Orthop J Sports Med 2022; 10:23259671211066856. [PMID: 35024369 PMCID: PMC8743951 DOI: 10.1177/23259671211066856] [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: 08/31/2021] [Accepted: 09/27/2021] [Indexed: 11/29/2022] Open
Abstract
Background: Despite appropriate care, a subset of patients with ankle fractures has persistent pain. This condition may be associated with intra-articular pathology, which is present up to 65% of the time. Purpose: To quantify how much of the talus is visible through an open approach to a standard supination external rotation bimalleolar ankle fracture as a percentage of the entire weightbearing surface of the talus. Study Design: Descriptive laboratory study. Methods: Standard ankle approaches to lateral and medial malleolar fractures were performed in 4 cadaveric ankles from 2 cadavers. Osteotomies were made to simulate a supination external rotation bimalleolar ankle fracture based on the Lauge-Hansen classification. The visible segments of talar cartilage were removed. The tali were then exhumed, and the entire weightbearing superior portion of the talus was assessed and compared with the amount of cartilage removed by an open approach. The mean of the data points as well as the 95% confidence interval were calculated. Results: Four ankle specimens from 2 cadavers were used for these measurements. The mean surface area of the talus was 14.0 cm2 (95% CI, 13.3-14.7 cm2), while the mean area visible via an open approach was 2.1 cm2 (95% CI, 0.5-3.6 cm2). The mean proportion of the talus visualized via an open approach was 14.8% (95% CI, 3.6-26.1%). Conclusion: These findings indicate that the true area of weightbearing talar surface visible during an open exposure may be less than what many surgeons postulate. Clinical Relevance: Only a small fracture of the talus is visible via an open approach to the talus during fracture fixation. This could warrant arthroscopic evaluation of these injuries to evaluate and treat osteocondral lesions resulting from ankle fractures.
Collapse
Affiliation(s)
| | | | - Phillip J Karsen
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - David G Deckey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Andrea Fernandez
- University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Todd A Kile
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Mark C Drakos
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Karan A Patel
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| |
Collapse
|
30
|
Brinkman JC, Deckey DG, Tummala SV, Hassebrock JD, Spangehl MJ, Bingham JS. Orthopaedic Residency Applicants' Perspective on Program-Based Social Media. JB JS Open Access 2022; 7:JBJSOA-D-22-00001. [PMID: 35620527 PMCID: PMC9116946 DOI: 10.2106/jbjs.oa.22.00001] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Social media and online resources have been used in graduate medical education for years. In addition to an official residency program website, many orthopaedic surgery programs have an established social media presence to interact, educate, and engage with prospective applicants. The role of social media in orthopaedic surgery has significantly expanded in recent years. Despite its increasing use, the specific impact of social media on orthopaedic surgery residency applicants remains unknown.
Collapse
Affiliation(s)
- Joseph C. Brinkman
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - David G. Deckey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Sailesh V. Tummala
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | | | - Mark J. Spangehl
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Joshua S. Bingham
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| |
Collapse
|
31
|
Rosenow CS, Brinkman JC, Deckey DG, Tummala SV, Pollock JR, Spangehl MJ, Bingham JS. Orthopaedic Surgery Away Rotations. JB JS Open Access 2022; 7:JBJSOA-D-21-00119. [PMID: 36147654 PMCID: PMC9484814 DOI: 10.2106/jbjs.oa.21.00119] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Away rotations have become a critical factor for a successful orthopaedic surgery residency match. Away rotations significantly improve an applicant's chance of matching into an orthopaedic residency. Away rotations were limited during the 2020 to 2021 academic year because of the COVID-19 pandemic. During the 2021 to 2022 academic year, the American Association of Medical Colleges coalition recommended students only complete 1 rotation outside their home institution, whereas the American Orthopaedic Association Council of Residency Directors argued that multiple rotations should be allowed. We sought to quantify the impact of these restrictions on orthopaedic surgery applicants during the 2020 to 2021 residency application cycle.
Collapse
Affiliation(s)
| | | | - David G. Deckey
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | | | | | - Mark J. Spangehl
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Joshua S. Bingham
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| |
Collapse
|
32
|
Deckey DG, Tummala S, Verhey JT, Hassebrock JD, Dulle D, Miller MD, Chhabra A. Prevalence, Biomechanics, and Pathologies of the Meniscofemoral Ligaments: A Systematic Review. Arthrosc Sports Med Rehabil 2021; 3:e2093-e2101. [PMID: 34977667 PMCID: PMC8689266 DOI: 10.1016/j.asmr.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 09/15/2021] [Indexed: 11/08/2022] Open
Abstract
Purpose To systematically review the literature to examine current understanding of the meniscofemoral ligaments (MFLs), their function, their importance in clinical management, and known anatomical variants. Methods A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed, EMBASE, and Cochrane databases. Studies were included if they reported on the biomechanical, radiographic, or arthroscopic evaluation of human MFLs, or if they reported on an anatomical variant. These were then categorized as cadaveric, radiographic, or clinical. Biomechanical, radiographic, patient-reported, and functional outcomes data were recorded. Results Forty-seven studies were included in the qualitative analysis, and 26 of them were included in the quantitative analysis. Of these, there were 15 cadaveric, 3 arthroscopic, and 9 radiographic studies that reported on the prevalence of MFLs. Overall, when looking at all modalities, the presence of either the anterior or posterior MFL (aMFL, pMFL) has been noted to be 70.8%, with it being the aMFL 17.4% and the pMFL 40.6%. The presence of both ligaments occurs in approximately 17.6% of individuals. Eleven reported on mean MFL length and thickness. When evaluating mean length in both men and women, the aMFL has been reported between 21.6 and 28.3 mm and the pMFL length in this population is between 23.4 and 31.2 mm. Five reported on cross-sectional area. Nine additional papers report anatomical variants. Conclusions This review shows that there continues to be a variable incidence of MFLs reported in the literature, but our understanding of their function continues to broaden. A growing number of anatomic and biomechanical studies have demonstrated the importance of the MFLs in supporting knee stability. Specifically, the MFLs serve an important role in protecting the lateral meniscus and augmenting the function of the posterior cruciate ligament. Clinical Relevance Our findings will aid the clinician in both identifying and treating pathologies of the meniscofemoral ligaments.
Collapse
|
33
|
McQuivey KS, Christopher ZK, Deckey DG, Mi L, Bingham JS, Spangehl MJ. Surgical Ergonomics and Musculoskeletal Pain in Arthroplasty Surgeons. J Arthroplasty 2021; 36:3781-3787.e7. [PMID: 34303581 DOI: 10.1016/j.arth.2021.06.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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: 04/09/2021] [Revised: 06/04/2021] [Accepted: 06/21/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND One occupational hazard inherent to total joint replacement surgeons is procedural-related musculoskeletal pain (MSP). The purpose of this study is to identify the prevalence of work-related MSP among arthroplasty surgeons and analyze associated behaviors, attitudes, and beliefs toward surgical ergonomics. METHODS A survey was sent to members of the American Association of Hip and Knee Surgeons. The survey included 3 main sections: demographics, symptoms by body part, and attitudes/beliefs/behaviors regarding surgical ergonomics. Pain was reported using the Numeric Rating Scale (0 = no pain, 10 = maximum pain), and well-being was assessed using the Maslach Burnout Inventory. RESULTS In total, 586 surgeons completed the survey: 96.1% male and 3.9% female. Most surgeons (96.5%) experience procedural-related MSP. Collectively, surgeons reported an average pain score of 3.7/10 (standard deviation ±1.95). Significant levels of MSP (≥5/10) were most common in the lower back (34.2%), hands (24.8%), and the neck (21.2%). There was a positive association among higher MSP and burnout (P < .001), callousness toward others (P = .005), and decreased overall happiness (P < .001). MSP was also found to have a significant impact on surgeon behavior including the degree of irritability (P < .001), alcohol intake (P < .001), and poor sleep patterns (P < .001). CONCLUSION The prevalence of MSP among arthroplasty surgeons is extremely high. This study demonstrates that MSP has a significant impact on career attitudes, lifestyle, and overall surgeon well-being. This study may also contribute to future work to prevent cumulative chronic ailments, disability, and lost productivity of arthroplasty surgeons through promotion of improved ergonomics and risk-reduction strategies. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Kade S McQuivey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | | | - David G Deckey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Lanyu Mi
- Division of Biomedical Statistics and Informations, Mayo Clinic Arizona, Scottsdale, AZ
| | - Joshua S Bingham
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Mark J Spangehl
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ
| |
Collapse
|
34
|
Pollock JR, Doan MK, Moore ML, Hassebrock JD, Makovicka JL, Deckey DG, Kile TA, Patel KA. 30-Day Outcomes for Total Ankle Arthroplasty in Patients With Anemia. Foot Ankle Int 2021; 42:1463-1468. [PMID: 34109838 DOI: 10.1177/10711007211017512] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND While anemia has been associated with poor surgical outcomes in total knee arthroplasty and total hip arthroplasty, the effects of anemia on total ankle arthroplasty remain unknown. This study examines how preoperative anemia affects postoperative outcomes in total ankle arthroplasty. METHODS A retrospective analysis was performed using the American College of Surgeons National Surgery Quality Improvement Project database from 2011 to 2018 for total ankle arthroplasty procedures. Hematocrit (HCT) levels were used to determine preoperative anemia. RESULTS Of the 1028 patients included in this study, 114 patients were found to be anemic. Univariate analysis demonstrated anemia was significantly associated with an increased average hospital length of stay (2.2 vs 1.8 days, P < .008), increased rate of 30-day readmission (3.5% vs 1.1%, P = .036), increased 30-day reoperation (2.6% vs 0.4%, P = .007), extended length of stay (64% vs 49.9%, P = .004), wound complication (1.75% vs 0.11%, P = .002), and surgical site infection (2.6% vs 0.6%, P = .017). Multivariate logistic regression analysis found anemia to be significantly associated with extended hospital length of stay (odds ratio [OR], 1.62; 95% CI, 1.07-2.45; P = .023) and increased reoperation rates (OR, 5.47; 95% CI, 1.15-26.00; P = .033). Anemia was not found to be a predictor of increased readmission rates (OR, 3.13; 95% CI, 0.93-10.56; P = .066) or postoperative complications (OR, 1.27; 95% CI, 0.35-4.56; P = .71). CONCLUSION This study found increasing severity of anemia to be associated with extended hospital length of stay and increased reoperation rates. Providers and patients should be aware of the increased risks of total ankle arthroplasty with preoperative anemia. LEVEL OF EVIDENCE Level III, retrospective comparative study.
Collapse
Affiliation(s)
- Jordan R Pollock
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Matt K Doan
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - M Lane Moore
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | | | | | - David G Deckey
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Todd A Kile
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Karan A Patel
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| |
Collapse
|
35
|
Haglin JM, Arthur JR, Deckey DG, Moore ML, Makovicka JL, Spangehl MJ. A Comprehensive Monetary Analysis of Inpatient Total Hip and Knee Arthroplasties Billed to Medicare by Hospitals: 2011-2017. J Arthroplasty 2021; 36:S134-S140. [PMID: 33339635 DOI: 10.1016/j.arth.2020.11.035] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/16/2020] [Accepted: 11/24/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Total joint arthroplasty (TJA) has been a recent target of reimbursement reform. As such, the purpose of this study was to evaluate trends in Medicare reimbursement to hospitals for TJA patients from 2011 to 2017. METHODS The Inpatient Utilization and Payment Public Use File was queried for all primary total hip and knee arthroplasty episodes. This file includes all services billed to Medicare via the Inpatient Prospective Payment System. Extracted data included hospital charges and amount paid by Medicare. All data were adjusted for inflation to 2017 US dollars. Multiple linear mixed-model regression analyses were conducted to assess change over time, and geo-modelling was used to represent reimbursement by location. RESULTS A total of 3,368,924 primary TJA procedures were billed to Medicare by hospitals from 2011 to 2017 and included in the study. The mean inflation-adjusted Medicare payment to hospitals for DRG 469 decreased from $22,783.66 to $19,604.62 per procedure (-$3179.04; -14.0%; P < .001) and decreased from $13,290.79 to $11,771.54 for DRG 470 (-$1519.25; -11.4%, P = .011) from 2011 to 2017. Meanwhile, the mean charge submitted by hospitals increased by $6483.39 and $5115.60 for DRGs 469 and 470, respectively (+7.4% for 469, +9.3% for 470; P < .001). Medicare reimbursement to hospitals varied by state. CONCLUSION During the study period, the mean Medicare reimbursement to hospitals decreased for TJA from 2011 to 2017. Meanwhile, the average charge submitted by hospitals increased. As alternative payment models continue to undergo evaluation and development, these data are important for the advancement of more agreeable reimbursement models in arthroplasty care.
Collapse
Affiliation(s)
- Jack M Haglin
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ
| | | | - David G Deckey
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ
| | - Michael L Moore
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ
| | | | | |
Collapse
|
36
|
Haglin JM, Arthur JR, Deckey DG, Makovicka JL, Pollock JR, Spangehl MJ. Temporal Analysis of Medicare Physician Reimbursement and Procedural Volume for all Hip and Knee Arthroplasty Procedures Billed to Medicare Part B From 2000 to 2019. J Arthroplasty 2021; 36:S121-S127. [PMID: 33637380 DOI: 10.1016/j.arth.2021.02.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [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: 12/05/2020] [Revised: 01/24/2021] [Accepted: 02/02/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The purpose of this study was to evaluate trends in annual arthroplasty volume among the Medicare population, as well as assess true Medicare reimbursement to physicians for all hip and knee arthroplasty procedures billed to Medicare since year 2000. METHODS The publicly available Medicare Part B National Summary Data File from years 2000 to 2019 was utilized. Collected data included true physician reimbursements for all primary total hip and knee, unicompartmental knee, and revision hip/knee arthroplasty procedures from 2000 to 2019. Monetary data was adjusted for inflation to year 2019 dollars. Change was assessed and compared by procedure type. RESULTS From 2000 to 2019, physicians billed Medicare Fee-for-service for 8,363,821 hip and knee arthroplasty procedures. During this time, the annual number of included arthroplasty procedures billed to Medicare increased by 100%. From 2000 to 2019 across all included procedures, the mean physician reimbursement after adjusting for inflation decreased by -$729.82 (-38.9%) per procedure. This varied by procedure type. Unicompartmental knee arthroplasty was the only procedure to experience an increased mean reimbursement when adjusting for inflation, increasing by $241.40 (+16.6%) per procedure from 2000 to 2019. CONCLUSION This study demonstrates decreasing Medicare reimbursement to physicians within hip and knee arthroplasty from 2000 to 2019 when adjusting for inflation. This study is important for informing the potential development of more equitable payment models and maintaining access for arthroplasty care moving forward.
Collapse
Affiliation(s)
- Jack M Haglin
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ
| | | | - David G Deckey
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ
| | | | - Jordan R Pollock
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ
| | | |
Collapse
|
37
|
Christopher ZK, McQuivey KS, Deckey DG, Haglin J, Spangehl MJ, Bingham JS. Acute or chronic periprosthetic joint infection? Using the ESR ∕ CRP ratio to aid in determining the acuity of periprosthetic joint infections. J Bone Jt Infect 2021; 6:229-234. [PMID: 34159047 PMCID: PMC8209584 DOI: 10.5194/jbji-6-229-2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 05/31/2021] [Indexed: 01/15/2023] Open
Abstract
Introduction: The gold standard for determining the duration of periprosthetic joint infection (PJI) is a thorough history. Currently, there are no well-defined objective criteria to determine the duration of PJI, and little evidence exists regarding the ratio between ESR (mm/h) and CRP (mg/L) in joint arthroplasty. This study suggests the ESR / CRP ratio will help differentiate acute from chronic PJI. Methods: Retrospective review of patients with PJI was performed. Inclusion criteria: patients > 18 years old who underwent surgical revision for PJI and had documented ESR and CRP values. Subjects were divided into two groups: PJI for greater (chronic) or less than (acute) 4 weeks and the ESR / CRP ratio was compared between them. Receiver-operating characteristic (ROC) curves were evaluated to determine the utility of the ESR / CRP ratio in characterizing the duration of PJI. Results: 147 patients were included in the study (81 acute and 66 chronic). The mean ESR / CRP ratio in acute patients was 0.48 compared to 2.87 in chronic patients ( p < 0.001 ). The ESR / CRP ROC curve demonstrated an excellent area under the curve (AUC) of 0.899. The ideal cutoff value was 0.96 for ESR / CRP to predict a chronic ( > 0.96 ) vs. acute ( < 0.96 ) PJI. The sensitivity at this value was 0.74 (95 % CI 0.62-0.83) and the specificity was 0.90 (95 % CI 0.81-0.94). Conclusions: The ESR / CRP ratio may help determine the duration of PJI in uncertain cases. This metric may give arthroplasty surgeons more confidence in defining the duration of the PJI and therefore aid in treatment selection.
Collapse
Affiliation(s)
| | - Kade S McQuivey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - David G Deckey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Jack Haglin
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Mark J Spangehl
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Joshua S Bingham
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| |
Collapse
|
38
|
Deckey DG, Rosenow CS, Verhey JT, Brinkman JC, Mayfield CK, Clarke HD, Bingham JS. Robotic-assisted total knee arthroplasty improves accuracy and precision compared to conventional techniques. Bone Joint J 2021; 103-B:74-80. [PMID: 34053292 DOI: 10.1302/0301-620x.103b6.bjj-2020-2003.r1] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [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] [Indexed: 12/15/2022]
Abstract
AIMS Robotic-assisted total knee arthroplasty (RA-TKA) is theoretically more accurate for component positioning than TKA performed with mechanical instruments (M-TKA). Furthermore, the ability to incorporate soft-tissue laxity data into the plan prior to bone resection should reduce variability between the planned polyethylene thickness and the final implanted polyethylene. The purpose of this study was to compare accuracy to plan for component positioning and precision, as demonstrated by deviation from plan for polyethylene insert thickness in measured-resection RA-TKA versus M-TKA. METHODS A total of 220 consecutive primary TKAs between May 2016 and November 2018, performed by a single surgeon, were reviewed. Planned coronal plane component alignment and overall limb alignment were all 0° to the mechanical axis; tibial posterior slope was 2°; and polyethylene thickness was 9 mm. For RA-TKA, individual component position was adjusted to assist gap-balancing but planned coronal plane alignment for the femoral and tibial components and overall limb alignment remained 0 ± 3°; planned tibial posterior slope was 1.5°. Mean deviations from plan for each parameter were compared between groups for positioning and size and outliers were assessed. RESULTS In all, 103 M-TKAs and 96 RA-TKAs were included. In RA-TKA versus M-TKA, respectively: mean femoral positioning (0.9° (SD 1.2°) vs 1.7° (SD 1.1°)), mean tibial positioning (0.3° (SD 0.9°) vs 1.3° (SD 1.0°)), mean posterior tibial slope (-0.3° (SD 1.3°) vs 1.7° (SD 1.1°)), and mean mechanical axis limb alignment (1.0° (SD 1.7°) vs 2.7° (SD 1.9°)) all deviated significantly less from the plan (all p < 0.001); significantly fewer knees required a distal femoral recut (10 (10%) vs 22 (22%), p = 0.033); and deviation from planned polyethylene thickness was significantly less (1.4 mm (SD 1.6) vs 2.7 mm (SD 2.2), p < 0.001). CONCLUSION RA-TKA is significantly more accurate and precise in planning both component positioning and final polyethylene insert thickness. Future studies should investigate whether this increased accuracy and precision has an impact on clinical outcomes. The greater accuracy and reproducibility of RA-TKA may be important as precise new goals for component positioning are developed and can be further individualized to the patient. Cite this article: Bone Joint J 2021;103-B(6 Supple A):74-80.
Collapse
Affiliation(s)
- David G Deckey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | | | - Jens T Verhey
- Alix School of Medicine, Mayo Medical School, Scottsdale, Arizona, USA
| | - Joseph C Brinkman
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Cory K Mayfield
- Department of Orthopedics, University of Southern California, Los Angeles, California, USA
| | - Henry D Clarke
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA.,Alix School of Medicine, Mayo Medical School, Scottsdale, Arizona, USA
| | - Joshua S Bingham
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA.,Alix School of Medicine, Mayo Medical School, Scottsdale, Arizona, USA
| |
Collapse
|
39
|
Deckey DG, Gulbrandsen MT, Hinckley NB, Lara N, Mayfield CK, Makovicka JL, Adeniyi B, Chang MS. Does Laterality Matter? The Effect of Unilateral v. Bilateral Sacroiliac Screw Fixation on Personal Hygiene. Global Spine J 2021; 13:1036-1041. [PMID: 34000853 DOI: 10.1177/21925682211015675] [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] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective comparative analysis of prospective cohort. OBJECTIVE To determine whether sacroiliac (SI) screw fixation ipsilateral to hand dominance compared to bilateral fixation impacts personal hygiene (wiping) after toileting. METHODS Inclusion criteria were adult spinal deformity (ASD) patients with long arthrodesis (≥T12-pelvis) who had undergone primary unilateral or bilateral SI fixation with a minimum of 2-years-follow-up. RESULTS 117 consecutive patients were included and separated into 2 groups: bilateral SI fixation (BL, n = 61) and unilateral SI fixation (UNI, n = 56), with no difference in age. Of UNI patients, 10.7% (6) performed personal hygiene with a different hand after surgery, compared to 6.6% (4) of patients who received BL fixation (P = 0.422). All UNI patients who switched hands were right-hand dominant, and 5/6 received right-sided fixation. There was no statistical difference found between number of levels fused (<8, 9-11, or >11 levels) and changes in personal hygiene habits. Over a third of patients from both groups had difficulty performing personal hygiene after fusion (UNI = 39.3% BL = 36.1%, P = 0.719). CONCLUSION SI screws increase the difficulty of performing personal hygiene; yet, the side of unilateral screws does not significantly change personal hygiene habits when compared to bilateral screw placement. Moreover, the length of the construct does not have a significant impact on ability to perform personal hygiene, cause changes in habits, or require the assistance of another individual. However, among our sample of individuals, bilateral fixation did result in a higher rate of revision instrumentation.
Collapse
Affiliation(s)
- David G Deckey
- 23387Mayo Clinic Arizona, Department of Orthopaedic Surgery; Phoenix, AZ, USA
| | | | | | - Nina Lara
- 23387Mayo Clinic Arizona, Department of Orthopaedic Surgery; Phoenix, AZ, USA
| | - Cory K Mayfield
- Keck School of Medicine, 5116University of Southern California; Los Angeles, CA, USA
| | - Justin L Makovicka
- 23387Mayo Clinic Arizona, Department of Orthopaedic Surgery; Phoenix, AZ, USA
| | | | - Michael S Chang
- 23387Mayo Clinic Arizona, Department of Orthopaedic Surgery; Phoenix, AZ, USA.,Sonoran Spine Center; Tempe, AZ, USA
| |
Collapse
|
40
|
Lovato ZR, Deckey DG, Chung AS, Crandall DG, Revella J, Chang MS. Adult spine deformity surgery in elderly patients: are outcomes worse in patients 75 years and older? Spine Deform 2020; 8:1353-1359. [PMID: 32696446 DOI: 10.1007/s43390-020-00169-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 01/06/2020] [Accepted: 07/13/2020] [Indexed: 10/23/2022]
Abstract
STUDY DESIGN Retrospective study of a prospectively collected database at one center. OBJECTIVES Assess the outcomes and complications of adult spinal deformity (ASD) surgery in patients that are 75 years and older compared with patients of 65-75 years of age. With increasing amounts of ASD surgery being performed on elderly patients, it is important to assess how age plays a factor in corrective reconstruction surgery. METHODS Inclusion criteria for the study were all patients ≥ 65 years of age that underwent thoracolumbar deformity correction involving ≥ four levels at a single institution by two surgeons. Patients were divided based on age into 65-74.9 or ≥ 75 groups. Radiographic parameters were measured preoperatively, postoperatively, and at 2 years. The Numeric Rating Scale (NRS) and Oswestry Disability Index (ODI) were collected preoperatively, at 1 year, and 2 years. Comorbidities included were based around the Charlson Comorbidity Index (CCI) and compared to the incidence of complications and need for further surgery. RESULTS Both age groups had improvements in their radiographic parameters postoperatively which was maintained at 2 years. Comparing the different age groups with similar comorbidity burden in regard to complications and need for additional surgery yielded no statistically significant difference between groups. Both groups had comparable decreases in NRS and increases in ODI at 2 years. CONCLUSIONS Analysis of our study population indicates that there is no difference between the outcomes and complications of deformity surgery in patients 75 years and older when compared to a younger elderly population. It also does not appear that a ≥ 3 comorbidity burden has a significant impact on the complications or need for additional surgery in our elderly spinal deformity surgery population. LEVEL OF EVIDENCE Level IV.
Collapse
Affiliation(s)
- Zachary R Lovato
- Sonoran Spine Center, 1255 W Rio Salado Parkway, Suite 107, Tempe, Arizona, USA.,Sonoran Spine Research and Education Foundation, 1255 W Rio Salado Parkway, Tempe, Arizona, USA
| | - David G Deckey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, Arizona, USA.
| | - Andrew S Chung
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, Arizona, USA
| | - Dennis G Crandall
- Sonoran Spine Center, 1255 W Rio Salado Parkway, Suite 107, Tempe, Arizona, USA.,Sonoran Spine Research and Education Foundation, 1255 W Rio Salado Parkway, Tempe, Arizona, USA.,Department of Orthopaedic Surgery, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, Arizona, USA.,University of Arizona College of Medicine, 475 N 5th St, Phoenix, Arizona, USA
| | - Jan Revella
- Sonoran Spine Research and Education Foundation, 1255 W Rio Salado Parkway, Tempe, Arizona, USA
| | - Michael S Chang
- Sonoran Spine Center, 1255 W Rio Salado Parkway, Suite 107, Tempe, Arizona, USA.,Sonoran Spine Research and Education Foundation, 1255 W Rio Salado Parkway, Tempe, Arizona, USA.,Department of Orthopaedic Surgery, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, Arizona, USA.,University of Arizona College of Medicine, 475 N 5th St, Phoenix, Arizona, USA
| |
Collapse
|
41
|
Deckey DG, Scott KL, Hinckley NB, Makovicka JL, Hassebrock JD, Tummala SV, Pena A, Asprey W, Chhabra A. Hand and Wrist Injuries in Men's and Women's National Collegiate Athletic Association Basketball. Orthop J Sports Med 2020; 8:2325967120953070. [PMID: 33062767 PMCID: PMC7536375 DOI: 10.1177/2325967120953070] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/22/2020] [Indexed: 11/25/2022] Open
Abstract
Background: Hand and wrist injuries (HWIs) are common in National Collegiate Athletic
Association (NCAA) basketball players and can negatively affect performance.
There is limited literature available on this topic. Purpose: To open a discussion on prevention strategies and encourage future research
on HWIs in basketball athletes. Study Design: Descriptive epidemiology study. Methods: HWIs sustained by male and female NCAA basketball players during the
2009-2010 through 2013-2014 academic years and reported to the NCAA Injury
Surveillance Program (NCAA-ISP) database were utilized to characterize the
epidemiology thereof. Rates and distributions of HWIs were identified within
the context of mechanism of injury, injury recurrence, and time lost from
sport. Results: Over the 5-year period, 81 HWIs in women and 171 HWIs in men were identified
through the NCAA-ISP database. These were used to estimate 3515 HWIs
nationally in women’s basketball athletes and 7574 HWIs nationally in men’s
basketball athletes. The rate of HWIs in women was 4.20 per 10,000
athlete-exposures (AEs) and in men was 7.76 per 10,000 AEs, making men 1.85
times more likely to sustain HWIs compared with women. In men, HWIs were
3.31 times more likely to occur in competition compared with practice, while
in women, HWIs were 2.40 times more likely to occur in competition than in
practice. Based on position, guards, both men and women, were the most
likely to suffer HWIs. Conclusion: HWIs were common in collegiate basketball players. Most injuries were new,
and the majority of players were restricted from participation for less than
24 hours. Men were more likely to be injured compared with women, and
injuries were most common in the setting of competition for both sexes. The
majority of injuries was considered minor and did not extensively limit
participation; however, prevention and detection remain important for
optimal performance.
Collapse
Affiliation(s)
- David G Deckey
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Kelly L Scott
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | | | | | | | - Sailesh V Tummala
- John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Austin Pena
- Alix School of Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Walker Asprey
- Alix School of Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Anikar Chhabra
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| |
Collapse
|
42
|
Garcia D, Mayfield CK, Leong J, Deckey DG, Zega A, Glasser J, Daniels AH, Eberson C, Green A, Born C. Early adherence and biofilm formation of Cutibacterium acnes (formerly Propionibacterium acnes) on spinal implant materials. Spine J 2020; 20:981-987. [PMID: 31972305 DOI: 10.1016/j.spinee.2020.01.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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: 09/19/2019] [Revised: 01/08/2020] [Accepted: 01/09/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Cutibacterium acnes (C. acnes) is associated with infection following shoulder and spine surgery due to follicular pore concentrations in these anatomic regions. It has been established that it can form biofilms on surgical implant materials, which may contribute to its role in perioperative infection, but its behavior of early colonization on those materials is not yet well understood. PURPOSE The purpose of this study was to evaluate the time to adherence and subsequent biofilm formation of C. acnes in the first 24 hours on implant materials commonly used in spinal surgery. STUDY DESIGN We compared the colonization and behavior of C. acnes over time when applied to five commonly used spine implant materials - polyether ether ketone (PEEK), cobalt chromium (CC), stainless steel (SS), titanium, and titanium alloy. METHODS C. acnes was applied onto the samples of PEEK, CC, SS, titanium, and titanium alloy, and allowed to adhere for periods of 4, 8, 12, 16, and 20 hours. Nonadherent bacteria were then washed from the samples. These samples were then allowed to continue incubating for a total 24 hours. Scanning electron microscopy and confocal laser scanning microscopy were used to visualize all samples for the presence and quantification of C. acnes adherence at each time period. Subsequent transition to biofilm formation on these samples was assessed via scanning electron microscopy at each time period. RESULTS The PEEK specimens exhibited the highest amount of surface biological burden in the first 24 hours compared with the other materials, which displayed little or no adherence. Rapid biofilm formation first observed at 8 hours of allowed adhesion on PEEK, whereas no significant biofilm formation was seen on the other materials during the observed time period. CONCLUSIONS Although C. acnes is known to have a slow proliferation rate, the results of this investigation demonstrate that it can rapidly adhere to and form a biofilm on PEEK. These data suggest that the use of PEEK implants placed during spinal surgery may facilitate early intraoperative colonization, and subsequent infection, compared with metallic implants. CLINICAL SIGNIFICANCE The findings of this study suggest that PEEK may prove to be problematic as a choice of implant material in cases were C. acnes infection is a possibility.
Collapse
Affiliation(s)
- Dioscaris Garcia
- The Diane N. Weiss Center for Orthopedic Trauma Research, Rhode Island Hospital, Providence, RI 02906, USA.
| | - Cory K Mayfield
- The Diane N. Weiss Center for Orthopedic Trauma Research, Rhode Island Hospital, Providence, RI 02906, USA
| | - Jacqueline Leong
- The Diane N. Weiss Center for Orthopedic Trauma Research, Rhode Island Hospital, Providence, RI 02906, USA
| | - David G Deckey
- The Diane N. Weiss Center for Orthopedic Trauma Research, Rhode Island Hospital, Providence, RI 02906, USA
| | - Alexandra Zega
- The Diane N. Weiss Center for Orthopedic Trauma Research, Rhode Island Hospital, Providence, RI 02906, USA
| | - Jillian Glasser
- The Diane N. Weiss Center for Orthopedic Trauma Research, Rhode Island Hospital, Providence, RI 02906, USA
| | - Alan H Daniels
- The Diane N. Weiss Center for Orthopedic Trauma Research, Rhode Island Hospital, Providence, RI 02906, USA
| | - Craig Eberson
- The Diane N. Weiss Center for Orthopedic Trauma Research, Rhode Island Hospital, Providence, RI 02906, USA
| | - Andrew Green
- The Diane N. Weiss Center for Orthopedic Trauma Research, Rhode Island Hospital, Providence, RI 02906, USA
| | - Christopher Born
- The Diane N. Weiss Center for Orthopedic Trauma Research, Rhode Island Hospital, Providence, RI 02906, USA
| |
Collapse
|
43
|
Hassebrock JD, Makovicka JL, Wong M, Patel KA, Scott KL, Deckey DG, Chhabra A. Minimally Invasive Robotic-Assisted Patellofemoral Arthroplasty. Arthrosc Tech 2020; 9:e425-e433. [PMID: 32368460 PMCID: PMC7188930 DOI: 10.1016/j.eats.2019.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 11/18/2019] [Indexed: 02/03/2023] Open
Abstract
Isolated patellofemoral arthritis is a common debilitating condition in adults older than 40 years of age. Surgical options such as patellofemoral arthroplasty exist for those who failed to respond to nonoperative treatment. However, early patellofemoral arthroplasty techniques often resulted in poor outcomes due to mal-tracking and malalignment of components. Robotic-assisted surgery recently has been introduced as an alternative to classic patellofemoral arthroplasty, with the potential to improve the anatomical fit and reproducibility of implant positioning. We present the technique for minimally invasive robotic-assisted patellofemoral arthroplasty system.
Collapse
Affiliation(s)
| | | | - Michael Wong
- Department of Orthopedic Surgery, Ochsner Clinical School, New Orleans, Louisiana, U.S.A
| | - Karan A. Patel
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Kelly L. Scott
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - David G. Deckey
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Anikar Chhabra
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona,Address correspondence to Dr. Anikar Chhabra, Department of Orthopedic Surgery, Mayo Clinic Arizona, 5777 East Mayo Blvd., Phoenix, AZ 85054.
| |
Collapse
|
44
|
Ralston B, Arthur J, Makovicka JL, Hassebrock J, Tummala S, Deckey DG, Patel K, Chhabra A, Hartigan D. Hip and Groin Injuries in National Collegiate Athletic Association Women's Soccer Players. Orthop J Sports Med 2020; 8:2325967119892320. [PMID: 32030343 PMCID: PMC6977238 DOI: 10.1177/2325967119892320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 08/27/2019] [Accepted: 09/03/2019] [Indexed: 11/25/2022] Open
Abstract
Background: Hip and groin injuries are common in competitive soccer players and have been shown to be significant sources of time loss. There are few studies describing the epidemiology of hip and groin injuries in female National Collegiate Athletic Association (NCAA) soccer players. Purpose: To describe the epidemiology of hip and groin injuries in women’s collegiate soccer players. Study Design: Descriptive epidemiology study. Methods: The NCAA Injury Surveillance System/Program (ISS/ISP) was analyzed from 2004 through 2014 for data related to hip and groin injuries in female collegiate soccer players. Injuries and athlete-exposures (AEs) were reported by athletic trainers. Data were stratified by time of season, event type, injury type, treatment outcome, time loss, and player field position. Results: Between 2004 and 2014, there were 439 recorded hip or groin injuries in female soccer players and an overall rate of injury of 0.57 per 1000 AEs. Injuries were 12.0 times more likely to occur during the preseason (4.41/1000 AEs) as opposed to during the regular season (0.37/1000 AEs) (injury rate ratio [IRR], 12.01; 95% confidence interval [CI], 9.92-14.55) or postseason (0.38/1000 AEs) (IRR, 11.55; 95% CI, 7.06-18.91). Rates of injury were similar during the regular season and postseason (IRR, 0.96; 95% CI, 0.59-1.58). Rates of injury were higher during competition (0.69/1000 AEs) than during practice (0.52/1000 AEs) (IRR, 1.33; 95% CI, 1.08-1.63). Most injuries were new (87.5%; n = 384) and unlikely to recur (12.5%; n = 55). Conclusion: Hip and groin injuries in female NCAA soccer players are uncommon, and fortunately, most players return to play quickly without recurrence. Future prospective studies should evaluate the effectiveness of strength and conditioning programs in preventing these injuries.
Collapse
Affiliation(s)
- Bridget Ralston
- University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Jaymeson Arthur
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | | | - Jeff Hassebrock
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Sailesh Tummala
- John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - David G Deckey
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Karan Patel
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Anikar Chhabra
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - David Hartigan
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| |
Collapse
|
45
|
Makovicka JL, Chung AS, Patel KA, Deckey DG, Hassebrock JD, Tokish JM. Superior capsule reconstruction for irreparable rotator cuff tears: a systematic review of biomechanical and clinical outcomes by graft type. J Shoulder Elbow Surg 2020; 29:392-401. [PMID: 31522915 DOI: 10.1016/j.jse.2019.07.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [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: 04/14/2019] [Revised: 06/25/2019] [Accepted: 07/01/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Superior capsular reconstruction (SCR) has recently been proposed as a surgical solution to the irreparable rotator cuff tear and has gained popularity because of promising early results. Therefore, the purpose of this study is to review the biomechanical and clinical outcomes in shoulders with this condition treated with SCR. METHODS A systematic review was conducted following PRISMA guidelines using PubMed, EMBASE, and Cochrane databases. Studies were included if they reported biomechanical, radiographic, or clinical outcomes data after undergoing SCR in shoulders with irreparable rotator cuff tears. Studies were broken down into 3 categories: cadaveric biomechanical studies, autograft clinical outcome studies, and allograft clinical outcome studies. Biomechanical, radiographic, patient-reported, and functional outcomes data were recorded for each study. RESULTS Eight cadaveric biomechanical studies, 5 autograft clinical studies, and 4 allograft clinical studies met inclusion criteria. In biomechanical studies, subacromial contact pressure and superior humeral translation were decreased in most tested scenarios. An increase in American Shoulder and Elbow Surgeons (ASES) scores, forward elevation and external rotation values, and acromiohumeral distance (AHD) were found in all autograft clinical studies reporting. Allograft clinical studies reported increases in ASES scores, forward elevation values, and AHD but decreases in visual analog scale scores in all studies reporting. CONCLUSIONS SCR is emerging as a viable surgical option to address the irreparable rotator cuff tear. Biomechanical studies suggest that the humeral head-stabilizing effect of SCR appears to translate into improved clinical outcomes. Future research should focus on further defining the indications, limitations, and optimal technique.
Collapse
Affiliation(s)
| | - Andrew S Chung
- Department of Orthopedics, Mayo Clinic, Phoenix, AZ, USA
| | - Karan A Patel
- Department of Orthopedics, Mayo Clinic, Phoenix, AZ, USA
| | - David G Deckey
- Department of Orthopedics, Mayo Clinic, Phoenix, AZ, USA
| | | | - John M Tokish
- Department of Orthopedics, Mayo Clinic, Phoenix, AZ, USA.
| |
Collapse
|
46
|
Hresko MT, Deckey DG, Hinchcliff E, Kalish LA. Comparative Sacral Morphology in Spondylolisthesis Patients. Spine Deform 2019; 7:945-949. [PMID: 31732006 DOI: 10.1016/j.jspd.2019.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 03/22/2018] [Revised: 03/25/2019] [Accepted: 03/31/2019] [Indexed: 11/17/2022]
Abstract
STUDY DESIGN Retrospective comparative case series. OBJECTIVES Evaluation of sacral morphology in spondylolisthesis patients compared with asymptomatic controls. SUMMARY OF BACKGROUND DATA Patients with spondylolisthesis are known to differ from asymptomatic controls in sagittal plane anatomy, but few studies examine the coronal and axial plane differences in these cohorts. METHODS This is a retrospective evaluation of magnetic resonance imaging of the lumbosacral spine in 29 spondylolisthesis patients and an asymptomatic cohort (n = 154). Measurements of the linear distance and angular position of L5 and sacrum were performed in the sagittal, coronal, and axial planes. Receiver operating characteristic (ROC) curve analysis quantified these associations. High- and low-grade spondylolisthesis patients were compared with two-sample t-tests. All p-values are two-sided and considered significant when p < .05. RESULTS Axial measurements showed the distance of the right to left anterior ala and the L5 body width did not differ between the cohorts. Sacroiliac (SI) joint angles in the spondylolisthesis cohort were closer to the true sagittal plane than in the controls 109° versus 121° (p < .001). In the sagittal plane, the linear measurement of the ratio of the midpoint anteroposterior width L5 to the sacral end plate was larger in the high-grade patients than the low-grade patients and controls. In addition, the kyphosis between S1-S2 and S2-S3 was larger in the spondylolisthesis cohort. CONCLUSIONS The SI joints in patients with spondylolisthesis were orientated closer to the sagittal plane than in the controls. An awareness of this positioning may be important in surgical implant insertion as well as rehabilitation of hip extensor weakness. The main anatomical differences found in this study were in the sagittal plane. Sacral end plate abnormalities were well visualized and consistent with radiographic findings in the literature. LEVEL OF EVIDENCE Level III, diagnostic.
Collapse
Affiliation(s)
- M Timothy Hresko
- Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - David G Deckey
- Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA; Tufts Medical School, 145 Harrison Avenue, Boston, MA 02111, USA
| | - Emily Hinchcliff
- MD Anderson Hospital, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Leslie A Kalish
- Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA; Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| |
Collapse
|
47
|
Makovicka JL, Deckey DG, Patel KA, Hassebrock JD, Chung AS, Tummala SV, Hydrick TC, Pena A, Chhabra A. Epidemiology of Lumbar Spine Injuries in Men's and Women's National Collegiate Athletic Association Basketball Athletes. Orthop J Sports Med 2019; 7:2325967119879104. [PMID: 31700939 PMCID: PMC6823986 DOI: 10.1177/2325967119879104] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: Lumbar spine injuries (LSIs) are common in both men’s and women’s National Collegiate Athletic Association (NCAA) basketball players and can frequently lead to reinjuries and persistent pain. Purpose: To describe the epidemiology of an LSI in collegiate men’s and women’s basketball during the 2009-2010 through 2013-2014 academic years. Study Design: Descriptive epidemiology study. Methods: The incidence and characteristics of LSIs were identified utilizing the NCAA Injury Surveillance Program (ISP). Rates of injury were calculated as the number of injuries divided by the total number of athlete-exposures (AEs). AEs were defined as any student participation in 1 NCAA-sanctioned practice or competition. Incidence rate ratios (IRRs) were then calculated to compare the rates of injury between season, event type, mechanism, injury recurrence, and time lost from sport. Results: The NCAA ISP reported 124 LSIs from an average of 28 and 29 men’s and women’s teams, respectively. These were used via validated weighting methodology to estimate a total of 5197 LSIs nationally. The rate of LSIs in women was 2.16 per 10,000 AEs, while men suffered LSIs at a rate of 3.47 per 10,000 AEs. Men were 1.61 times more likely to suffer an LSI compared with women. In men, an LSI was 3.48 times more likely to occur in competition when compared with practice, while in women, an LSI was 1.36 times more likely to occur in competition than in practice. Women suffered the highest LSI rate during the postseason, while the highest rate in men was during the regular season. The majority of both female (58.9%; n = 1004) and male (73.1%; n = 2353) athletes returned to play within 24 hours of injury. Conclusion: To date, this is the largest study to characterize LSIs in NCAA basketball and provides needed information on the prevalence and timing of these injuries. The majority of injuries in both sexes were new, and most athletes returned to play in less than 24 hours. Injury rates were highest during competition in both sexes.
Collapse
Affiliation(s)
| | - David G Deckey
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Karan A Patel
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | | | - Andrew S Chung
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Sailesh V Tummala
- John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | | | - Austin Pena
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona, USA
| | - Anikar Chhabra
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| |
Collapse
|
48
|
Christopher ZK, Deckey DG, Chung AS, Spangehl MJ. Patellar osteolysis after total knee arthroplasty with patellar resurfacing: a potentially underappreciated problem. Arthroplast Today 2019; 5:435-441. [PMID: 31886386 PMCID: PMC6921183 DOI: 10.1016/j.artd.2019.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 02/21/2019] [Revised: 09/02/2019] [Accepted: 09/17/2019] [Indexed: 11/30/2022] Open
Abstract
Osteolysis of the patella following total knee arthroplasty is both uncommon and poorly described in the literature. We describe 3 cases of total knee arthroplasty with patella resurfacing that later presented with anterior knee pain with patellar osteolysis without evidence of patellar implant failure: 2 males and 1 female patient, all with bilateral knee osteoarthritis. Osteolysis of the patella was identified radiographically between 2 and 16 years from the index procedure. We theorize that high pressures across the patella-femoral joint, in obese or muscular patients, may play a role in the formation of these patellar osteolytic lesions. We suspect that the prevalence of this phenomenon is under-recognized in the literature and may increase with longer term follow-up and awareness.
Collapse
Affiliation(s)
| | | | | | - Mark J. Spangehl
- Corresponding author. Department of Orthopedics, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ 85054, USA. Tel.: +1 480 342 6202.
| |
Collapse
|
49
|
Makovicka JL, Patel KA, Deckey DG, Hassebrock JD, Chung AS, Tummala SV, Hydrick TC, Gulbrandsen M, Hartigan DE, Chhabra A. Lower Back Injuries in National Collegiate Athletic Association Football Players: A 5-Season Epidemiological Study. Orthop J Sports Med 2019; 7:2325967119852625. [PMID: 31245431 PMCID: PMC6582304 DOI: 10.1177/2325967119852625] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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] [Indexed: 11/17/2022] Open
Abstract
Background: Low back injuries are common in collegiate football players and can frequently lead to persistent pain, reinjuries, and time lost from participation. Purpose: To describe the epidemiology of back injuries in National Collegiate Athletic Association (NCAA) football players during the 2009/2010 through 2013/2014 academic years utilizing the NCAA Injury Surveillance Program (ISP) database. Study Design: Descriptive epidemiology study. Methods: A convenience sample of NCAA varsity football teams was utilized to determine the rates and patterns of back injuries as well as to generate national injury estimates. The rates and distribution of back injuries were identified within the context of mechanism of injury, injury chronicity, and time lost from sport. Injury rates were calculated as the number of injuries divided by the total number of athlete-exposures (AEs). Incidence rate ratios were calculated to compare the rates of injury between season, event type, mechanism of injury, injury chronicity, and time lost from sport. Results: Nationally, there were 267 low back injuries reported in the database. These were used to estimate 7076 back injuries over the 5-year period, approximately 82% of which were new injuries. The injuries occurred at a rate of 2.70 per 10,000 AEs. Overall, injuries were 3.12 times more likely to occur in competitions than in practices. Athletes were 4.67 times more likely to sustain a back injury during the preseason compared with the postseason but were 1.41 times more likely to sustain a low back injury during the preseason compared with the regular season. Both contact and noncontact were reported equally as the mechanism of injury (37.8% and 38.3%, respectively), and unspecified low back pain was the most common injury (64.2%). Only 1.6% of patients required surgery for their injury, and the majority of athletes (59.6%) returned to play within 24 hours. Conclusion: There was a relatively high rate of lumbar back injuries at the collegiate level (2.70/10,000 AEs), the majority of which were new injuries. About 18% of reported injuries were reinjuries. Although very few required surgery, a careful examination and work-up should be conducted to evaluate each injury. Regimented physical therapy and reconditioning programs are recommended to avert reinjuries.
Collapse
Affiliation(s)
| | - Karan A Patel
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - David G Deckey
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | | | - Andrew S Chung
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Sailesh V Tummala
- John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | | | | | - David E Hartigan
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Anikar Chhabra
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| |
Collapse
|
50
|
Deckey DG, Eltorai AE, Jindal G, Daniels AH. Analysis of Malpractice Claims Involving Diagnostic and Interventional Neuroradiology. J Am Coll Radiol 2019; 16:764-769. [DOI: 10.1016/j.jacr.2018.10.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 10/16/2018] [Accepted: 10/25/2018] [Indexed: 01/10/2023]
|