Pub Date : 2020-09-15DOI: 10.5435/JAAOS-D-19-00272
T. Tan, A. Rondon, Max R. Greenky, N. Shohat, K. Goswami, J. Purtill
BACKGROUND Many surgeons prefer to discharge patients home due to patient preferences, improved outcomes, and decreased costs. Despite an institutional protocol to send total hip arthroplasty (THA) patients home, some patients still required postacute care (PAC) facilities. This study aimed to create two predictive models based on preoperative and postoperative risk factors to identify which patients require PAC facilities. METHODS A retrospective review of 2,372 patients undergoing primary unilateral THA at a single institution from 2012 to 2017 was done. An electronic query followed by manual review identified discharge disposition, demographic factors, comorbidities, and other patient factors. Of the 2,372 patients, 6.2% were discharged to skilled nursing facilities or inpatient rehabilitation facilities and 93.8% discharged home. Univariate and multivariate analysis were conducted to create two predictive models for patient discharge: preoperative visit and postoperative hospital course. RESULTS Of 45 variables evaluated, 7 were found to be notable predictors for PAC facility discharge. In descending order, these included age 65 years or greater, non-Caucasian race, history of depression, female sex, and greater comorbidities. In addition to preoperative factors, in-hospital complications and surgical duration of 90 minutes or greater led to a higher likelihood of PAC facility discharge. Both models had excellent predictive assessments with area under curve values of 0.77 and 0.80 for the preoperative visit and postoperative models, respectively. DISCUSSION This study identifies both preoperative and postoperative risk factors that predispose patients to nonroutine discharges after THA. Orthopaedic surgeons may use these models to better predict which patients are predisposed to discharge to PAC facilities.
{"title":"Which Patients Require Unexpected Admission to Postacute Care Facilities After Total Hip Arthroplasty?","authors":"T. Tan, A. Rondon, Max R. Greenky, N. Shohat, K. Goswami, J. Purtill","doi":"10.5435/JAAOS-D-19-00272","DOIUrl":"https://doi.org/10.5435/JAAOS-D-19-00272","url":null,"abstract":"BACKGROUND\u0000Many surgeons prefer to discharge patients home due to patient preferences, improved outcomes, and decreased costs. Despite an institutional protocol to send total hip arthroplasty (THA) patients home, some patients still required postacute care (PAC) facilities. This study aimed to create two predictive models based on preoperative and postoperative risk factors to identify which patients require PAC facilities.\u0000\u0000\u0000METHODS\u0000A retrospective review of 2,372 patients undergoing primary unilateral THA at a single institution from 2012 to 2017 was done. An electronic query followed by manual review identified discharge disposition, demographic factors, comorbidities, and other patient factors. Of the 2,372 patients, 6.2% were discharged to skilled nursing facilities or inpatient rehabilitation facilities and 93.8% discharged home. Univariate and multivariate analysis were conducted to create two predictive models for patient discharge: preoperative visit and postoperative hospital course.\u0000\u0000\u0000RESULTS\u0000Of 45 variables evaluated, 7 were found to be notable predictors for PAC facility discharge. In descending order, these included age 65 years or greater, non-Caucasian race, history of depression, female sex, and greater comorbidities. In addition to preoperative factors, in-hospital complications and surgical duration of 90 minutes or greater led to a higher likelihood of PAC facility discharge. Both models had excellent predictive assessments with area under curve values of 0.77 and 0.80 for the preoperative visit and postoperative models, respectively.\u0000\u0000\u0000DISCUSSION\u0000This study identifies both preoperative and postoperative risk factors that predispose patients to nonroutine discharges after THA. Orthopaedic surgeons may use these models to better predict which patients are predisposed to discharge to PAC facilities.","PeriodicalId":110802,"journal":{"name":"The Journal of the American Academy of Orthopaedic Surgeons","volume":"97 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127388572","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-09-01DOI: 10.5435/jaaos-d-19-00165
R. Shah, D. Manning, B. Butler, K. Bilimoria
INTRODUCTION A growing number of online hospital rating systems for orthopaedic surgery are found. Although the accuracy and consistency of these systems have been questioned in other fields of medicine, no formal analysis of these systems in orthopaedics has been found. METHODS Five hospital rating systems (US News, HealthGrades, CareChex, Women's Choice, and Hospital Compare) were examined which designate "high-performing" and "low-performing" hospitals for orthopaedic surgery. Descriptive analysis was conducted for all hospitals defined as high- or low-performing in any of the five rating systems, and assessment for agreement/disagreement between ratings was done. A subsample of hospitals ranked by all systems was then created, and agreement between rating systems was investigated using a Cohen's kappa. Each hospital was included in a multinomial logistic regression model investigating which hospital characteristics increased the odds of being favorably/unfavorably rated by each system. RESULTS One thousand six hundred forty hospitals were evaluated by every rating system. Six hundred thirty-eight unique hospitals were identified as high-performing by at least 1 rating system; however, no hospital was ranked as high-performing by all five rating systems. Four hundred fifty-two unique hospitals were identified as low-performing; however, no hospital was ranked as low-performing by all the three rating systems which define low-performing hospitals. Within the study subsample of hospitals evaluated by each system, little agreement between any combination of rating systems (κ < 0.10) regarding top-tier or bottom-tier performance was found. It was more likely for a hospital to be considered high-performing by one system and low-performing by another (10.66%) than for the majority of the five rating systems to consider a hospital high-performing (3.76%). CONCLUSION Little agreement between hospital quality rating systems for orthopaedic surgery is found. Publicly available hospital ratings for performance in orthopaedic surgery offer conflicting results and provide little guidance to patients, providers, or payers when selecting a hospital for orthopaedic surgery. LEVEL OF EVIDENCE Level 1 economic study.
{"title":"Do Hospital Rankings Mislead Patients? Variability Among National Rating Systems for Orthopaedic Surgery.","authors":"R. Shah, D. Manning, B. Butler, K. Bilimoria","doi":"10.5435/jaaos-d-19-00165","DOIUrl":"https://doi.org/10.5435/jaaos-d-19-00165","url":null,"abstract":"INTRODUCTION\u0000A growing number of online hospital rating systems for orthopaedic surgery are found. Although the accuracy and consistency of these systems have been questioned in other fields of medicine, no formal analysis of these systems in orthopaedics has been found.\u0000\u0000\u0000METHODS\u0000Five hospital rating systems (US News, HealthGrades, CareChex, Women's Choice, and Hospital Compare) were examined which designate \"high-performing\" and \"low-performing\" hospitals for orthopaedic surgery. Descriptive analysis was conducted for all hospitals defined as high- or low-performing in any of the five rating systems, and assessment for agreement/disagreement between ratings was done. A subsample of hospitals ranked by all systems was then created, and agreement between rating systems was investigated using a Cohen's kappa. Each hospital was included in a multinomial logistic regression model investigating which hospital characteristics increased the odds of being favorably/unfavorably rated by each system.\u0000\u0000\u0000RESULTS\u0000One thousand six hundred forty hospitals were evaluated by every rating system. Six hundred thirty-eight unique hospitals were identified as high-performing by at least 1 rating system; however, no hospital was ranked as high-performing by all five rating systems. Four hundred fifty-two unique hospitals were identified as low-performing; however, no hospital was ranked as low-performing by all the three rating systems which define low-performing hospitals. Within the study subsample of hospitals evaluated by each system, little agreement between any combination of rating systems (κ < 0.10) regarding top-tier or bottom-tier performance was found. It was more likely for a hospital to be considered high-performing by one system and low-performing by another (10.66%) than for the majority of the five rating systems to consider a hospital high-performing (3.76%).\u0000\u0000\u0000CONCLUSION\u0000Little agreement between hospital quality rating systems for orthopaedic surgery is found. Publicly available hospital ratings for performance in orthopaedic surgery offer conflicting results and provide little guidance to patients, providers, or payers when selecting a hospital for orthopaedic surgery.\u0000\u0000\u0000LEVEL OF EVIDENCE\u0000Level 1 economic study.","PeriodicalId":110802,"journal":{"name":"The Journal of the American Academy of Orthopaedic Surgeons","volume":"06 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128958063","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-07-01DOI: 10.5435/JAAOS-D-18-00254
Benjamin A. Winston, Minhazur Sarker, D. Putnam, Paxton Gehling, Connor Eagleton, D. Friess
INTRODUCTION Pelvic fractures are diverse injuries with varying degrees of severity. Treatment recommendations are determined by the associated instability. For likely stable patterns, postmobilization imaging is used to assess for occult instability. This study assesses the utility of postmobilization images and determines how often they alter the recommendations for treatment. METHODS Records at a single level 1 trauma center from January 2007 through December 2014 were reviewed, and patients with Current Procedural Terminology codes and International Classification of Diseases, Ninth Revision codes for pelvic and acetabular fractures were identified. For those chosen for nonsurgical treatment at presentation, a detailed chart review was performed to identify patients who had postmobilization radiographs and to determine whether this imaging led to a change in treatment recommendations. RESULTS Inclusion criteria were met by 762 patients whose average age was 50 years. Of 331 patients planned for nonsurgical treatment at presentation, 168 (51%) had postmobilization images. The postmobilization radiographs did not alter treatment recommendations in any of these patients; however, three of these patients underwent surgical stabilization based on the patients' report of pain with attempted mobilization. DISCUSSION Routine postmobilization imaging has limited value for patients with pelvic injuries and a low likelihood for instability, such as those with incomplete sacral fractures. Eliminating this step would reduce cost and decrease radiation exposure. The need for change in treatment plan or further imaging should be based on the patient's clinical progress with weight bearing. LEVEL OF EVIDENCE Level 4.
{"title":"The Utility of Obtaining Postmobilization Imaging in Nonsurgical Pelvic Ring Injuries.","authors":"Benjamin A. Winston, Minhazur Sarker, D. Putnam, Paxton Gehling, Connor Eagleton, D. Friess","doi":"10.5435/JAAOS-D-18-00254","DOIUrl":"https://doi.org/10.5435/JAAOS-D-18-00254","url":null,"abstract":"INTRODUCTION\u0000Pelvic fractures are diverse injuries with varying degrees of severity. Treatment recommendations are determined by the associated instability. For likely stable patterns, postmobilization imaging is used to assess for occult instability. This study assesses the utility of postmobilization images and determines how often they alter the recommendations for treatment.\u0000\u0000\u0000METHODS\u0000Records at a single level 1 trauma center from January 2007 through December 2014 were reviewed, and patients with Current Procedural Terminology codes and International Classification of Diseases, Ninth Revision codes for pelvic and acetabular fractures were identified. For those chosen for nonsurgical treatment at presentation, a detailed chart review was performed to identify patients who had postmobilization radiographs and to determine whether this imaging led to a change in treatment recommendations.\u0000\u0000\u0000RESULTS\u0000Inclusion criteria were met by 762 patients whose average age was 50 years. Of 331 patients planned for nonsurgical treatment at presentation, 168 (51%) had postmobilization images. The postmobilization radiographs did not alter treatment recommendations in any of these patients; however, three of these patients underwent surgical stabilization based on the patients' report of pain with attempted mobilization.\u0000\u0000\u0000DISCUSSION\u0000Routine postmobilization imaging has limited value for patients with pelvic injuries and a low likelihood for instability, such as those with incomplete sacral fractures. Eliminating this step would reduce cost and decrease radiation exposure. The need for change in treatment plan or further imaging should be based on the patient's clinical progress with weight bearing.\u0000\u0000\u0000LEVEL OF EVIDENCE\u0000Level 4.","PeriodicalId":110802,"journal":{"name":"The Journal of the American Academy of Orthopaedic Surgeons","volume":"32 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"130398611","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-07-01DOI: 10.5435/jaaos-d-19-00113
Anat V. Lubetzky, A. Soroka, D. Harel, T. Errico, J. Bendo, J. Leitner, S. Shabat, Eli Ashkenazi, Y. Floman, M. Moffat, Y. Masharawi
INTRODUCTION Balance and fall risk before and after lumbar surgery was assessed to determine whether balance at baseline predicts long-term postsurgical outcomes. METHODS Forty-three patients in the United States and Israel performed the single-leg stance (SLS) test, four square step test (FSST), and 8-foot up-and-go (8FUG) test before and 2 to 4 months after lumbar spine surgery. They completed the Oswestry Disability Index (ODI) and pain rating before and 12 months after lumbar surgery. RESULTS From baseline to follow-up, the SLS time was 3.74 seconds longer (P = 0.01), the FSST time was 1.94 seconds faster (P < 0.001), and the 8FUG time was 1.55 seconds faster (P = 0.02). Before surgery, 26% of the patients were considered high fall risk according to the FSST and 51% according to the 8FUG. Postsurgery, all patients could complete the physical tests, but 26% remained at high fall risk according to the 8FUG and 7.5% according to the FSST. The three physical measures together explained 30% of the variance in postsurgical ODI scores (P = 0.02). Age was not correlated with performance. DISCUSSION Risk of falling is higher than surgeons suspect. Balance tests (ie, SLS, FSST, and 8FUG) are quick and easy to administer. The findings support the importance of screening for balance and fall risk in adults undergoing lumbar spine surgery.
评估腰椎手术前后的平衡和跌倒风险，以确定基线平衡是否能预测术后长期预后。方法43例美国和以色列患者在腰椎手术前和术后2 ~ 4个月分别进行单腿站立(SLS)试验、4平方步试验(FSST)和8英尺起落(8FUG)试验。他们在腰椎手术前和手术后12个月完成了Oswestry残疾指数(ODI)和疼痛评分。结果从基线到随访，SLS时间延长了3.74 s (P = 0.01)， FSST时间缩短了1.94 s (P < 0.001)， 8FUG时间缩短了1.55 s (P = 0.02)。术前，26%的患者根据FSST和51%的患者根据8FUG被认为是高跌倒风险。术后，所有患者均可完成体格检查，但根据8FUG和FSST，仍有26%和7.5%的患者存在高跌倒风险。三种物理测量加起来解释了30%的术后ODI评分差异(P = 0.02)。年龄与表现无关。跌倒的风险比外科医生想象的要高。平衡测试(即SLS, FSST和8FUG)快速且易于管理。研究结果支持了在接受腰椎手术的成年人中进行平衡和跌倒风险筛查的重要性。
{"title":"Static and Dynamic Balance in Adults Undergoing Lumbar Spine Surgery: Screening and Prediction of Postsurgical Outcomes.","authors":"Anat V. Lubetzky, A. Soroka, D. Harel, T. Errico, J. Bendo, J. Leitner, S. Shabat, Eli Ashkenazi, Y. Floman, M. Moffat, Y. Masharawi","doi":"10.5435/jaaos-d-19-00113","DOIUrl":"https://doi.org/10.5435/jaaos-d-19-00113","url":null,"abstract":"INTRODUCTION\u0000Balance and fall risk before and after lumbar surgery was assessed to determine whether balance at baseline predicts long-term postsurgical outcomes.\u0000\u0000\u0000METHODS\u0000Forty-three patients in the United States and Israel performed the single-leg stance (SLS) test, four square step test (FSST), and 8-foot up-and-go (8FUG) test before and 2 to 4 months after lumbar spine surgery. They completed the Oswestry Disability Index (ODI) and pain rating before and 12 months after lumbar surgery.\u0000\u0000\u0000RESULTS\u0000From baseline to follow-up, the SLS time was 3.74 seconds longer (P = 0.01), the FSST time was 1.94 seconds faster (P < 0.001), and the 8FUG time was 1.55 seconds faster (P = 0.02). Before surgery, 26% of the patients were considered high fall risk according to the FSST and 51% according to the 8FUG. Postsurgery, all patients could complete the physical tests, but 26% remained at high fall risk according to the 8FUG and 7.5% according to the FSST. The three physical measures together explained 30% of the variance in postsurgical ODI scores (P = 0.02). Age was not correlated with performance.\u0000\u0000\u0000DISCUSSION\u0000Risk of falling is higher than surgeons suspect. Balance tests (ie, SLS, FSST, and 8FUG) are quick and easy to administer. The findings support the importance of screening for balance and fall risk in adults undergoing lumbar spine surgery.","PeriodicalId":110802,"journal":{"name":"The Journal of the American Academy of Orthopaedic Surgeons","volume":"10 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"134087813","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-07-01DOI: 10.5435/JAAOS-D-18-00445
Meir T Marmor, A. Huang, R. Knox, Safa T. Herfat, R. Firoozabadi
BACKGROUND The optimal treatment of acetabular fractures in the senior cohort is undetermined. Total hip arthroplasty in the setting of an acetabular fracture is increasing in popularity. However, there is concern regarding the fixation of a prosthetic cup in a fractured acetabulum. The purpose of this study is to map the area of stable articular surface and bone corridors available for cup fixation in this fracture cohort. METHODS CT scans of acetabular fractures in 131 consecutive geriatric patients older than 65 years from two level 1 academic trauma centers were analyzed. Acetabular fractures were classified using the Letournel classification, the available stable articular surface, and the bone corridors available for fixation. RESULTS Fractures involving the anterior column were the most common fracture type seen. The dome only pattern was the most common stable articular surface pattern. The sciatic corridor was available for fixation in all fracture types, followed by the gluteal pillar corridor. Most fractures had at least two corridors (93%) available for screw fixation. CONCLUSIONS The findings of this study may aid in the development and evaluation of fixation strategies for acetabular cups allowing geriatric acetabular fracture patients earlier weight bearing after primary hip arthroplasty.
{"title":"Mapping of the Stable Articular Surface and Available Bone Corridors for Cup Fixation in Geriatric Acetabular Fractures.","authors":"Meir T Marmor, A. Huang, R. Knox, Safa T. Herfat, R. Firoozabadi","doi":"10.5435/JAAOS-D-18-00445","DOIUrl":"https://doi.org/10.5435/JAAOS-D-18-00445","url":null,"abstract":"BACKGROUND\u0000The optimal treatment of acetabular fractures in the senior cohort is undetermined. Total hip arthroplasty in the setting of an acetabular fracture is increasing in popularity. However, there is concern regarding the fixation of a prosthetic cup in a fractured acetabulum. The purpose of this study is to map the area of stable articular surface and bone corridors available for cup fixation in this fracture cohort.\u0000\u0000\u0000METHODS\u0000CT scans of acetabular fractures in 131 consecutive geriatric patients older than 65 years from two level 1 academic trauma centers were analyzed. Acetabular fractures were classified using the Letournel classification, the available stable articular surface, and the bone corridors available for fixation.\u0000\u0000\u0000RESULTS\u0000Fractures involving the anterior column were the most common fracture type seen. The dome only pattern was the most common stable articular surface pattern. The sciatic corridor was available for fixation in all fracture types, followed by the gluteal pillar corridor. Most fractures had at least two corridors (93%) available for screw fixation.\u0000\u0000\u0000CONCLUSIONS\u0000The findings of this study may aid in the development and evaluation of fixation strategies for acetabular cups allowing geriatric acetabular fracture patients earlier weight bearing after primary hip arthroplasty.","PeriodicalId":110802,"journal":{"name":"The Journal of the American Academy of Orthopaedic Surgeons","volume":"18 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126273195","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-07-01DOI: 10.5435/JAAOS-D-18-00830
P. Chalmers, L. Beck, Matthew D Miller, Irene Stertz, Heath B. Henninger, R. Tashjian
BACKGROUND Our purpose was to determine whether glenoid retroversion associates with asymmetric rotator cuff muscle atrophy in eccentric glenohumeral osteoarthritis (GHOA) and if this asymmetry is worsening of GHOA-related atrophy. METHODS Two groups of shoulder magnetic resonance images were studied: patients older than 50 years without a rotator cuff tear or GHOA (control group) and patients preoperative to anatomic total shoulder arthroplasty (GHOA group). Retroversion and rotator cuff muscle cross-sectional areas were measured using reliable and accurate techniques. Proportional muscle areas were created by dividing by total cuff area to correct for differences in overall patient size. Walch grades were assigned via consensus. RESULTS The control group consisted of 102 patients and the GHOA cohort consisted of 141 patients. Within the eccentric GHOA group, retroversion associated with relative increasing supraspinatus (r = 0.268, P = 0.035), increasing infraspinatus (r = 0.273, P = 0.032), and decreasing subscapularis areas (r = -0.343, P = 0.006). However, the combined GHOA group had a significantly higher relative subscapularis area than the control group (P = 0.026). CONCLUSION In the eccentric GHOA, increasing retroversion is associated with increasing volume of the posterior cuff relative to the anterior cuff muscles, which is a reversal of the asymmetric increasing volume of the anterior cuff relative to the posterior cuff muscles seen with concentric GHOA. LEVEL OF EVIDENCE Diagnostic, level III.
背景:我们的目的是确定偏心型盂肱骨关节炎(GHOA)患者的盂后翻是否与不对称肩袖肌萎缩有关，以及这种不对称是否会加重GHOA相关的萎缩。方法对50岁以上无肩袖撕裂或无高肩关节置换术患者(对照组)和术前解剖全肩关节置换术患者(高肩关节置换术组)肩关节磁共振图像进行研究。使用可靠和准确的技术测量后倾和肩袖肌横截面积。比例肌肉面积通过除以总袖带面积来纠正患者整体尺寸的差异。沃尔什的分数是通过协商一致的方式分配的。结果对照组102例，GHOA组141例。在偏心性GHOA组中，脊柱后倾与冈上肌相对增加(r = 0.268, P = 0.035)、冈下肌相对增加(r = 0.273, P = 0.032)、肩胛下肌相对减少(r = -0.343, P = 0.006)相关。而联合GHOA组肩胛下肌相对面积明显高于对照组(P = 0.026)。结论在偏心型高置换术中，后袖相对于前袖肌肉的体积增加与后袖的后倾程度增加有关，这与同心型高置换术中前袖相对于后袖肌肉的体积不对称增加是相反的。证据等级:诊断性，III级。
{"title":"Glenoid Retroversion Associates With Asymmetric Rotator Cuff Muscle Atrophy in Those With Walch B-type Glenohumeral Osteoarthritis.","authors":"P. Chalmers, L. Beck, Matthew D Miller, Irene Stertz, Heath B. Henninger, R. Tashjian","doi":"10.5435/JAAOS-D-18-00830","DOIUrl":"https://doi.org/10.5435/JAAOS-D-18-00830","url":null,"abstract":"BACKGROUND\u0000Our purpose was to determine whether glenoid retroversion associates with asymmetric rotator cuff muscle atrophy in eccentric glenohumeral osteoarthritis (GHOA) and if this asymmetry is worsening of GHOA-related atrophy.\u0000\u0000\u0000METHODS\u0000Two groups of shoulder magnetic resonance images were studied: patients older than 50 years without a rotator cuff tear or GHOA (control group) and patients preoperative to anatomic total shoulder arthroplasty (GHOA group). Retroversion and rotator cuff muscle cross-sectional areas were measured using reliable and accurate techniques. Proportional muscle areas were created by dividing by total cuff area to correct for differences in overall patient size. Walch grades were assigned via consensus.\u0000\u0000\u0000RESULTS\u0000The control group consisted of 102 patients and the GHOA cohort consisted of 141 patients. Within the eccentric GHOA group, retroversion associated with relative increasing supraspinatus (r = 0.268, P = 0.035), increasing infraspinatus (r = 0.273, P = 0.032), and decreasing subscapularis areas (r = -0.343, P = 0.006). However, the combined GHOA group had a significantly higher relative subscapularis area than the control group (P = 0.026).\u0000\u0000\u0000CONCLUSION\u0000In the eccentric GHOA, increasing retroversion is associated with increasing volume of the posterior cuff relative to the anterior cuff muscles, which is a reversal of the asymmetric increasing volume of the anterior cuff relative to the posterior cuff muscles seen with concentric GHOA.\u0000\u0000\u0000LEVEL OF EVIDENCE\u0000Diagnostic, level III.","PeriodicalId":110802,"journal":{"name":"The Journal of the American Academy of Orthopaedic Surgeons","volume":"144 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126876460","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-07-01DOI: 10.5435/JAAOS-D-18-00400
S. Konda, Ariana Lott, K. Egol
INTRODUCTION The purpose of this study was to combine a validated middle-age and geriatric trauma risk assessment tool (STTGMA) with a novel cost-prediction tool to create an objective triage tool for elderly hip fractures that would guide value-based care initiatives. METHODS From October 2014 to January 2018, all patients aged ≥55 years who were admitted with a primary diagnosis of hip fracture to a single level 1 trauma center were enrolled. Upon evaluation in the emergency department, demographics, injury severity, and functional status were recorded to calculate the trauma triage score (STTGMARisk). A model to predict high-cost hip fracture patients was created using similar variables (STTGMACost). RESULTS Three hundred sixty-one consecutive operative hip fracture patients were enrolled. Inpatient mortalities were skewed toward STTGMARisk3 with 21.4% of patients in this high-risk group ultimately expiring during their hospitalization. High-cost patients were correctly skewed to the STTGMACost2 and STTGMACost3 groups with 88.9% of all high-cost operatively treated hip fracture correctly triaged to these cohorts. Statistically significant variations were found in cost within each STTGMARisk group. CONCLUSIONS A simple risk score calculated upon admission (STTGMARisk and STTGMACost) was able to be used as a triage tool not only to differentiate increased mortality risk but also to predict high-cost patients based on resource utilization in hip fracture patients. LEVEL OF EVIDENCE Prognostic, level II.
{"title":"Development of a Value-based Algorithm for Inpatient Triage of Elderly Hip Fracture Patients.","authors":"S. Konda, Ariana Lott, K. Egol","doi":"10.5435/JAAOS-D-18-00400","DOIUrl":"https://doi.org/10.5435/JAAOS-D-18-00400","url":null,"abstract":"INTRODUCTION\u0000The purpose of this study was to combine a validated middle-age and geriatric trauma risk assessment tool (STTGMA) with a novel cost-prediction tool to create an objective triage tool for elderly hip fractures that would guide value-based care initiatives.\u0000\u0000\u0000METHODS\u0000From October 2014 to January 2018, all patients aged ≥55 years who were admitted with a primary diagnosis of hip fracture to a single level 1 trauma center were enrolled. Upon evaluation in the emergency department, demographics, injury severity, and functional status were recorded to calculate the trauma triage score (STTGMARisk). A model to predict high-cost hip fracture patients was created using similar variables (STTGMACost).\u0000\u0000\u0000RESULTS\u0000Three hundred sixty-one consecutive operative hip fracture patients were enrolled. Inpatient mortalities were skewed toward STTGMARisk3 with 21.4% of patients in this high-risk group ultimately expiring during their hospitalization. High-cost patients were correctly skewed to the STTGMACost2 and STTGMACost3 groups with 88.9% of all high-cost operatively treated hip fracture correctly triaged to these cohorts. Statistically significant variations were found in cost within each STTGMARisk group.\u0000\u0000\u0000CONCLUSIONS\u0000A simple risk score calculated upon admission (STTGMARisk and STTGMACost) was able to be used as a triage tool not only to differentiate increased mortality risk but also to predict high-cost patients based on resource utilization in hip fracture patients.\u0000\u0000\u0000LEVEL OF EVIDENCE\u0000Prognostic, level II.","PeriodicalId":110802,"journal":{"name":"The Journal of the American Academy of Orthopaedic Surgeons","volume":"110 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"124089221","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-06-15DOI: 10.5435/JAAOS-D-19-00347
B. Vopat, L. Vopat, Megan Bechtold, Kevin A. Hodge
Blood flow restriction therapy (BFRT) is an innovative training method for the development of muscle strength and hypertrophy in the athletic and clinical settings. Through the combination of venous occlusion and low-load resistance training, it induces muscle development through a number of proposed mechanisms including anaerobic metabolism, cellular swelling, and induction of type 2 muscle fibers. Muscle weakness and atrophy are prevalent among musculoskeletal rehabilitation patients, causing delayed return to functional activity. In traditional resistance training, muscle development requires exercise loads of 70% of one-repetition maximum (1RM), but the stress placed on connective tissues and joints can be detrimental to the elderly and rehabilitation patients. However, BFRT with loads of 20% to 40% of 1RM has been shown consistently in the literature to increase muscle strength, hypertrophy, and angiogenesis. The rate of adverse effects has not been found to be greater than that in traditional high-load resistance training, but its effects on the cardiovascular system have yet to be evaluated in long-term studies. Although further investigations are needed to determine the exact mechanism and optimal usage, current evidence is promising for the application of BFRT in athletes, rehabilitation patients, and the elderly patients.
{"title":"Blood Flow Restriction Therapy: Where We Are and Where We Are Going.","authors":"B. Vopat, L. Vopat, Megan Bechtold, Kevin A. Hodge","doi":"10.5435/JAAOS-D-19-00347","DOIUrl":"https://doi.org/10.5435/JAAOS-D-19-00347","url":null,"abstract":"Blood flow restriction therapy (BFRT) is an innovative training method for the development of muscle strength and hypertrophy in the athletic and clinical settings. Through the combination of venous occlusion and low-load resistance training, it induces muscle development through a number of proposed mechanisms including anaerobic metabolism, cellular swelling, and induction of type 2 muscle fibers. Muscle weakness and atrophy are prevalent among musculoskeletal rehabilitation patients, causing delayed return to functional activity. In traditional resistance training, muscle development requires exercise loads of 70% of one-repetition maximum (1RM), but the stress placed on connective tissues and joints can be detrimental to the elderly and rehabilitation patients. However, BFRT with loads of 20% to 40% of 1RM has been shown consistently in the literature to increase muscle strength, hypertrophy, and angiogenesis. The rate of adverse effects has not been found to be greater than that in traditional high-load resistance training, but its effects on the cardiovascular system have yet to be evaluated in long-term studies. Although further investigations are needed to determine the exact mechanism and optimal usage, current evidence is promising for the application of BFRT in athletes, rehabilitation patients, and the elderly patients.","PeriodicalId":110802,"journal":{"name":"The Journal of the American Academy of Orthopaedic Surgeons","volume":"33 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-06-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122016026","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-06-15DOI: 10.5435/JAAOS-D-19-00276
M. Mead, T. Atkinson, A. Srivastava, N. Walter
BACKGROUND Over 90% of graduating orthopaedic residents now pursue fellowship training, and only 15% of practicing orthopaedic surgeons now characterize themselves as generalists. Fellowship training has significant financial effects due to both opportunity cost of that year of training and changes in compensation throughout one's career. The purpose of this study was to estimate the financial return on investment by pursuing additional training in an orthopaedic fellowship versus general practice. METHODS Using described techniques of financial analysis, net present value (NPV), internal rate of return (IRR), and break-even point were estimated over the average working career length of an orthopaedic surgeon. Compensation data were drawn from the American Medical Group Association physician compensation surveys. Seven fellowships were studied and referenced to a career in general orthopaedic practice. RESULTS Fellowship training in spine surgery yields the highest return on investment with a break-even point of 5 years. Adult reconstruction has a positive NPV and IRR, but when corrected for number of hours worked per week offers no productivity advantage to general practice. Sports medicine and trauma offer neutral returns, but when corrected for work hours, NPV and IRR both become negative. Hand, pediatrics, and foot and ankle never break even following the loss of compensation realized during fellowship year. DISCUSSION The recent trend across all medical specialties has been for increased fellowship training and subspecialization. There are numerous reasons to pursue fellowship training, both personal and financial. This study presents an updated estimate of the financial impact of fellowship training in orthopaedics. This analysis demonstrates that selecting different fellowships can generate positive, negative, or neutral financial returns. This study has the potential to influence residents' decisions to pursue general practice versus fellowship training and identifies economic drivers, which may lead to preferential pursuit of certain subspecialties.
{"title":"The Return on Investment of Orthopaedic Fellowship Training: A Ten-year Update.","authors":"M. Mead, T. Atkinson, A. Srivastava, N. Walter","doi":"10.5435/JAAOS-D-19-00276","DOIUrl":"https://doi.org/10.5435/JAAOS-D-19-00276","url":null,"abstract":"BACKGROUND\u0000Over 90% of graduating orthopaedic residents now pursue fellowship training, and only 15% of practicing orthopaedic surgeons now characterize themselves as generalists. Fellowship training has significant financial effects due to both opportunity cost of that year of training and changes in compensation throughout one's career. The purpose of this study was to estimate the financial return on investment by pursuing additional training in an orthopaedic fellowship versus general practice.\u0000\u0000\u0000METHODS\u0000Using described techniques of financial analysis, net present value (NPV), internal rate of return (IRR), and break-even point were estimated over the average working career length of an orthopaedic surgeon. Compensation data were drawn from the American Medical Group Association physician compensation surveys. Seven fellowships were studied and referenced to a career in general orthopaedic practice.\u0000\u0000\u0000RESULTS\u0000Fellowship training in spine surgery yields the highest return on investment with a break-even point of 5 years. Adult reconstruction has a positive NPV and IRR, but when corrected for number of hours worked per week offers no productivity advantage to general practice. Sports medicine and trauma offer neutral returns, but when corrected for work hours, NPV and IRR both become negative. Hand, pediatrics, and foot and ankle never break even following the loss of compensation realized during fellowship year.\u0000\u0000\u0000DISCUSSION\u0000The recent trend across all medical specialties has been for increased fellowship training and subspecialization. There are numerous reasons to pursue fellowship training, both personal and financial. This study presents an updated estimate of the financial impact of fellowship training in orthopaedics. This analysis demonstrates that selecting different fellowships can generate positive, negative, or neutral financial returns. This study has the potential to influence residents' decisions to pursue general practice versus fellowship training and identifies economic drivers, which may lead to preferential pursuit of certain subspecialties.","PeriodicalId":110802,"journal":{"name":"The Journal of the American Academy of Orthopaedic Surgeons","volume":"140 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-06-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123776295","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-06-15DOI: 10.5435/jaaos-d-19-00271
Emily M. Schultz, Justin C Frisby, Sandra A. Miskiel, Deep Patel, M. Mulcahey, T. W. B. Kim
INTRODUCTION The Orthopaedic In-Training Examination (OITE) assesses orthopaedic resident knowledge over 275 multiple-choice questions.Since the first publication examining the contents of the pathology section was published over ten years ago, the pathology content has been renamed (oncology) and revamped. As the overall extent of these alterations is currently unknown, the efficacy of current orthopaedic oncology educational practices for optimal OITE performance should be questioned. To determine how the oncology (pathology) material has changed, we compared the following characteristics from previous examinations (2002 to 2006) to current examinations (2012 to 2016): (1) What are the average number of oncology questions being asked? (2) What are the specific imaging modalities presented for examinee interpretation? (3) Which pathologic diagnoses are commonly examined? (4) What is the pattern of taxonomic question classifications? METHODS The 2012 to 2016 OITE study guides were reviewed, and each oncology question was categorized into one of the following: benign or malignant, imaging modality grouping, common pathologic diagnosis, question type, and taxonomic classification. The aforementioned information was extrapolated from the previous pathology publication published in 2010 to create the previous examination cohort (2002 to 2006). The current examination characteristics were then compared with those of the previous examinations. RESULTS The current number of oncology OITE questions significantly decreased from previous years (27.2 versus 21.2; P = 0.015). Current examinations displayed a significant increase in testing the interpretation of diagnostic imaging modalities compared with previous examinations (78.3% versus 55.8%; P < 0.001). The current examinations examined a wide spectrum of pathologic diagnoses, including previously untested pathologies. The number of taxonomy 1 questions on current examinations significantly decreased (36.8% versus 24.5%; P = 0.032), whereas the number of taxonomy 3 questions significantly increased from previous examinations (48.1% versus 32.4%; P = 0.032). DISCUSSION This study demonstrated that the nature of the orthopaedic oncology (pathology) section has changed over the past 10 years. Although the overall number of pathology-related questions decreased, the difficulty level of these questions increased, demanding a higher level of knowledge and critical thinking. A formal orthopaedic oncology rotation may be the best method to educate and improve OITE oncology performance. LEVEL OF EVIDENCE Prognostic study, level III.
{"title":"The Changing Nature of the Oncology Section of the Orthopaedic In-Training Examination.","authors":"Emily M. Schultz, Justin C Frisby, Sandra A. Miskiel, Deep Patel, M. Mulcahey, T. W. B. Kim","doi":"10.5435/jaaos-d-19-00271","DOIUrl":"https://doi.org/10.5435/jaaos-d-19-00271","url":null,"abstract":"INTRODUCTION\u0000The Orthopaedic In-Training Examination (OITE) assesses orthopaedic resident knowledge over 275 multiple-choice questions.Since the first publication examining the contents of the pathology section was published over ten years ago, the pathology content has been renamed (oncology) and revamped. As the overall extent of these alterations is currently unknown, the efficacy of current orthopaedic oncology educational practices for optimal OITE performance should be questioned. To determine how the oncology (pathology) material has changed, we compared the following characteristics from previous examinations (2002 to 2006) to current examinations (2012 to 2016): (1) What are the average number of oncology questions being asked? (2) What are the specific imaging modalities presented for examinee interpretation? (3) Which pathologic diagnoses are commonly examined? (4) What is the pattern of taxonomic question classifications?\u0000\u0000\u0000METHODS\u0000The 2012 to 2016 OITE study guides were reviewed, and each oncology question was categorized into one of the following: benign or malignant, imaging modality grouping, common pathologic diagnosis, question type, and taxonomic classification. The aforementioned information was extrapolated from the previous pathology publication published in 2010 to create the previous examination cohort (2002 to 2006). The current examination characteristics were then compared with those of the previous examinations.\u0000\u0000\u0000RESULTS\u0000The current number of oncology OITE questions significantly decreased from previous years (27.2 versus 21.2; P = 0.015). Current examinations displayed a significant increase in testing the interpretation of diagnostic imaging modalities compared with previous examinations (78.3% versus 55.8%; P < 0.001). The current examinations examined a wide spectrum of pathologic diagnoses, including previously untested pathologies. The number of taxonomy 1 questions on current examinations significantly decreased (36.8% versus 24.5%; P = 0.032), whereas the number of taxonomy 3 questions significantly increased from previous examinations (48.1% versus 32.4%; P = 0.032).\u0000\u0000\u0000DISCUSSION\u0000This study demonstrated that the nature of the orthopaedic oncology (pathology) section has changed over the past 10 years. Although the overall number of pathology-related questions decreased, the difficulty level of these questions increased, demanding a higher level of knowledge and critical thinking. A formal orthopaedic oncology rotation may be the best method to educate and improve OITE oncology performance.\u0000\u0000\u0000LEVEL OF EVIDENCE\u0000Prognostic study, level III.","PeriodicalId":110802,"journal":{"name":"The Journal of the American Academy of Orthopaedic Surgeons","volume":"2020 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-06-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122233541","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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