Microfracture: surgical technique and rehabilitation to treat chondral defects

Full-thickness articular cartilage defects rarely heal spontaneously. Some patients may not have clinically significant problems from chondral defects, but most eventually have degenerative changes. Techniques to treat chondral defects include abrasion, drilling, autografts, allografts, and cell transplantation. The senior author (JRS) developed the microfracture technique to enhance chondral resurfacing by providing a suitable environment for new tissue formation and taking advantage of the body's own healing potential. Microfracture has been done in more than 1800 patients. Specially designed awls are used to make multiple perforations, or microfractures, into the subchondral bone plate. Perforations are made as close together as possible, but not so close that one breaks into another. They usually are approximately 3 to 4 mm apart. The integrity of the subchondral bone plate must be maintained. The released marrow elements (including mesenchymal stem cells, growth factors, and other healing proteins) form a surgically induced super clot that provides an enriched environment for new tissue formation. The rehabilitation program is crucial to optimize the results of the surgery. It promotes the ideal physical environment for the marrow mesenchymal stem cells to differentiate into articular cartilagelike cells, ultimately leading to development of a durable repair cartilage that fills the original defect.

Review: mesenchymal stem cells: cell-based reconstructive therapy in orthopedics

Adult stem cells provide replacement and repair descendants for normal turnover or injured tissues. These cells have been isolated and expanded in culture, and their use for therapeutic strategies requires technologies not yet perfected. In the 1970s, the embryonic chick limb bud mesenchymal cell culture system provided data on the differentiation of cartilage, bone, and muscle. In the 1980s, we used this limb bud cell system as an assay for the purification of inductive factors in bone. In the 1990s, we used the expertise gained with embryonic mesenchymal progenitor cells in culture to develop the technology for isolating, expanding, and preserving the stem cell capacity of adult bone marrow-derived mesenchymal stem cells (MSCs). The 1990s brought us into the new field of tissue engineering, where we used MSCs with site-specific delivery vehicles to repair cartilage, bone, tendon, marrow stroma, muscle, and other connective tissues. In the beginning of the 21st century, we have made substantial advances: the most important is the development of a cell-coating technology, called painting, that allows us to introduce informational proteins to the outer surface of cells. These paints can serve as targeting addresses to specifically dock MSCs or other reparative cells to unique tissue addresses. The scientific and clinical challenge remains: to perfect cell-based tissue-engineering protocols to utilize the body's own rejuvenation capabilities by managing surgical implantations of scaffolds, bioactive factors, and reparative cells to regenerate damaged or diseased skeletal tissues.

Use of the National Surgical Quality Improvement Program in orthopaedic surgery

BACKGROUND

The goal of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) is to improve patient safety. The database has been used by hospitals across the United States to decrease the rate of adverse events and improve surgical outcomes, including dramatic decreases in 30-day mortality, morbidity, and complication rates. However, only a few orthopaedic surgical studies have employed the ACS NSQIP database, all of which have limited their analysis to either single orthopaedic procedures or reported rates of adverse events without considering the effect of patient characteristics and comorbidities.

QUESTION/PURPOSES

Our specific purposes included (1) investigating the most common orthopaedic procedures and 30-day adverse events, (2) analyzing the proportion of adverse events in the top 30 most frequently identified orthopaedic procedures, and (3) identifying patient characteristics and clinical risk factors for adverse events in patients undergoing hip fracture repair.

METHODS

We used data from the ACS NSQIP database to identify a large prospective cohort of patients undergoing orthopaedic surgery procedures from 2005 to 2011 in more than 400 hospitals around the world. Outcome variables were separated into the following three categories: any complication, minor complication, and major complication. The rate of adverse events for the top 30 orthopaedic procedures was calculated. Bivariate and multivariate analyses were used to determine risk factors for each of the outcome variables for hip fracture repair.

RESULTS

Of the 1,979,084 surgical patients identified in the database, 146,774 underwent orthopaedic procedures (7%). Of the 30 most common orthopaedic procedures, the top three were TKA, THA, and knee arthroscopy with meniscectomy, which together comprised 55% of patients (55,575 of 101,862). We identified 5368 complications within the top 30 orthopaedic procedures, representing a 5% complication rate. The minor and major complication rates were 3.1% (n = 3174) and 2.8% (n = 2880), respectively. The most common minor complication identified was urinary tract infection (n = 1534) and the most common major complication identified was death (n = 850). An American Society of Anesthesiologists class of 3 or higher was a consistent risk factor for all three categories of complications in patients undergoing hip fracture repair.

CONCLUSIONS

The ACS NSQIP database allows for evaluating current trends of adverse events in selected surgical specialties. However, variables specific to orthopaedic surgery, such as open versus closed injury, are needed to improve the quality of the results.

Injectable bone cements for use in vertebroplasty and kyphoplasty: State-of-the-art review

Vertebroplasty (VP) and kyphoplasty (KP) are minimally invasive surgical procedures that have recently been introduced for the medical management of osteoporosis-induced vertebral compression fractures. The aim of VP is to stabilize the fractured vertebral body, while the goals of KP are to stabilize the fractured vertebral body and to restore its height to as near its prefracture level as possible. Both procedures involve injection of the setting dough of an injectable bone cement (IBC) into the fractured vertebral body, thereby highlighting the indispensable role that the IBC plays. Although there is a very large literature on IBCs, no detailed critical review of it has been published. Such a review is the subject of the present work, which is in seven parts. The review opens with a succinct introduction to VP and KP. The topics covered in the parts that follow are: (1) a listing of the 18 most desirable properties of an IBC (e.g., easy injectability, high radiopacity, and a resorption rate that is neither too high nor too low); (2) descriptions of the four classes of IBCs (calcium phosphates, acrylic bone cements, calcium sulfates, and composites); (3) concerns that have been raised with regard to the use of IBCs (such as the potential for thermal necrosis of tissue at the peri-augmentation site, when an acrylic bone cement is used); (4) explicative summaries of the main findings of literature studies on the influence of nine factors (such as powder particle size, powder-to-liquid ratio, and the method used to mix the powder and the liquid) on the values of various properties of IBCs; (5) explicative summaries of the main findings of literature studies on five fundamental matters, such as the aging mechanism of the powder, the thermokinetics of a setting dough, and the influence of the type of IBC used on various ex vivo biomechanical performance measures of VP- and KP-augmented vertebral bodies; and (6) descriptions of topics in six areas for future research, such as the determination of an overall index of the fatigue performance of an IBC and the development of internationally recognized standardized testing protocols to employ when a synthetic cancellous bone void model is used in the rapid in vitro screening of IBCs. The review ends with a summary of the most salient points and observations made.

Evaluation and Referral for Developmental Dysplasia of the Hip in Infants

Developmental dysplasia of the hip (DDH) encompasses a wide spectrum of clinical severity, from mild developmental abnormalities to frank dislocation. Clinical hip instability occurs in 1% to 2% of full-term infants, and up to 15% have hip instability or hip immaturity detectable by imaging studies. Hip dysplasia is the most common cause of hip arthritis in women younger than 40 years and accounts for 5% to 10% of all total hip replacements in the United States. Newborn and periodic screening have been practiced for decades, because DDH is clinically silent during the first year of life, can be treated more effectively if detected early, and can have severe consequences if left untreated. However, screening programs and techniques are not uniform, and there is little evidence-based literature to support current practice, leading to controversy. Recent literature shows that many mild forms of DDH resolve without treatment, and there is a lack of agreement on ultrasonographic diagnostic criteria for DDH as a disease versus developmental variations. The American Academy of Pediatrics has not published any policy statements on DDH since its 2000 clinical practice guideline and accompanying technical report. Developments since then include a controversial US Preventive Services Task Force "inconclusive" determination regarding usefulness of DDH screening, several prospective studies supporting observation over treatment of minor ultrasonographic hip variations, and a recent evidence-based clinical practice guideline from the American Academy of Orthopaedic Surgeons on the detection and management of DDH in infants 0 to 6 months of age. The purpose of this clinical report was to provide literature-based updated direction for the clinician in screening and referral for DDH, with the primary goal of preventing and/or detecting a dislocated hip by 6 to 12 months of age in an otherwise healthy child, understanding that no screening program has eliminated late development or presentation of a dislocated hip and that the diagnosis and treatment of milder forms of hip dysplasia remain controversial.

Augmented Reality in Surgery

OBJECTIVE

To evaluate the history and current knowledge of computer-augmented reality in the field of surgery and its potential goals in education, surgeon training, and patient treatment.

DATA SOURCES

National Library of Medicine's database and additional library searches.

STUDY SELECTION

Only articles suited to surgical sciences with a well-defined aim of study, methodology, and precise description of outcome were included.

DATA SYNTHESIS

Augmented reality is an effective tool in executing surgical procedures requiring low-performance surgical dexterity; it remains a science determined mainly by stereotactic registration and ergonomics. Strong evidence was found that it is an effective teaching tool for training residents. Weaker evidence was found to suggest a significant influence on surgical outcome, both morbidity and mortality. No evidence of cost-effectiveness was found.

CONCLUSIONS

Augmented reality is a new approach in executing detailed surgical operations. Although its application is in a preliminary stage, further research is needed to evaluate its long-term clinical impact on patients, surgeons, and hospital administrators. Its widespread use and the universal transfer of such technology remains limited until there is a better understanding of registration and ergonomics.

Surgical rates after observation and bracing for adolescent idiopathic scoliosis: an evidence-based review

STUDY DESIGN

: Systematic review of clinical studies.

OBJECTIVES

: To develop a pooled estimate of the prevalence of surgery after observation and after brace treatment in patients with adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

: Critical analysis of the studies evaluating bracing in AIS yields limited evidence concerning the effect of TLSOs on curve progression, rate of surgery, and the burden of suffering associated with AIS. Many patients choose bracing without an evidence-based estimate of their risk of surgery relative to no treatment. Therefore, such an estimate is needed to promote informed decision-making.

METHODS

: Multiple electronic databases were searched using the key words "adolescent idiopathic scoliosis," "observation," "orthotics," "surgery," and "bracing." The search was limited to the English language. Studies were included if observation or a TLSO was evaluated and if the sample closely matched the current indications for bracing (skeletal immaturity, age <15 years, Cobb angle between 20 degrees and 45 degrees ). One reviewer (L.A.D) selected the articles and abstracted the data, including research design, type of brace, minimum follow-up, and surgical rate. Additional data concerning inclusion criteria and risk factors for surgery included gender, Risser, age and Cobb angle at brace initiation, curve type, and dose (hours of recommended brace wear).

RESULTS

: Eighteen studies were included (observation = 3, bracing = 15). All were Level III or IV clinical series. Despite some uniformity in surgical indications, the surgical rates were extremely variable, ranging from 1 surgery of 72 patients (1%) to 51 of 120 patients (43%) after bracing, and from 2 surgeries of 15 patients (13%) to 18 of 47 patients (28%) after observation. When pooled, the bracing surgical rate was 23% compared with 22% in the observation group. Pooled estimates for surgical rate by type of brace, curve type, Cobb angle, Risser sign, and dose were also calculated.

CONCLUSION

: Comparing the pooled rates for these two interventions shows no clear advantage of either approach. Based on the evidence presented here, one cannot recommend one approach over the other to prevent the need for surgery in AIS. This recommendation carries a grade of D, indicating that the use of bracing relative to observation is supported by "troublingly inconsistent or inconclusive studies of any level." The decision to brace for AIS is often difficult for clinicians and families. An evidence-based estimate of the risk of surgery will provide additional information to use as they weigh the costs and benefits of bracing.

Commercially available extracellular matrix materials for rotator cuff repairs: state of the art and future trends

Rotator cuff tears, a common source of shoulder pathology, are often the cause of debilitating shoulder pain, reduced shoulder function and compromised joint mechanics. The treatment, evaluation and management of this disease puts an annual financial burden of 3 billion US dollars on the US economy. Despite surgical advances, there is a high rate of recurrent tears ranging (20-70%) after surgical repair, particularly for chronic, large to massive cuff tears. The inability to obtain a high healing rate in these tears has fueled investigation in the use of extracellular matrix (ECM) derived materials as a scaffolds for rotator cuff tendon repair and regeneration. The present paper reviews the current state of knowledge regarding the mechanical and biological characteristics of commercially available ECM materials, delineates indications for their clinical use and suggests future directions in developing ECM scaffolds for rotator cuff repair.

SARS-CoV-2 Impact on Elective Orthopaedic Surgery: Implications for Post-Pandemic Recovery

BACKGROUND

The aim of our study was to explore the impact of elective-surgery deferment on the United States health-care system and subsequent recovery after COVID-19 containment. Using an orthopaedic elective surgery model, we aimed to answer the following: (1) What is the expected recovery time until the health-care system is back to nearly full capacity for performing elective surgery? (2) What will be the expected backlog of elective surgery over time? (3) How should health care change to address the backlog?

METHODS

A Monte Carlo stochastic simulation-based analysis was performed to forecast the post-pandemic volume of elective, inpatient total joint arthroplasty and spinal fusion surgical cases. The cumulative backlog was calculated and analyzed. We tested model assumptions with sensitivity analyses.

RESULTS

Assuming that elective orthopaedic surgery resumes in June 2020, it will take 7, 12, and 16 months-in optimistic, ambivalent, and pessimistic scenarios, respectively-until the health-care system can perform 90% of the expected pre-pandemic forecasted volume of surgery. In the optimistic scenario, there will be a cumulative backlog of >1 million surgical cases at 2 years after the end of elective-surgery deferment.

CONCLUSIONS

The deferment of elective surgical cases during the SARS-CoV-2 pandemic will have a lasting impact on the United States health-care system. As part of disaster mitigation, it is critical to start planning for recovery now.

Intervertebral disc arthroplasty

STUDY DESIGN

Review article of current knowledge of disc arthroplasty.

OBJECTIVES

To review the rationale for disc replacement, the general principles of design, and early clinical results.

SUMMARY OF BACKGROUND DATA

Disc arthroplasty is an emerging treatment for patients with disc degeneration. Its theoretical advantages are to maintain motion, decrease the incidence of adjacent segment degeneration, avoid complications related to fusion, and allow early return to function.

METHODS

Literature review of currently implanted prostheses or those undergoing investigation.

RESULTS

At this time, the theoretical advantages are unproven clinically but have been confirmed in biomechanical and kinematic investigations. Multicenter studies of both cervical and lumbar prostheses have shown short-term results equivalent to fusion. Neurologic complications and failures have been rare. Prosthetic subsidence and long-term wear will most likely be potential failure mechanisms. Thus far, with the exception of nucleoplasty, these problems have not been observed.

CONCLUSIONS

The early results are satisfactory, but the basic premise that motion preservation will diminish adjacent segment degeneration is yet unproven. Long-term results are unavailable and failure modes are unknown. Before implantation, the surgeon and patient must understand the experimental nature of the devices.

Type II odontoid fractures of the cervical spine: do treatment type and medical comorbidities affect mortality in elderly patients?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine the influence of age, comorbidities, and treatment type on mortality in elderly patients with acute Type II odontoid fractures.

SUMMARY OF BACKGROUND DATA

Prior studies have documented increased morbidity and mortality among geriatric patients sustaining odontoid fractures. However, there is limited data regarding the effect of patient age, medical comorbidities, and treatment selection on mortality after Type II odontoid (C2) fractures in the elderly.

METHODS

An institutional registry was used to identify all Type II odontoid fractures sustained by patients aged 65 and older from 1991 to 2006. Demographic information, date of injury, associated injuries, treatment type, and comorbidities were abstracted from medical records. Mortality was ascertained using the National Death Index. Risks of mortality and their associated 95% confidence intervals (CIs) were calculated at 3 months, 1 year, 2 years, and 3 years. Multivariable Cox proportional hazard regression was used to evaluate independent factors affecting mortality stratified by age (65-74 years, 75-84 years, ≥ 85 years) and treatment type (operative or nonoperative treatment, and halo or collar immobilization).

RESULTS

Of 156 patients identified with Type II odontoid fracture, the average age was 82 years (SD = 7.8; Range: 65-101). One hundred and twelve patients (72%) were treated nonoperatively. At 3 years postinjury, there was a 39% (95% CI: 32-47) mortality rate for the entire cohort. Mortality for the operative group was 11% (95% CI: 2-21) at 3 months and 21% (95% CI: 9-32) at 1 year compared with 25% (95% CI: 17-33) at 3 months and 36% (95% CI: 27-45) at 1 year in the nonoperative group. The Cox regression model showed that the protective effect of surgery was seen in patients aged 65 to 74 years, in whom the hazard ratio associated with surgery for mortality after odontoid fracture was 0.4 (95% CI: 0.1-1.5). Those aged 75 to 84 years had a hazard ratio of 0.8 (95% CI: 0.3-2.3), and patients 85 years or older had a hazard ratio of 1.9 (95% CI: 0.6-6.1; P value for interaction between age and treatment = 0.09) with operative treatment having a protective effect in patients aged 65 to 74 years.

CONCLUSION

In a cohort of elderly patients, Type II odontoid fractures were associated with a high rate of mortality, regardless of intervention.

Trends in Medicare Reimbursement for Orthopedic Procedures: 2000 to 2016

Understanding trends in reimbursement is critical to the financial sustainability of orthopedic practices. Little research has examined physician fee trends over time for orthopedic procedures. This study evaluated trends in Medicare reimbursements for orthopedic surgical procedures. The Medicare Physician Fee Schedule was examined for Current Procedural Terminology code values for the most common orthopedic and nonorthopedic procedures between 2000 and 2016. Prices were adjusted for inflation to 2016-dollar values. To assess mean growth rate for each procedure and subspecialty, compound annual growth rates were calculated. Year-to-year dollar amount changes were calculated for each procedure and subspecialty. Reimbursement trends for individual procedures and across subspecialties were compared. Between 2000 and 2016, annual reimbursements decreased for all orthopedic procedures examined except removal of orthopedic implant. The orthopedic procedures with the greatest mean annual decreases in reimbursement were shoulder arthroscopy/decompression, total knee replacement, and total hip replacement. The orthopedic procedures with the least annual reimbursement decreases were carpal tunnel release and repair of ankle fracture. Rate of Medicare procedure reimbursement change varied between subspecialties. Trauma had the smallest decrease in annual change compared with spine, sports, and hand. Annual reimbursement decreased at a significantly greater rate for adult reconstruction procedures than for any of the other subspecialties. These findings indicate that reimbursement for procedures has steadily decreased, with the most rapid decrease seen in adult reconstruction. [Orthopedics. 2018; 41(2):95-102.].

Advances and future directions for management of trauma patients with musculoskeletal injuries

Musculoskeletal injuries are the most common reason for operative procedures in severely injured patients and are major determinants of functional outcomes. In this paper, we summarise advances and future directions for management of multiply injured patients with major musculoskeletal trauma. Improved understanding of fracture healing has created new possibilities for management of particularly challenging problems, such as delayed union and non union of fractures and large bone defects. Optimum timing of major orthopaedic interventions is guided by increased knowledge about the immune response after injury. Individual treatment should be guided by trading off the benefits of early definitive skeletal stabilisation, and the potentially life-threatening risks of systemic complications such as fat embolism, acute lung injury, and multiple organ failure. New methods for measurement of fracture healing and function and quality of life outcomes pave the way for landmark trials that will guide the future management of musculoskeletal injuries.

Management patterns in acute low back pain: the role of physical therapy

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To evaluate the relationship between early physical therapy (PT) for acute low back pain and subsequent use of lumbosacral injections, lumbar surgery, and frequent physician office visits for low back pain.

SUMMARY OF BACKGROUND DATA

Wide practice variations exist in the treatment of acute low back pain. PT has been advocated as an effective treatment in this setting although disagreement exists regarding its purported benefits.

METHODS

A national 20% sample of the Centers for Medicare and Medicaid Services physician outpatient billing claims was analyzed. Patients were selected who received treatment for low back pain between 2003 and 2004 (n = 439,195). To exclude chronic low back conditions, patients were excluded if they had a prior visit for back pain, lumbosacral injection, or lumbar surgery within the previous year. Main outcome measures were rates of lumbar surgery, lumbosacral injections, and frequent physician office visits for low back pain during the following year.

RESULTS

Based on logistic regression analysis, the adjusted odds ratio for undergoing surgery in the group of enrollees that received PT in the acute phase (<4 weeks) compared to those receiving PT in the chronic phase (>3 months) was 0.38 (95% confidence interval [CI], 0.360.41), adjusting for age, sex, diagnosis, treating physician specialty, and comorbidity. The adjusted odds ratio for receiving a lumbosacral injection in the group receiving PT in the acute phase was 0.46 (95% CI, 0.44-0.49), and the adjusted odds ratio for frequent physician office usage in the group receiving PT in the acute phase was 0.47 (95% CI, 0.44-0.50).

CONCLUSION

There was a lower risk of subsequent medical service usage among patients who received PT early after an episode of acute low back pain relative to those who received PT at later times. Medical specialty variations exist regarding early use of PT, with potential underutilization among generalist specialties.

Osteonecrosis of the hip: novel approaches to evaluation and treatment

The treatment of osteonecrosis of the hip remains a dilemma. Contemporary basic science research focuses on establishing the molecular etiology of this disease with the hope of identifying targets for pharmacologic intervention. Researchers have identified specific genetic polymorphisms that may predispose its development and these may allow early diagnosis and treatment of at-risk patients. Refinements in magnetic resonance imaging aid in the staging of patients with osteonecrosis and findings appear to correlate with clinical outcome. Novel nonoperative and operative modalities for the treatment of osteonecrosis are also under investigation. The results of new pharmacologic and biophysical treatments appear beneficial in delaying, and possibly preventing, the progression of precollapse lesions. New bone grafting strategies may enhance the results of core decompression. Although the results of conventional total hip arthroplasty have improved, newer surface replacement systems provide satisfactory short-term outcomes and may preserve bone stock in younger patients. Further research is needed to clarify the roles of these emerging technologies in the treatment of osteonecrosis of the hip. Until there is convincing evidence of efficacy in randomized clinical trials, we recommend appropriate staging and core decompression with or without bone graft for precollapse lesions and total hip arthroplasty or surface replacement for advanced disease.

A review of translational medicine. The future paradigm: how can we connect the orthopedic dots better?

INTRODUCTION

Patients with complex medical and surgical problems often travel great distances to prestigious university medical centers in search of solutions and in some cases for nothing more than a diagnosis of their condition. Translational medicine (TM) is an emerging method and process of facilitating medical advances efficiently from the scientist to the clinician. Most established clinicians and those in training know very little about this new discipline. The purpose of this article is to illustrate TM in varied scientific, medical and surgical fields.

MATERIALS AND METHODS

Anecdotal events in medicine and orthopaedics based upon a practicing orthopaedic surgeon's training and clinical experience are presented.

RESULTS

TM is rapidly assuming a greater presence in the medical community. The National Institute of Health (NIH) recognizes this discipline and has funded TM projects. Numerous institutions in Europe and the USA offer advanced degrees in TM. Finally there is a European Society for Translational Medicine (EUTMS), an International Society for Translational Medicine, and an Academy of Translational Medical Professionals (ATMP).

DISCUSSION

The examples of TM presented in this article support the argument for the formation of more TM networks on the local and regional levels. The need for increased participation of researchers and clinicians requires further study to identify the economic and social impact of TM.

CONCLUSIONS

The examples of TM presented in this article support the argument for the formation of more TM networks on the local and regional levels. Financial constraints for TM can be overcome by pooling government, academic, private, and industry resources in an organized fashion with oversight by a lead TM researcher.

Orthopaedic Surgical Selection and Inpatient Paradigms During the Coronavirus (COVID-19) Pandemic

The novel coronavirus pandemic, also known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has placed an immense strain on healthcare systems across the entire world. Consequently, multiple federal and state governments have placed restrictions on hospitals such as limiting "elective surgery" and recommending social or physical distancing. We review the literature on several areas that have been affected including surgical selection, inpatient care, and physician well-being. These areas affecting inpatient paradigms include surgical priority, physical or social distancing, file sharing for online clinical communications, and physician wellness. During this crisis, it is important that orthopaedic departments place an emphasis on personnel safety and slowing the spread of the virus so that the department can still maintain vital functions. Physical distancing and emerging technologies such as inpatient telemedicine and online file sharing applications can enable orthopaedic programs to still function while attempting to protect medical staff and patients from the novel coronavirus spread. This literature review sought to provide evidence-based guidance to orthopaedic departments during an unprecedented time. Orthopaedic surgeons should follow the Centers for Disease Control and Prevention guidelines, wear personal protective equipment (PPE) when appropriate, have teams created using physical distancing, understand the department's policy on elective surgery, and engage in routines which enhance physician wellness.

How Long Will It Take to Reach Gender Parity in Orthopaedic Surgery in the United States? An Analysis of the National Provider Identifier Registry

BACKGROUND

Although previous studies have evaluated how the proportion of women in orthopaedic surgery has changed over time, these analyses have been limited by small sample sizes, have primarily used data on residents, and have not included information on growth across subspecialties and geographic regions.

QUESTION/PURPOSE

We used the National Provider Identifier registry to ask: How have the (1) overall, (2) regional, and (3) subspecialty percentages of women among all currently practicing orthopaedic providers changed over time in the United States?

METHODS

The National Provider Identifier Registry of the Centers for Medicare and Medicaid Services (CMS) was queried for all active providers with taxonomy codes pertaining to orthopaedic subspecialties as of April 2020. Women orthopaedic surgeons were identified among all physicians with subspecialty taxonomy codes. As all providers are required to provide a gender when applying for an NPI, all providers with queried taxonomy codes additionally had gender classification. Our final cohort consisted of 31,296 practicing orthopaedic surgeons, of whom 8% (2363 of 31,296) were women. A total of 11,714 (37%) surgeons possessed taxonomy codes corresponding with a specific orthopaedic subspecialty. A univariate linear regression analysis was used to analyze trends in the annual proportions of women who are active orthopaedic surgeons based on NPI enumeration dates. Specifically, annual proportions were defined using cross-sections of the NPI registry on December 31 of each year. Linear regression was similarly used to evaluate changes in the annual proportion of women orthopaedic surgeons across United States Census regions and divisions, as well as orthopaedic subspecialties. The national growth rate was then projected forward to determine the year at which the representation of women orthopaedic surgeons would achieve parity with the proportion of all women physicians (36.3% or 340,018 of 936,254, as determined by the 2019 American Medical Association Physician Masterfile) and the proportion of all women in the United States (50.8% or 166,650,550 of 328,239,523 as determined by 2019 American Community Survey from the United States Census Bureau). Gender parity projections along with corresponding 95% confidence intervals were calculated using the Holt-Winters forecasting algorithm. The proportions of women physicians and women in the United States were assumed to remain fixed at 2019 values of 36.3% and 50.8%, respectively.

RESULTS

There was a national increase in the proportion of women orthopaedic surgeons between 2010 and 2019 (r2 = 0.98; p < 0.001) at a compound annual growth rate of 2%. Specifically, the national proportion of orthopaedic surgeons who were women increased from 6% (1670 of 26,186) to 8% (2350 of 30,647). Assuming constant growth at this rate following 2019, the time to achieve gender parity with the overall medical profession (that is, to achieve 36.3% women in orthopaedic surgery) is projected to be 217 years, or by the year 2236. Likewise, the time to achieve gender parity with the overall US population (which is 50.8% women) is projected to be 326 years, or by the year 2354. During our study period, there were increases in the proportion of women orthopaedic surgeons across US Census regions. The lowest growth was in the West (17%) and the South (19%). Similar growth was demonstrated across census divisions. In each orthopaedic subspecialty, we found increases in the proportion of women surgeons throughout the study period. Adult reconstruction (0%) and spine surgery (1%) had the lowest growth.

CONCLUSION

We calculate that at the current rate of change, it will take more than 200 years for orthopaedic surgery to achieve gender parity with the overall medical profession. Although some regions and subspecialties have grown at comparably higher rates, collectively, there has been minimal growth across all domains.

CLINICAL RELEVANCE

Given this meager growth, we believe that substantive changes must be made across all levels of orthopaedic education and leadership to steepen the current curve. These include mandating that all medical school curricula include dedicated exposure to orthopaedic surgery to increase the number of women coming through the orthopaedic pipeline. Additionally, we believe the Accreditation Council for Graduate Medical Education and individual programs should require specific benchmarks for the proportion of orthopaedic faculty and fellowship program directors, as well as for the proportion of incoming trainees, who are women. Furthermore, we believe there should be a national effort led by American Academy of Orthopaedic Surgeons and orthopaedic subspecialty societies to foster the academic development of women in orthopaedic surgery while recruiting more women into leadership positions. Future analyses should evaluate the efficacy of diversity efforts among other surgical specialties that have achieved or made greater strides toward gender parity, as well as how these programs can be implemented into orthopaedic surgery.

The incidence and healthcare costs of persistent postoperative pain following lumbar spine surgery in the UK: a cohort study using the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES)

OBJECTIVE

To characterise incidence and healthcare costs associated with persistent postoperative pain (PPP) following lumbar surgery.

DESIGN

Retrospective, population-based cohort study.

SETTING

Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES) databases.

PARTICIPANTS

Population-based cohort of 10 216 adults who underwent lumbar surgery in England from 1997/1998 through 2011/2012 and had at least 1 year of presurgery data and 2 years of postoperative follow-up data in the linked CPRD-HES.

PRIMARY AND SECONDARY OUTCOMES MEASURES

Incidence and total healthcare costs over 2, 5 and 10 years attributable to persistent PPP following initial lumbar surgery.

RESULTS

The rate of individuals undergoing lumbar surgery in the CPRD-HES linked data doubled over the 15-year study period, fiscal years 1997/1998 to 2011/2012, from 2.5 to 4.9 per 10 000 adults. Over the most recent 5-year period (2007/2008 to 2011/2012), on average 20.8% (95% CI 19.7% to 21.9%) of lumbar surgery patients met criteria for PPP. Rates of healthcare usage were significantly higher for patients with PPP across all types of care. Over 2 years following initial spine surgery, the mean cost difference between patients with and without PPP was £5383 (95% CI £4872 to £5916). Over 5 and 10 years following initial spine surgery, the mean cost difference between patients with and without PPP increased to £10 195 (95% CI £8726 to £11 669) and £14 318 (95% CI £8386 to £19 771), respectively. Extrapolated to the UK population, we estimate that nearly 5000 adults experience PPP after spine surgery annually, with each new cohort costing the UK National Health Service in excess of £70 million over the first 10 years alone.

CONCLUSIONS

Persistent pain affects more than one-in-five lumbar surgery patients and accounts for substantial long-term healthcare costs. There is a need for formal, evidence-based guidelines for a coherent, coordinated management strategy for patients with continuing pain after lumbar surgery.

Opioid Oversupply After Joint and Spine Surgery: A Prospective Cohort Study

BACKGROUND

Many patients receive prescription opioids at hospital discharge after surgery, yet little is known regarding how often these opioids go unused. We estimated the prevalence of unused opioids, use of nonopioid analgesics, and storage and disposal practices after same-day and inpatient surgery.

METHODS

In this prospective cohort study at a large, inner-city tertiary care hospital, we recruited individuals ≥18 years of age undergoing elective same-day or inpatient joint and spine surgery from August to November 2016. Using patient surveys via telephone calls, we assessed patient-reported outcomes at 2-day, 2-week, 1-month, and 6-month intervals, including: (1) stopping opioid treatment and in possession of unused opioid pills (primary outcome), (2) number of unused opioid tablets reported after stopping opioids, (3) use of nonopioid pain treatments, and (4) knowledge and practice regarding safe opioid storage and disposal.

RESULTS

Of 141 eligible patients, 140 (99%) consented (35% taking preoperative opioids; mean age 56 years [standard deviation 16 years]; 47% women). One- and 6-month follow-up was achieved for 115 (82%) and 110 patients (80%), respectively. Among patients who stopped opioid therapy, possession of unused opioids was reported by 73% (95% confidence intervals, 62%-82%) at 1-month follow-up and 34% (confidence interval, 24%-45%) at 6-month follow-up. At 1 month, 46% had ≥20 unused pills, 37% had ≥200 morphine milligram equivalents, and only 6% reported using multiple nonopioid adjuncts. Many patients reported unsafe storage and failure to dispose of opioids at both 1-month (91% and 96%, respectively) and 6-month (92% and 47%, respectively) follow-up.

CONCLUSIONS

After joint and spine surgery, many patients reported unused opioids, infrequent use of analgesic alternatives, and lack of knowledge regarding safe opioid storage and disposal. Interventions are needed to better tailor postoperative analgesia and improve the safe storage and disposal of prescription opioids.

Health economic analysis of adult deformity surgery

Given the substantial growth in frequency and expense of spine deformity surgery, and the general economic landscape of the health care system, health economics research has an important role in the literature on adult spinal deformity (ASD). The purpose of this article is to provide an update on the current state of health economics studies in the ASD literature and to introduce areas in which health economics might play some additional role in future research on ASD.

Postoperative Pain and Analgesic Requirements in the First Year after Intraoperative Methadone for Complex Spine and Cardiac Surgery

BACKGROUND

Methadone is a long-acting opioid that has been reported to reduce postoperative pain scores and analgesic requirements and may attenuate development of chronic postsurgical pain. The aim of this secondary analysis of two previous trials was to follow up with patients who had received a single intraoperative dose of either methadone or traditional opioids for complex spine or cardiac surgical procedures.

METHODS

Preplanned analyses of long-term outcomes were conducted for spinal surgery patients randomized to receive 0.2 mg/kg methadone at the start of surgery or 2 mg hydromorphone at surgical closure, and for cardiac surgery patients randomized to receive 0.3 mg/kg methadone or 12 μg/kg fentanyl intraoperatively. A pain questionnaire assessing the weekly frequency (the primary outcome) and intensity of pain was mailed to subjects 1, 3, 6, and 12 months after surgery. Ordinal data were compared with the Mann-Whitney U test, and nominal data were compared using the chi-square test or Fisher exact probability test. The criterion for rejection of the null hypothesis was P < 0.01.

RESULTS

Three months after surgery, patients randomized to receive methadone for spine procedures reported the weekly frequency of chronic pain was less (median score 0 on a 0 to 4 scale [less than once a week] vs. 3 [daily] in the hydromorphone group, P = 0.004). Patients randomized to receive methadone for cardiac surgery reported the frequency of postsurgical pain was less at 1 month (median score 0) than it was in patients randomized to receive fentanyl (median score 2 [twice per week], P = 0.004).

CONCLUSIONS

Analgesic benefits of a single dose of intraoperative methadone were observed during the first 3 months after spinal surgery (but not at 6 and 12 months), and during the first month after cardiac surgery, when the intensity and frequency of pain were the greatest.