M. Houdek, C. Wyles, C. Watts, E. Wagner, R. Sierra, R. Trousdale, M. Taunton
Background: There is debate regarding the role of single-anesthetic versus staged bilateral total hip arthroplasty (THA) for patients with end-stage bilateral osteoarthritis. Studies have shown that single-anesthetic bilateral THA is associated with systemic complications, but there are limited data comparing patient outcomes in a matched setting of bilateral THA. Methods: We identified 94 patients (188 hips) who underwent single-anesthetic bilateral THA. Fifty-seven percent of the patients were male. Patients had a mean age of 52.2 years and body mass index of 27.1 kg/m2. They were matched 1:1 on the basis of sex, age (±1 year), and year of surgery (±3 years) to a cohort of patients undergoing staged bilateral THA. In the staged group, there was <1 year between procedures (range, 5 days to 10 months). Mean follow-up was 4 years for each group. Results: Patients in the single-anesthetic group experienced shorter total operating room time and length of stay. There was no difference (hazard ratio [HR] = 0.73, p = 0.50) in the overall revision-free survival in patients undergoing single-anesthetic or staged bilateral THA. The risks of reoperation (HR = 0.69, p = 0.40), complications (HR = 0.83, p = 0.48), and mortality (HR = 0.47, p = 0.10) were similar. Single-anesthetic bilateral THA reduced the total cost of care (by 27%, p = 0.0001). Conclusions: In this matched cohort analysis, single-anesthetic bilateral THA was not associated with an increased risk of revision, reoperation, or postoperative complications, while decreasing cost. In our experience, single-anesthetic bilateral THA is a safe procedure that, for certain patients, offers an excellent means to deal with bilateral hip osteoarthritis. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
背景:对于终末期双侧骨关节炎患者，单麻醉与分期双侧全髋关节置换术(THA)的作用存在争议。研究表明，单麻醉双侧THA与全身并发症相关，但比较双侧THA匹配情况下患者预后的数据有限。方法:94例(188髋)行单麻醉双侧THA。57%的患者是男性。患者平均年龄52.2岁，体重指数27.1 kg/m2。他们根据性别、年龄(±1岁)和手术年份(±3岁)与接受分阶段双侧THA的患者进行1:1匹配。在分期组，手术间隔<1年(范围，5天至10个月)。每组平均随访4年。结果:单药组患者的总手术时间和住院时间较短。在接受单次麻醉或分阶段双侧THA的患者中，总体无修正生存期无差异(风险比[HR] = 0.73, p = 0.50)。再手术风险(HR = 0.69, p = 0.40)、并发症风险(HR = 0.83, p = 0.48)和死亡率(HR = 0.47, p = 0.10)相似。单麻醉双侧THA降低了总护理成本(27%，p = 0.0001)。结论:在这项匹配的队列分析中，单麻醉双侧THA与翻修、再手术或术后并发症的风险增加无关，同时降低了成本。根据我们的经验，单麻醉双侧全髋关节置换术是一种安全的手术，对某些患者来说，是治疗双侧髋关节骨关节炎的绝佳方法。证据等级:治疗性III级。有关证据水平的完整描述，请参见作者说明。
{"title":"Single-Anesthetic Versus Staged Bilateral Total Hip Arthroplasty: A Matched Cohort Study","authors":"M. Houdek, C. Wyles, C. Watts, E. Wagner, R. Sierra, R. Trousdale, M. Taunton","doi":"10.2106/JBJS.15.01223","DOIUrl":"https://doi.org/10.2106/JBJS.15.01223","url":null,"abstract":"Background: There is debate regarding the role of single-anesthetic versus staged bilateral total hip arthroplasty (THA) for patients with end-stage bilateral osteoarthritis. Studies have shown that single-anesthetic bilateral THA is associated with systemic complications, but there are limited data comparing patient outcomes in a matched setting of bilateral THA. Methods: We identified 94 patients (188 hips) who underwent single-anesthetic bilateral THA. Fifty-seven percent of the patients were male. Patients had a mean age of 52.2 years and body mass index of 27.1 kg/m2. They were matched 1:1 on the basis of sex, age (±1 year), and year of surgery (±3 years) to a cohort of patients undergoing staged bilateral THA. In the staged group, there was <1 year between procedures (range, 5 days to 10 months). Mean follow-up was 4 years for each group. Results: Patients in the single-anesthetic group experienced shorter total operating room time and length of stay. There was no difference (hazard ratio [HR] = 0.73, p = 0.50) in the overall revision-free survival in patients undergoing single-anesthetic or staged bilateral THA. The risks of reoperation (HR = 0.69, p = 0.40), complications (HR = 0.83, p = 0.48), and mortality (HR = 0.47, p = 0.10) were similar. Single-anesthetic bilateral THA reduced the total cost of care (by 27%, p = 0.0001). Conclusions: In this matched cohort analysis, single-anesthetic bilateral THA was not associated with an increased risk of revision, reoperation, or postoperative complications, while decreasing cost. In our experience, single-anesthetic bilateral THA is a safe procedure that, for certain patients, offers an excellent means to deal with bilateral hip osteoarthritis. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.","PeriodicalId":22579,"journal":{"name":"The Journal of Bone and Joint Surgery","volume":"17 1","pages":"48–54"},"PeriodicalIF":0.0,"publicationDate":"2017-01-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90226492","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}
R. Iorio, J. Bosco, J. Slover, Yousuf Sayeed, J. Zuckerman
Abstract: The Centers for Medicare & Medicaid Services (CMS) implemented the Bundled Payments for Care Improvement (BPCI) initiative in 2011. Through BPCI, organizations enlisted into payment agreements that include both performance and financial accountability for episodes of care. To succeed, BPCI requires quality maintenance and care delivery at lower costs. This necessitates physicians and hospitals to merge interests. Orthopaedic surgeons must assume leadership roles in cost containment, surgical safety, and quality assurance to deliver cost-effective care. Because most orthopaedic surgeons practice independently and are not employed by hospitals, models of physician-hospital alignment (e.g., physician-hospital organizations) or contracted gainsharing arrangements between practices and hospitals may be necessary for successful bundled pricing. Under BPCI, hospitals, surgeons, or third parties share rewards but assume risks for the bundle. For patients, cost savings must be associated with maintenance or improvement in quality metrics. However, the definition of quality can vary, as can the rewards for processes and outcomes. Risk stratification for potential complications should be considered in bundled pricing agreements to prevent the exclusion of patients with substantial comorbidities and higher care costs (e.g., hip fractures treated with prostheses). Bundled pricing depends on economies of scale for success; smaller institutions must be cautious, as 1 costly patient could substantially impact the finances of its entire program. CMS recommends a minimum of 100 to 200 cases yearly. We also suggest that participants utilize technologies to maximize efficiency and provide the best possible environment for implementation of bundled payments. Substantial investment in infrastructure is required to develop programs to improve coordination of care, manage quality data, and distribute payments. Smaller institutions may have difficulty devoting resources to these infrastructural changes, although changes may be implemented more thoroughly once initiated. Herein, we discuss our early total joint arthroplasty BPCI experience at our tertiary-care academic medical center.
{"title":"Single Institution Early Experience with the Bundled Payments for Care Improvement Initiative","authors":"R. Iorio, J. Bosco, J. Slover, Yousuf Sayeed, J. Zuckerman","doi":"10.2106/JBJS.16.00066","DOIUrl":"https://doi.org/10.2106/JBJS.16.00066","url":null,"abstract":"Abstract: The Centers for Medicare & Medicaid Services (CMS) implemented the Bundled Payments for Care Improvement (BPCI) initiative in 2011. Through BPCI, organizations enlisted into payment agreements that include both performance and financial accountability for episodes of care. To succeed, BPCI requires quality maintenance and care delivery at lower costs. This necessitates physicians and hospitals to merge interests. Orthopaedic surgeons must assume leadership roles in cost containment, surgical safety, and quality assurance to deliver cost-effective care. Because most orthopaedic surgeons practice independently and are not employed by hospitals, models of physician-hospital alignment (e.g., physician-hospital organizations) or contracted gainsharing arrangements between practices and hospitals may be necessary for successful bundled pricing. Under BPCI, hospitals, surgeons, or third parties share rewards but assume risks for the bundle. For patients, cost savings must be associated with maintenance or improvement in quality metrics. However, the definition of quality can vary, as can the rewards for processes and outcomes. Risk stratification for potential complications should be considered in bundled pricing agreements to prevent the exclusion of patients with substantial comorbidities and higher care costs (e.g., hip fractures treated with prostheses). Bundled pricing depends on economies of scale for success; smaller institutions must be cautious, as 1 costly patient could substantially impact the finances of its entire program. CMS recommends a minimum of 100 to 200 cases yearly. We also suggest that participants utilize technologies to maximize efficiency and provide the best possible environment for implementation of bundled payments. Substantial investment in infrastructure is required to develop programs to improve coordination of care, manage quality data, and distribute payments. Smaller institutions may have difficulty devoting resources to these infrastructural changes, although changes may be implemented more thoroughly once initiated. Herein, we discuss our early total joint arthroplasty BPCI experience at our tertiary-care academic medical center.","PeriodicalId":22579,"journal":{"name":"The Journal of Bone and Joint Surgery","volume":"29 1","pages":"e2"},"PeriodicalIF":0.0,"publicationDate":"2017-01-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77295049","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}
Background: Pectoralis major tendon ruptures have become increasingly common injuries among young, active individuals over the past 30 years; however, there is presently a paucity of reported outcome data. We investigated the ability to return to full preoperative level of function, complications, reoperation rates, and risk factors for failure following surgical repair of the pectoralis major tendon in a cohort of young, highly active individuals. Methods: All U.S. active-duty military patients undergoing pectoralis major tendon repair between 2008 and 2013 were identified from the Military Health System using the Management Analysis and Reporting Tool (M2). Demographic characteristics, injury characteristics, and trends in preoperative and postoperative self-reported pain scale (0 to 10) and strength were extracted. The ability to return to the full preoperative level of function and rates of rerupture and reoperation were the primary outcome measures. Univariate analysis followed by multivariate analysis identified significant variables. Results: A total of 257 patients with pectoralis major tendon repair were identified with a mean follow-up (and standard deviation) of 47.8 ± 17 months (range, 24 to 90 months). At the time of the latest follow-up, 242 patients (94%) were able to return to the full preoperative level of military function. Fifteen patients (5.8%) were unable to return to duty because of persistent upper-extremity disability. A total of 15 reruptures occurred in 14 patients (5.4%). Increasing body mass index and active psychiatric conditions were significant predictors of inability to return to function (odds ratio, 1.56 [p = 0.0001] for increasing body mass index; and odds ratio, 6.59 [p = 0.00165] for active psychiatric conditions) and total failure (odds ratio, 1.26 [p = 0.0012] for increasing body mass index; and odds ratio, 2.73 [p = 0.0486] for active psychiatric conditions). Conclusions: We demonstrate that 94% of patients were able to return to the full preoperative level of function within active military duty following surgical repair of pectoralis major tendon rupture and 5.4% of patients experienced rerupture after primary repair. Increasing body mass index and active psychiatric diagnoses are significant risk factors for an inability to return to function and postoperative failures. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
{"title":"Return to Function, Complication, and Reoperation Rates Following Primary Pectoralis Major Tendon Repair in Military Service Members","authors":"Drew W Nute, N. Kusnezov, J. Dunn, B. Waterman","doi":"10.2106/JBJS.16.00124","DOIUrl":"https://doi.org/10.2106/JBJS.16.00124","url":null,"abstract":"Background: Pectoralis major tendon ruptures have become increasingly common injuries among young, active individuals over the past 30 years; however, there is presently a paucity of reported outcome data. We investigated the ability to return to full preoperative level of function, complications, reoperation rates, and risk factors for failure following surgical repair of the pectoralis major tendon in a cohort of young, highly active individuals. Methods: All U.S. active-duty military patients undergoing pectoralis major tendon repair between 2008 and 2013 were identified from the Military Health System using the Management Analysis and Reporting Tool (M2). Demographic characteristics, injury characteristics, and trends in preoperative and postoperative self-reported pain scale (0 to 10) and strength were extracted. The ability to return to the full preoperative level of function and rates of rerupture and reoperation were the primary outcome measures. Univariate analysis followed by multivariate analysis identified significant variables. Results: A total of 257 patients with pectoralis major tendon repair were identified with a mean follow-up (and standard deviation) of 47.8 ± 17 months (range, 24 to 90 months). At the time of the latest follow-up, 242 patients (94%) were able to return to the full preoperative level of military function. Fifteen patients (5.8%) were unable to return to duty because of persistent upper-extremity disability. A total of 15 reruptures occurred in 14 patients (5.4%). Increasing body mass index and active psychiatric conditions were significant predictors of inability to return to function (odds ratio, 1.56 [p = 0.0001] for increasing body mass index; and odds ratio, 6.59 [p = 0.00165] for active psychiatric conditions) and total failure (odds ratio, 1.26 [p = 0.0012] for increasing body mass index; and odds ratio, 2.73 [p = 0.0486] for active psychiatric conditions). Conclusions: We demonstrate that 94% of patients were able to return to the full preoperative level of function within active military duty following surgical repair of pectoralis major tendon rupture and 5.4% of patients experienced rerupture after primary repair. Increasing body mass index and active psychiatric diagnoses are significant risk factors for an inability to return to function and postoperative failures. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.","PeriodicalId":22579,"journal":{"name":"The Journal of Bone and Joint Surgery","volume":"67 1","pages":"25–32"},"PeriodicalIF":0.0,"publicationDate":"2017-01-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90925215","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}
K. Fehring, M. Abdel, M. Ollivier, T. Mabry, A. Hanssen
Background: Two-stage exchange arthroplasty after a previous, failed 2-stage exchange procedure is fraught with difficulties, and there are no clear guidelines for treatment or prognosis given the heterogeneous group of patients in whom this procedure has been performed. The Musculoskeletal Infection Society (MSIS) staging system was developed in an attempt to stratify patients according to infection type, host status, and local soft-tissue status. The purpose of this study was to report the results of 2-stage exchange arthroplasty following a previous, failed 2-stage exchange protocol for periprosthetic knee infection as well as to identify risk factors for failure. Methods: We retrospectively identified 45 patients who had undergone 2 or more 2-stage exchange arthroplasties for periprosthetic knee infection from 2000 to 2013. Patients were stratified according to the MSIS system, and risk factors for failure were analyzed. The minimum follow-up was 2 years (mean, 6 years; range, 24 to 132 months). Results: At the time of follow-up, twenty-two (49%) of the patients had undergone another revision due to infection and 28 (62%) had undergone another revision for any reason. The infection recurred in 6 (75%) of 8 substantially immunocompromised hosts (MSIS type C) and in 3 (30%) of 10 uncompromised hosts (type A) following the second 2-stage exchange arthroplasty (p = 0.06). The infection recurred in 4 (80%) of 5 patients with compromise of the extremity (MSIS type 3) and 3 (33%) of 9 patients with an uncompromised extremity (type 1) (p = 0.27). Both extremely compromised hosts with an extremely compromised extremity (type C3) had recurrence of the infection whereas 3 (30%) of the 10 uncompromised patients with no or less compromise of the extremity (type A1 or A2) did. Five patients in the failure group underwent a third 2-stage exchange arthroplasty following reinfection, and 3 of them were infection-free at the time of the latest follow-up. Conclusions: Uncompromised hosts (MSIS type A) with an acceptable wound (MSIS type 1 or 2) had a 70% rate of success (7 of 10) after a repeat 2-stage exchange arthroplasty, whereas type-B2 hosts had a 50% success rate (10 of 20). The repeat 2-stage exchange procedure failed in both type-C3 hosts; thus, alternative salvage procedures should be considered for such patients. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
{"title":"Repeat Two-Stage Exchange Arthroplasty for Periprosthetic Knee Infection Is Dependent on Host Grade","authors":"K. Fehring, M. Abdel, M. Ollivier, T. Mabry, A. Hanssen","doi":"10.2106/JBJS.16.00075","DOIUrl":"https://doi.org/10.2106/JBJS.16.00075","url":null,"abstract":"Background: Two-stage exchange arthroplasty after a previous, failed 2-stage exchange procedure is fraught with difficulties, and there are no clear guidelines for treatment or prognosis given the heterogeneous group of patients in whom this procedure has been performed. The Musculoskeletal Infection Society (MSIS) staging system was developed in an attempt to stratify patients according to infection type, host status, and local soft-tissue status. The purpose of this study was to report the results of 2-stage exchange arthroplasty following a previous, failed 2-stage exchange protocol for periprosthetic knee infection as well as to identify risk factors for failure. Methods: We retrospectively identified 45 patients who had undergone 2 or more 2-stage exchange arthroplasties for periprosthetic knee infection from 2000 to 2013. Patients were stratified according to the MSIS system, and risk factors for failure were analyzed. The minimum follow-up was 2 years (mean, 6 years; range, 24 to 132 months). Results: At the time of follow-up, twenty-two (49%) of the patients had undergone another revision due to infection and 28 (62%) had undergone another revision for any reason. The infection recurred in 6 (75%) of 8 substantially immunocompromised hosts (MSIS type C) and in 3 (30%) of 10 uncompromised hosts (type A) following the second 2-stage exchange arthroplasty (p = 0.06). The infection recurred in 4 (80%) of 5 patients with compromise of the extremity (MSIS type 3) and 3 (33%) of 9 patients with an uncompromised extremity (type 1) (p = 0.27). Both extremely compromised hosts with an extremely compromised extremity (type C3) had recurrence of the infection whereas 3 (30%) of the 10 uncompromised patients with no or less compromise of the extremity (type A1 or A2) did. Five patients in the failure group underwent a third 2-stage exchange arthroplasty following reinfection, and 3 of them were infection-free at the time of the latest follow-up. Conclusions: Uncompromised hosts (MSIS type A) with an acceptable wound (MSIS type 1 or 2) had a 70% rate of success (7 of 10) after a repeat 2-stage exchange arthroplasty, whereas type-B2 hosts had a 50% success rate (10 of 20). The repeat 2-stage exchange procedure failed in both type-C3 hosts; thus, alternative salvage procedures should be considered for such patients. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.","PeriodicalId":22579,"journal":{"name":"The Journal of Bone and Joint Surgery","volume":"29 1","pages":"19–24"},"PeriodicalIF":0.0,"publicationDate":"2017-01-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80074480","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}
Background: The Association of American Medical Colleges publishes residency match data and reports through the National Resident Matching Program (NRMP) every year. The purpose of this study was to analyze trends in orthopaedic surgery residency matching data and characteristics of successful applicants to counsel medical students with regard to their chances of matching. Methods: The annual reports of the NRMP were searched annually from 2006 to 2014 to determine the number of orthopaedic surgery residency positions available, the number of applicants, and the match rate among applicants. Comparisons were performed between matched applicants and unmatched applicants with regard to the number of contiguous ranks and distinct specialties, United States Medical Licensing Examination (USMLE) scores, number of research experiences and research products (abstracts, presentations, posters, publications), and proportion of Alpha Omega Alpha (AOA) Honor Medical Society members and students at a top-40, National Institutes of Health (NIH)-funded medical school. Results: The number of orthopaedic surgery positions available and number of applicants increased at a mean rate of 9 positions and 65 applicants per year (p = 0.11). The mean number of contiguous ranks for U.S. senior medical students was 11.5 for those who matched and 5.5 for those who did not match (p < 0.0001). The USMLE scores for applicants who matched were significantly greater than for those who did not match in each category: Step-1 scores for U.S. seniors (p < 0.001) and independent applicants (p = 0.039), and Step-2 scores for U.S. seniors (p < 0.01) and independent applicants (p = 0.026). The mean number of research products was significantly greater for matched U.S. seniors compared with unmatched U.S. seniors (p = 0.035). A significantly higher proportion of matched U.S. seniors compared with unmatched U.S. seniors were AOA members and students at a top-40, NIH-funded medical school (both p < 0.0001). Conclusions: Successful applicants in the Match for orthopaedic surgery residency have higher USMLE Step-1 and 2 scores, number of research experiences and research products, and contiguous ranks. A higher proportion of successful applicants are AOA members and students at a top-40, NIH-funded medical school.
{"title":"A Comparison of Matched and Unmatched Orthopaedic Surgery Residency Applicants from 2006 to 2014: Data from the National Resident Matching Program","authors":"J. Schrock, M. Kraeutler, M. Dayton, E. McCarty","doi":"10.2106/JBJS.16.00293","DOIUrl":"https://doi.org/10.2106/JBJS.16.00293","url":null,"abstract":"Background: The Association of American Medical Colleges publishes residency match data and reports through the National Resident Matching Program (NRMP) every year. The purpose of this study was to analyze trends in orthopaedic surgery residency matching data and characteristics of successful applicants to counsel medical students with regard to their chances of matching. Methods: The annual reports of the NRMP were searched annually from 2006 to 2014 to determine the number of orthopaedic surgery residency positions available, the number of applicants, and the match rate among applicants. Comparisons were performed between matched applicants and unmatched applicants with regard to the number of contiguous ranks and distinct specialties, United States Medical Licensing Examination (USMLE) scores, number of research experiences and research products (abstracts, presentations, posters, publications), and proportion of Alpha Omega Alpha (AOA) Honor Medical Society members and students at a top-40, National Institutes of Health (NIH)-funded medical school. Results: The number of orthopaedic surgery positions available and number of applicants increased at a mean rate of 9 positions and 65 applicants per year (p = 0.11). The mean number of contiguous ranks for U.S. senior medical students was 11.5 for those who matched and 5.5 for those who did not match (p < 0.0001). The USMLE scores for applicants who matched were significantly greater than for those who did not match in each category: Step-1 scores for U.S. seniors (p < 0.001) and independent applicants (p = 0.039), and Step-2 scores for U.S. seniors (p < 0.01) and independent applicants (p = 0.026). The mean number of research products was significantly greater for matched U.S. seniors compared with unmatched U.S. seniors (p = 0.035). A significantly higher proportion of matched U.S. seniors compared with unmatched U.S. seniors were AOA members and students at a top-40, NIH-funded medical school (both p < 0.0001). Conclusions: Successful applicants in the Match for orthopaedic surgery residency have higher USMLE Step-1 and 2 scores, number of research experiences and research products, and contiguous ranks. A higher proportion of successful applicants are AOA members and students at a top-40, NIH-funded medical school.","PeriodicalId":22579,"journal":{"name":"The Journal of Bone and Joint Surgery","volume":"179 1","pages":"e1"},"PeriodicalIF":0.0,"publicationDate":"2017-01-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80082100","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}
J. Clohisy, J. Ackerman, Geneva R. Baca, J. Baty, P. Beaulé, Young-Jo Kim, M. Millis, D. Podeszwa, P. Schoenecker, R. Sierra, Ernest L Sink, D. Sucato, R. Trousdale, I. Zaltz
Background: Current literature describing the periacetabular osteotomy (PAO) is mostly limited to retrospective case series. Larger, prospective cohort studies are needed to provide better clinical evidence regarding this procedure. The goals of the current study were to (1) report minimum 2-year patient-reported outcomes (pain, hip function, activity, overall health, and quality of life), (2) investigate preoperative clinical and disease characteristics as predictors of clinical outcomes, and (3) report the rate of early failures and reoperations in patients undergoing contemporary PAO surgery. Methods: A large, prospective, multicenter cohort of PAO procedures was established, and outcomes at a minimum of 2 years were analyzed. A total of 391 hips were included for analysis (79% of the patients were female, and the average patient age was 25.4 years). Patient-reported outcomes, conversion to total hip replacement, reoperations, and major complications were documented. Variables with a p value of ⩽0.10 in the univariate linear regressions were included in the multivariate linear regression. The backward stepwise selection method was used to determine the final risk factors of clinical outcomes. Results: Clinical outcome analysis demonstrated major clinically important improvements in pain, function, quality of life, overall health, and activity level. Increasing age and a body mass index status of overweight or obese were predictive of improved results for certain outcome metrics. Male sex and mild acetabular dysplasia were predictive of lesser improvements in certain outcome measures. Three (0.8%) of the hips underwent early conversion to total hip arthroplasty, 12 (3%) required reoperation, and 26 (7%) experienced a major complication. Conclusions: This large, prospective cohort study demonstrated the clinical success of contemporary PAO surgery for the treatment of symptomatic acetabular dysplasia. Patient and disease characteristics demonstrated predictive value that should be considered in surgical decision-making. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
{"title":"Patient-Reported Outcomes of Periacetabular Osteotomy from the Prospective ANCHOR Cohort Study","authors":"J. Clohisy, J. Ackerman, Geneva R. Baca, J. Baty, P. Beaulé, Young-Jo Kim, M. Millis, D. Podeszwa, P. Schoenecker, R. Sierra, Ernest L Sink, D. Sucato, R. Trousdale, I. Zaltz","doi":"10.2106/JBJS.15.00798","DOIUrl":"https://doi.org/10.2106/JBJS.15.00798","url":null,"abstract":"Background: Current literature describing the periacetabular osteotomy (PAO) is mostly limited to retrospective case series. Larger, prospective cohort studies are needed to provide better clinical evidence regarding this procedure. The goals of the current study were to (1) report minimum 2-year patient-reported outcomes (pain, hip function, activity, overall health, and quality of life), (2) investigate preoperative clinical and disease characteristics as predictors of clinical outcomes, and (3) report the rate of early failures and reoperations in patients undergoing contemporary PAO surgery. Methods: A large, prospective, multicenter cohort of PAO procedures was established, and outcomes at a minimum of 2 years were analyzed. A total of 391 hips were included for analysis (79% of the patients were female, and the average patient age was 25.4 years). Patient-reported outcomes, conversion to total hip replacement, reoperations, and major complications were documented. Variables with a p value of ⩽0.10 in the univariate linear regressions were included in the multivariate linear regression. The backward stepwise selection method was used to determine the final risk factors of clinical outcomes. Results: Clinical outcome analysis demonstrated major clinically important improvements in pain, function, quality of life, overall health, and activity level. Increasing age and a body mass index status of overweight or obese were predictive of improved results for certain outcome metrics. Male sex and mild acetabular dysplasia were predictive of lesser improvements in certain outcome measures. Three (0.8%) of the hips underwent early conversion to total hip arthroplasty, 12 (3%) required reoperation, and 26 (7%) experienced a major complication. Conclusions: This large, prospective cohort study demonstrated the clinical success of contemporary PAO surgery for the treatment of symptomatic acetabular dysplasia. Patient and disease characteristics demonstrated predictive value that should be considered in surgical decision-making. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.","PeriodicalId":22579,"journal":{"name":"The Journal of Bone and Joint Surgery","volume":"27 1","pages":"33–41"},"PeriodicalIF":0.0,"publicationDate":"2017-01-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90299855","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}
Background: Severe hip contractures in arthrogrypsosis are multiplanar, which can preclude or can greatly complicate sitting and ambulation. The reorientational osteotomy at the intertrochanteric level preserves preoperative hip motion but moves it to a more functional domain. We retrospectively compared preoperative and postoperative hip motion and evaluated the ambulatory abilities of patients who underwent the procedure. Methods: Since 2008, 65 patients with arthrogryposis had 119 reorientational proximal femoral osteotomies with a minimum follow-up of 2 years. The mean patient age at the time of the surgical procedure was 48 months. An intertrochanteric wedge osteotomy aligned the femoral shaft with the body axis, leaving the hip joint in its preexisting position. A cannulated hip blade plate was used for fixation. Hip motions were recorded preoperatively, at implant removal, and at the time of the latest follow-up, as was ambulatory ability. Results: Eighty-one hips had a mean flexion contracture of 52° preoperatively, which improved by 35°; 84 hips with a mean preoperative adduction of −20° improved by 42°; 101 hips with a mean preoperative internal rotation of −16° improved by 35° (p < 0.0001 for all). The flexion-extension total arc of motion for the 119 hips improved by 13° (p < 0.0001). Only 11 of 94 hips that preoperatively flexed ≥90° did not do so postoperatively, but none of the patients reported seating difficulties and one of the patients had already regained hip flexion of >90° by a soft-tissue release. At a mean follow-up of 40 months, 36 patients were independently ambulatory and 20 patients were walker-dependent. Conclusions: Children with arthrogryposis often have the potential for ambulation if the limb positioning can be optimized. The reorientational hip osteotomy corrects the hip contractures by altering the range of motion but not the total arc of motion. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
{"title":"Reorientational Proximal Femoral Osteotomies for Arthrogrypotic Hip Contractures","authors":"H. V. van Bosse, R. Saldana","doi":"10.2106/JBJS.16.00304","DOIUrl":"https://doi.org/10.2106/JBJS.16.00304","url":null,"abstract":"Background: Severe hip contractures in arthrogrypsosis are multiplanar, which can preclude or can greatly complicate sitting and ambulation. The reorientational osteotomy at the intertrochanteric level preserves preoperative hip motion but moves it to a more functional domain. We retrospectively compared preoperative and postoperative hip motion and evaluated the ambulatory abilities of patients who underwent the procedure. Methods: Since 2008, 65 patients with arthrogryposis had 119 reorientational proximal femoral osteotomies with a minimum follow-up of 2 years. The mean patient age at the time of the surgical procedure was 48 months. An intertrochanteric wedge osteotomy aligned the femoral shaft with the body axis, leaving the hip joint in its preexisting position. A cannulated hip blade plate was used for fixation. Hip motions were recorded preoperatively, at implant removal, and at the time of the latest follow-up, as was ambulatory ability. Results: Eighty-one hips had a mean flexion contracture of 52° preoperatively, which improved by 35°; 84 hips with a mean preoperative adduction of −20° improved by 42°; 101 hips with a mean preoperative internal rotation of −16° improved by 35° (p < 0.0001 for all). The flexion-extension total arc of motion for the 119 hips improved by 13° (p < 0.0001). Only 11 of 94 hips that preoperatively flexed ≥90° did not do so postoperatively, but none of the patients reported seating difficulties and one of the patients had already regained hip flexion of >90° by a soft-tissue release. At a mean follow-up of 40 months, 36 patients were independently ambulatory and 20 patients were walker-dependent. Conclusions: Children with arthrogryposis often have the potential for ambulation if the limb positioning can be optimized. The reorientational hip osteotomy corrects the hip contractures by altering the range of motion but not the total arc of motion. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.","PeriodicalId":22579,"journal":{"name":"The Journal of Bone and Joint Surgery","volume":"44 1","pages":"55–64"},"PeriodicalIF":0.0,"publicationDate":"2017-01-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79956805","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}
Background: Opioid use is endemic in the U.S. and is associated with morbidity and mortality. The impact of long-term opioid use on joint-replacement outcomes remains unknown. We tested the hypothesis that use of opioids is associated with adverse outcomes after total knee arthroplasty (TKA). Methods: We performed a retrospective analysis of patients who had had TKA within the U.S. Veterans Affairs (VA) system over a 6-year period and had been followed for 1 year postoperatively. The length of time for which an opioid had been prescribed and the morphine equivalent dose were calculated for each patient. Patients for whom opioids had been prescribed for >3 months in the year prior to the TKA were assigned to the long-term opioid group. A natural language processing-based machine-learning classifier was developed to classify revisions due to infectious and non-infectious causes on the basis of the postoperative note. Survival curves for the time to knee revision or manipulation were used to compare the long-term opioid group with the patients who did not take opioids long-term. Hazard and odds ratios for knee revision and manipulation were obtained as well. Results: Of 32,636 patients (94.4% male; mean age [and standard deviation], 64.45 ± 9.41 years) who underwent TKA, 12,772 (39.1%) were in the long-term opioid group and 734 (2.2%) had a revision within a year after the TKA. Chronic kidney disease, diabetes, and long-term opioid use were associated with revision within 1 year—with odds ratios (95% confidence intervals [CIs]) of 1.76 (1.37 to 2.22), 1.11 (0.93 to 1.31), and 1.40 (1.19 to 1.64), respectively—and were also the leading factors associated with a revision at any time after the index TKA—with odds ratios (95% CIs) of 1.61 (1.34 to 1.92), 1.21 (1.08 to 1.36), and 1.28 (1.15 to 1.43), respectively. Long-term opioid use had a hazard ratio of 1.19 (95% CI = 1.10 to 0.24) in the analysis of its relationship with knee revision, but the hazard was not significant in the analysis of its association with knee manipulation. The accuracy of the text classifier was 0.94, with the area under the receiver operating characteristic curve being 0.99. There was no association between long-term use of opioids and the specific cause for knee revision. Conclusions: Long-term opioid use prior to TKA was associated with an increased risk of knee revision during the first year after TKA among predominantly male patients treated in the VA system. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
{"title":"Preoperative Opioid Use Is Associated with Early Revision After Total Knee Arthroplasty: A Study of Male Patients Treated in the Veterans Affairs System","authors":"A. Ben-Ari, H. Chansky, I. Rozet","doi":"10.2106/JBJS.16.00167","DOIUrl":"https://doi.org/10.2106/JBJS.16.00167","url":null,"abstract":"Background: Opioid use is endemic in the U.S. and is associated with morbidity and mortality. The impact of long-term opioid use on joint-replacement outcomes remains unknown. We tested the hypothesis that use of opioids is associated with adverse outcomes after total knee arthroplasty (TKA). Methods: We performed a retrospective analysis of patients who had had TKA within the U.S. Veterans Affairs (VA) system over a 6-year period and had been followed for 1 year postoperatively. The length of time for which an opioid had been prescribed and the morphine equivalent dose were calculated for each patient. Patients for whom opioids had been prescribed for >3 months in the year prior to the TKA were assigned to the long-term opioid group. A natural language processing-based machine-learning classifier was developed to classify revisions due to infectious and non-infectious causes on the basis of the postoperative note. Survival curves for the time to knee revision or manipulation were used to compare the long-term opioid group with the patients who did not take opioids long-term. Hazard and odds ratios for knee revision and manipulation were obtained as well. Results: Of 32,636 patients (94.4% male; mean age [and standard deviation], 64.45 ± 9.41 years) who underwent TKA, 12,772 (39.1%) were in the long-term opioid group and 734 (2.2%) had a revision within a year after the TKA. Chronic kidney disease, diabetes, and long-term opioid use were associated with revision within 1 year—with odds ratios (95% confidence intervals [CIs]) of 1.76 (1.37 to 2.22), 1.11 (0.93 to 1.31), and 1.40 (1.19 to 1.64), respectively—and were also the leading factors associated with a revision at any time after the index TKA—with odds ratios (95% CIs) of 1.61 (1.34 to 1.92), 1.21 (1.08 to 1.36), and 1.28 (1.15 to 1.43), respectively. Long-term opioid use had a hazard ratio of 1.19 (95% CI = 1.10 to 0.24) in the analysis of its relationship with knee revision, but the hazard was not significant in the analysis of its association with knee manipulation. The accuracy of the text classifier was 0.94, with the area under the receiver operating characteristic curve being 0.99. There was no association between long-term use of opioids and the specific cause for knee revision. Conclusions: Long-term opioid use prior to TKA was associated with an increased risk of knee revision during the first year after TKA among predominantly male patients treated in the VA system. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.","PeriodicalId":22579,"journal":{"name":"The Journal of Bone and Joint Surgery","volume":"97 1","pages":"1–9"},"PeriodicalIF":0.0,"publicationDate":"2017-01-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80537101","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}
C. Brusalis, Apurva S. Shah, X. Luan, Meaghan Lutts, W. Sankar
Background: Dedicated orthopaedic trauma operating rooms have improved operating room efficiency, physician schedules, and patient outcomes in adult populations. The purpose of this study was to determine if a dedicated orthopaedic trauma operating room was associated with improved patient flow and cost savings at a level-I pediatric trauma center. Methods: A retrospective analysis was performed for two 3-year intervals before and after implementation of a weekday, unbooked operating room reserved for orthopaedic trauma cases. Index procedures for 5 common fractures were investigated, including supracondylar humeral fractures, both bone forearm fractures, lateral condylar fractures, tibial fractures, and femoral fractures. To provide a control group to account for potential extrinsic changes in hospital efficiency, laparoscopic appendectomies were also analyzed. For each procedure, efficiency parameters and surgical complications, defined as unplanned reoperations, were compared between time periods. The mean cost reduction per patient was calculated on the basis of the mean daily cost of an inpatient hospital bed. Results: Of 1,469 orthopaedic procedures analyzed, 719 cases occurred before the implementation of the dedicated orthopaedic trauma operating room, and 750 cases were performed after the implementation. The frequency of after-hours procedures (5 P.M. to 7 A.M.) was reduced by 48% (p < 0.001). The mean wait time for the operating room decreased among supracondylar humeral fractures, lateral condylar fractures, and tibial fractures, whereas no significant decrease (p = 0.302) occurred among 2,076 laparoscopic appendectomy cases. The mean duration of the surgical procedure and the mean time in the operating room were not significantly affected. Across all orthopaedic procedures, the mean duration of inpatient hospitalization decreased by 5.6 hours (p < 0.001), but no significant difference occurred among appendectomies. Decreased length of stay resulted in a mean cost reduction of $1,251 per patient. Supracondylar humeral fracture cases performed after implementation of the dedicated orthopaedic trauma operating room had fewer surgical complications (p = 0.018). No difference in complication rate was detected among the other orthopaedic procedures. Conclusions: A dedicated orthopaedic trauma operating room in a pediatric trauma center was associated with fewer after-hours procedures, decreased wait time to the surgical procedure, reduced length of hospitalization, and decreased cost.
{"title":"A Dedicated Orthopaedic Trauma Operating Room Improves Efficiency at a Pediatric Center","authors":"C. Brusalis, Apurva S. Shah, X. Luan, Meaghan Lutts, W. Sankar","doi":"10.2106/JBJS.16.00640","DOIUrl":"https://doi.org/10.2106/JBJS.16.00640","url":null,"abstract":"Background: Dedicated orthopaedic trauma operating rooms have improved operating room efficiency, physician schedules, and patient outcomes in adult populations. The purpose of this study was to determine if a dedicated orthopaedic trauma operating room was associated with improved patient flow and cost savings at a level-I pediatric trauma center. Methods: A retrospective analysis was performed for two 3-year intervals before and after implementation of a weekday, unbooked operating room reserved for orthopaedic trauma cases. Index procedures for 5 common fractures were investigated, including supracondylar humeral fractures, both bone forearm fractures, lateral condylar fractures, tibial fractures, and femoral fractures. To provide a control group to account for potential extrinsic changes in hospital efficiency, laparoscopic appendectomies were also analyzed. For each procedure, efficiency parameters and surgical complications, defined as unplanned reoperations, were compared between time periods. The mean cost reduction per patient was calculated on the basis of the mean daily cost of an inpatient hospital bed. Results: Of 1,469 orthopaedic procedures analyzed, 719 cases occurred before the implementation of the dedicated orthopaedic trauma operating room, and 750 cases were performed after the implementation. The frequency of after-hours procedures (5 P.M. to 7 A.M.) was reduced by 48% (p < 0.001). The mean wait time for the operating room decreased among supracondylar humeral fractures, lateral condylar fractures, and tibial fractures, whereas no significant decrease (p = 0.302) occurred among 2,076 laparoscopic appendectomy cases. The mean duration of the surgical procedure and the mean time in the operating room were not significantly affected. Across all orthopaedic procedures, the mean duration of inpatient hospitalization decreased by 5.6 hours (p < 0.001), but no significant difference occurred among appendectomies. Decreased length of stay resulted in a mean cost reduction of $1,251 per patient. Supracondylar humeral fracture cases performed after implementation of the dedicated orthopaedic trauma operating room had fewer surgical complications (p = 0.018). No difference in complication rate was detected among the other orthopaedic procedures. Conclusions: A dedicated orthopaedic trauma operating room in a pediatric trauma center was associated with fewer after-hours procedures, decreased wait time to the surgical procedure, reduced length of hospitalization, and decreased cost.","PeriodicalId":22579,"journal":{"name":"The Journal of Bone and Joint Surgery","volume":"114 1","pages":"42–47"},"PeriodicalIF":0.0,"publicationDate":"2017-01-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85389375","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}
E. Swart, Paulvalery Roulette, Daniel Leas, K. Bozic, M. Karunakar
Background: The decision between open reduction and internal fixation (ORIF) and arthroplasty for a displaced femoral neck fracture in a patient ⩽65 years old can be challenging. Both options have potential drawbacks; if a fracture treated with ORIF fails to heal it may require a revision operation, whereas a relatively young patient who undergoes arthroplasty may need revision within his/her lifetime. The purpose of this study was to employ decision analysis modeling techniques to generate evidence-based treatment recommendations in this clinical scenario. Methods: A Markov decision analytic model was created to simulate outcomes after ORIF, total hip arthroplasty (THA), or hemiarthroplasty in patients who had sustained a displaced femoral neck fracture between the ages of 40 and 65 years. The variables in the model were populated with values from studies with high-level evidence and from national registry data reported in the literature. The model was used to estimate the threshold age above which THA would be the superior strategy. Results were tested using sensitivity analysis and probabilistic statistical analysis. Results: THA was found to be a cost-effective option for a displaced femoral neck fracture in an otherwise healthy patient who is >54 years old, a patient with mild comorbidity who is >47 years old, and a patient with multiple comorbidities who is >44 years old. The average clinical outcomes of THA and ORIF were similar for patients 40 to 65 years old, although ORIF had a wider variability in outcomes based on the success or failure of the initial fixation. For all ages and cases, hemiarthroplasty was associated with worse outcomes and higher costs. Conclusions: Compared with ORIF, primary THA can be a cost-effective treatment for displaced femoral neck fractures in patients 45 to 65 years of age, with the age cutoff favoring THA decreasing as the medical comorbidity and risk of ORIF fixation failure increase. Hemiarthroplasty has worse outcomes at higher costs and is not recommended in this age group. Level of Evidence: Economic and decision analysis Level III. See Instructions for Authors for a complete description of levels of evidence.
{"title":"ORIF or Arthroplasty for Displaced Femoral Neck Fractures in Patients Younger Than 65 Years Old: An Economic Decision Analysis","authors":"E. Swart, Paulvalery Roulette, Daniel Leas, K. Bozic, M. Karunakar","doi":"10.2106/JBJS.16.00406","DOIUrl":"https://doi.org/10.2106/JBJS.16.00406","url":null,"abstract":"Background: The decision between open reduction and internal fixation (ORIF) and arthroplasty for a displaced femoral neck fracture in a patient ⩽65 years old can be challenging. Both options have potential drawbacks; if a fracture treated with ORIF fails to heal it may require a revision operation, whereas a relatively young patient who undergoes arthroplasty may need revision within his/her lifetime. The purpose of this study was to employ decision analysis modeling techniques to generate evidence-based treatment recommendations in this clinical scenario. Methods: A Markov decision analytic model was created to simulate outcomes after ORIF, total hip arthroplasty (THA), or hemiarthroplasty in patients who had sustained a displaced femoral neck fracture between the ages of 40 and 65 years. The variables in the model were populated with values from studies with high-level evidence and from national registry data reported in the literature. The model was used to estimate the threshold age above which THA would be the superior strategy. Results were tested using sensitivity analysis and probabilistic statistical analysis. Results: THA was found to be a cost-effective option for a displaced femoral neck fracture in an otherwise healthy patient who is >54 years old, a patient with mild comorbidity who is >47 years old, and a patient with multiple comorbidities who is >44 years old. The average clinical outcomes of THA and ORIF were similar for patients 40 to 65 years old, although ORIF had a wider variability in outcomes based on the success or failure of the initial fixation. For all ages and cases, hemiarthroplasty was associated with worse outcomes and higher costs. Conclusions: Compared with ORIF, primary THA can be a cost-effective treatment for displaced femoral neck fractures in patients 45 to 65 years of age, with the age cutoff favoring THA decreasing as the medical comorbidity and risk of ORIF fixation failure increase. Hemiarthroplasty has worse outcomes at higher costs and is not recommended in this age group. Level of Evidence: Economic and decision analysis Level III. See Instructions for Authors for a complete description of levels of evidence.","PeriodicalId":22579,"journal":{"name":"The Journal of Bone and Joint Surgery","volume":"61 1","pages":"65–75"},"PeriodicalIF":0.0,"publicationDate":"2017-01-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84969236","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}
京公网安备 11010802042870号
京ICP备2023020795号-1
扫码关注我们
求助内容：
应助结果提醒方式：