Volume 31-4, Winter 2022

Publication Trends of Residents Accepted for Shoulder and Elbow Fellowships - Austin B. Fares, MD; Jordan T. Carter, BS; Andrew G. Chan, MD, MPH; Rami Khalifa, MD, PhD; Kelly G. Kilcoyne, MD; and William M. Weiss, MD

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This study aims to evaluate the research productivity trends in orthopaedic residents who were selected for shoulder and elbow fellowships from 2010 to 2019. We hypothesize that residents matching into orthopaedic shoulder and elbow fellowships are increasing both their publication number and publication quality from 2010 to 2019. Fellows of orthopaedic shoulder and elbow programs from 2010 to 2019 were identified through publicly accessible information on fellowship programs. Each fellow’s publication data during their residency was collected via publicly available search engines, and analyzed to include: fellowship year, residency years, fellowship program and location, total publications, number of publications in high-impact general orthopaedic and shoulder and elbow journals, and authorship position. A total of 176 orthopaedic shoulder and elbow fellows from 17 different programs were identified and included in the study. The fellows produced a total of 668 publications, published 172 articles in high impact journals, and had first authorship on 49% of the studies. On average, there were 3.8 publications per fellow per year from 2010 to 2019. There were 5.7 publications produced per fellow in 2018–2019, compared to just 2.92 publications per fellow in 2010–2011. Overall, there was an increasing trend in publications, publications in high impact journals, and first authorship publications per applicant matching into shoulder and elbow fellowship from 2010 to 2019. (Journal of Surgical Orthopaedic Advances 31(4):205–208, 2022)

Key words: shoulder and elbow, orthopaedic surgery fellowship, research, publications, orthopaedic surgery residency

Post-operative Immobilization in Total Elbow Arthroplasty for Rheumatoid Arthritis: A Systematic Review of Outcomes - Michael M. Polmear, MD; John P. Scanaliato, MD; Stephen Rossettie, BS, MBA; Julia Bader, PhD; Leon J. Nesti, MD, PhD; and John C. Dunn, MD

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The purpose of this analysis is to determine the effect of length of immobilization following total elbow arthroplasty (TEA) for rheumatoid arthritis on the outcomes, complications, and survival of the implant. A review of TEA literature was performed. Post-operative motion was categorized into three groups: no post-operative immobilization (group 1), short-term 2–5 days immobilization (group 2), and extended 7–14 days immobilization (group 3). Thirty-six articles reporting on 43 studies involving 2,346 elbows in 2015 patients were included. Total complication rates were 23% at 8.9 years for group 1, 31% at 6.8 years for group 2, and 31% at 6.9 years for group 3. Survival rates were 79% at 15.3 years, 75% at 10.4 years, and 92% at 9.1 years for each group, respectively. Total complication rates were lowest in elbows without post-operative immobilization. However, survival rates were greatest in elbows with extended post-operative immobilization. (Journal of Surgical Orthopaedic Advances 31(4):209–217, 2022)

Key words: total elbow arthroplasty, rheumatoid arthritis, post-operative immobilization, complications, survival

Impact of Certificate of Need on Lumbar Discectomy Reimbursement and Utilization - Chason Ziino, MD; Abiram Bala, MD; Shay Warren, MD; and Ivan Cheng, MD

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The Certificate of Need (CON) program was established to respond to increasing healthcare costs; however, its impact on spine surgery trends is not well understood. The purpose of this study was to evaluate the impact of CON status on utilization of single-level lumbar discectomy. A combined Medicare and private payer database was used to identify single level lumbar discectomies performed from 2007 to 2015. Utilization and reimbursement trends were compared using the compound annual growth rate (CAGR) with reimbursement adjusted by the consumer price index. For this study, 30,617 lumbar discectomies were analyzed. Procedure utilization increased across all settings. CAGR was highest in the outpatient CON group (19.7%) and lowest in the inpatient non-CON group (0.5%). Reimbursement increased in the outpatient setting (CAGR: 1.2% CON, 1.0% non- CON), but decreased in the inpatient setting (CAGR: -6.1% CON, -5.5% non-CON). These trends are important to consider in a value-based healthcare environment. (Journal of Surgical Orthopaedic Advances 31(4):218–221, 2022)

Key words: certificate-of-need, lumbar discectomy, cost, government regulation

Severity of Covid-19 Lockdown Orders Corresponds to Orthopaedic Trauma Volume - Kasa B. Cooper, MD; Adam K. Lee, MD; Douglass W. Tucker, MD; Eric Siegel, MS; Simon C. Mears, MD PhD; and Steven M. Cherney, MD

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During the Coronavirus Disease 2019 (COVID-19) pandemic, states implemented social distancing guidelines. This study examines the effect of the severity of lockdown orders on orthopaedic trauma volume. Two institutions, one in a state with strict stay home (SH) orders and one in a state with lax social distancing (SD) orders, were examined. Surgical case counts, total orthopaedic case counts, orthopaedic trauma case counts, institution trauma activations, and mechanism of injury data were collected and compared to control periods. For SH versus SD, total surgical cases decreased 48.6% vs. 62%; orthopaedic cases decreased 51.8% vs. 62%, and orthopaedic trauma cases decreased 34% v. 0%. Orthopaedic trauma cases comprised more of both institutions’ total cases. Total surgical cases decreased at both SH and SD, but orthopaedic trauma cases did not decrease at SD. More strict social distancing orders correlate with greater reduction in orthopaedic trauma cases. (Journal of Surgical Orthopaedic Advances 31(4):222–225, 2022)

Key words: Coronavirus 2019, COVID-19, orthopaedic trauma, social distancing, pandemic, lockdown

The Impact of COVID-19 on Surgical Volume and Productivity at an Academic Orthopaedic Surgery Department - Jay M. Levin, MD, MBA; Elshaday Belay, MD; Craig Akoh, MD; and Oke Anakwenze, MD, MBA

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COVID-19 pandemic rapidly progressed, resulting in temporary cessation of elective surgery in the U.S. The goal of this study was to evaluate the impact of COVID-19 on surgical volume, charges, work relative value units (WRVUs), and net receipts at an academic orthopaedic surgery department. Volume of cases per month decreased from 745 cases in February to 173 cases in April, with a 75% decrease in charges and a 73% decrease in WRVUs. The largest decreases in productivity were in Sports (92% decrease in charges and WRVUs), Pediatrics (88% decrease in charges, 87% decrease in WRVUs), and Joints (81% decrease in charges, 78% decrease in WRVUs). Oncology was least impacted (27% decrease in charges, 20% decrease in WRVUs). Recovery after shutdown was rapid, with charges and WRVUs returning to pre-COVID levels by June. Productivity of the Sports, Pediatrics and Joints were most impacted, while Oncology, Hand, and Trauma were least impacted. (Journal of Surgical Orthopaedic Advances 31(4):226–229, 2022)

Key words: COVID, WRVU, charges, cancellation, coronavirus, academic

Reliability Testing of the Mayo Elbow Performance Score in Post-operative Patients - Aaron Baessler, MD; Robert Renn Eason, BS, MS; Myles R. Joyce, BS; Daniel T. Dibaba, PhD; Jim Y. Wan, PhD; Frederick M. Azar, MD; Tyler J. Brolin, MD; and Thomas W. Throckmorton, MD

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This study aimed to determine intra-observer and inter-observer reliability of the Mayo Elbow Performance Score (MEPS). Patients undergoing elbow surgery completed a MEPS questionnaire initially and another 2–3 weeks later. During the second interview, patients completed the Oxford Elbow Score (OES) for comparison. Intraclass correlation coefficients (ICC) and Pearson correlation coefficients (PCC) > 0.80 indicated substantial agreement. In 42 patients who had elbow surgery, the average MEPS score initially was 78 (range, 5–100, SD 22.4) and 77 (range, 5–100, SD 21.5) at second interview. The average normalized OES score was 79 (range, 17–100, SD 23.6). The ICC for MEPS scores at the two time points was 0.90, and the PCC between the MEPS and OES scores was 0.87, indicating substantial agreement. The MEPS has strong intra-observer reliability at different time points and strong inter-observer reliability when compared with the OES, validating the MEPS as an outcome measure of elbow surgery. (Journal of Surgical Orthopaedic Advances 31(4):229–232, 2022)

Key words: elbow, Mayo Elbow Performance Score, MEPS, intra-observer reliability, inter-observer reliability, validation, outcomes

Thermal Output of Oscillation Versus Forward Drilling of Bone - Suman Medda, MD; Matthew J. Duffin, MD; Samuel Rosas, MD; Raymond B. Kessler, MD; Sharon Babcock, MD; Jason J. Halvorson, MD; Eben A. Carroll, MD; and Holly T. Pilson, MD

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This study’s objective was to identify a difference in maximum temperature change during forward versus oscillating drilling of cadaveric bone. Paired femurs were dissected from the soft tissue of five cadavers. Each cadaver had one femur assigned to forward and the other to oscillation. The first drill hole was 2.5 cm distal to the lesser trochanter and the remaining 10 holes were evenly spaced 2 cm apart. A System 7 drill and 3.5 mm drill bit were attached to an Instron 5500R to provide a progressive force of 50 Newtons per minute for each drill hole. A thermal camera recorded each drilling. A new drill bit was used for each femur. Fifty bicortical drillings were analyzed in each group. The average time to complete forward drilling (45.0 seconds) was shorter compared to oscillation (55.5 s, p < 0.001). The average force required for forward drilling (27.7 N) was lower than for oscillation (44.3N, p < 0.001). The maximum change in temperature during the drilling process was similar (oscillating 100.2° F vs. forward 100.7° F, p = 0.871). The maximum change in temperature at the near cortex was lower for oscillation (78.1°F) compared to forward drilling (89.1°F, p = 0.011), while the maximum change at the far cortex was lower for forward drilling (89.3°F) compared to oscillation (95.8°F, p = 0.115) but not significantly. Overall, there is no difference in the thermal output between techniques. Oscillation may be beneficial in proximity to vital structures or to navigate narrow bony corridors, but it requires additional time and force. (Journal of Surgical Orthopaedic Advances 31(4):233–236, 2022)

Key words: oscillation, thermal osteonecrosis, drilling

Categorization of Adverse Events Reported to the FDA Pertaining to Tibia Intramedullary Nailing - Gina Provenzano, MD; Destie Provenzano, MS; Benjamin J. Best, DO; and Alan Afsari, MD

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OpenFDA is an open access database maintained by the United States Food and Drug Administration (FDA) that we queried for adverse events (AEs) related to product devices used during tibia intramedullary nailing (IMN) procedures. There was a total of 1,799 reports pertaining to tibial intramedullary nailing from 1996 to 2020. Causes included infection (451), nonunion (380), intraoperative issue (343), painful hardware (234), implant fracture (195), other (68), loosening (35), surgeon error (24), packing problem (24), patient injury (12), expiration (12), contamination (11) and allergic reaction (10). The total number of events increased in 2016 and 2018, which was attributed to 510k approval for Stryker. Of the AEs, 1,400 resulted in an injury to the patient. In total, 78% occurred in the post-operative period, and 68% required additional surgery. Most incidents related to tibia IMNs result in injury and require additional surgery. When new products are released, AEs occur quickly and in bulk. (Journal of Surgical Orthopaedic Advances 31(4):237–241, 2022)

Key words: intramedullary nail, tibia fracture, adverse events, OpenFDA

Risk Factors for Wound Complication Following Primary Total Hip Arthroplasty - Kyleen Jan, BS; Arya Dadhania, BS; Michael Foy, BS; Anshum Sood, MD; and Mark Gonzalez, MD, PhD

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This study assessed the National Surgical Quality Improvement Program (NSQIP), which provides data on 30-day post-operative complications from 500+ institutions, to identify risk factors for wound complications in patients undergoing primary total hip arthroplasty (THA). Patients undergoing primary THA between 2010–2017 were retrospectively reviewed. Patients experiencing post-operative wound complications were stratified based on pre-operative characteristics. Multivariate regression model was used to assess these characteristics as independent risk factors for post-operative complications. Of 119,096 patients undergoing primary THA, 1,264 (1.06%), 280 (0.2%), 622 (0.52%) and 139 (0.12%) experienced wound complications, deep surgical site infection, superficial surgical site infection, and wound dehiscence, respectively. Pre-operative transfusion (p < 0.0001), steroid use (p = 0.01), and obesity (p < 0.0001) were risk factors for wound dehiscence. Pre-operative transfusion (p < 0.0001), cardiac comorbidities (p = 0.02), and steroid use (p = 0.01) were risk factors for superficial surgical site infection. Assessment of the NSQIP identified modifiable risk factors for wound complications following primary THA, including pre-operative transfusion, steroid use, and obesity. (Journal of Surgical Orthopaedic Advances 31(4):242–247, 2022)

Key words: NSQIP, wound, dehiscence, infection, THA, post-operative complication

Post-operative Outcomes and Survivorship for Shoulder Arthroplasty Following Glenohumeral Tumor Resection - Christine S. Peters, MD; Tianyi David Luo, MD; Elliott Edward Voss, MD; Anastasios Papadonikolakis, MD; and Cynthia L. Emory, MD

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A paucity of data exists for post-operative complications and survivorship in patients undergoing resection arthroplasty procedures for treatment of glenohumeral tumors. This study investigates patient and tumor characteristics, 90-day and long- term post-operative complications, and overall survivorship following glenohumeral tumor resection arthroplasty procedures. This single-center retrospective review identified 13 patients, with mean age of 51.6 ± 15.7 years, mean body mass index of 26.5 ± 6.4 kg/m2, and mean Charlson Comorbidity Index of 4.9 ± 2.4, who underwent shoulder arthroplasty procedures for glenohumeral tumors, most commonly for chondrosarcoma (n = 5) and metastatic disease (n = 3). Nine patients (69.2%) underwent revision surgeries at a median of 677 days, most commonly for prosthesis instability, dislocation (n=4) or aseptic loosening (n = 3). Seven patients (53.8%) were deceased at a median of 593.6 days. Resection arthroplasty in the treatment of glenohumeral tumors demonstrates low rates of complications during the global period but are fraught with long-term complications. This data provides pertinent information to pre-operatively counsel patients on post-operative expectations. (Journal of Surgical Orthopaedic Advances 31(4):248–251, 2022)

Key words: giant cell tumor, chondrosarcoma, proximal humerus arthroplasty, tumor prosthesis

Descriptive Analysis of Orthopaedic Surgery Residency Program Directors - Frederick Mun, BS, BA; Alyssa R. Scott, BS; Nicole R. Legro, MD; Henry A. Boateng, MD; Paul J. Juliano, MD; and William L. Hennrikus, MD

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The purpose of this study was to analyze the demographics and backgrounds of U.S. orthopaedic surgery residency program directors (PDs). We collected publicly available information on 189 orthopaedic surgery residency PDs. Of those PDs, 90% were male MDs with an average age of 52. The average age at PD appointment was 45. The average duration of appointment was 7 years. About 81% of programs were university-affiliated, and 61% were in an urban environment. PDs attended 100 medical schools, 129 residencies, and 96 fellowships. Of PDs, 87% completed fellowships, commonly in trauma and sports medicine. There was no significant difference between male and female PDs when comparing age, academic appointment, or urban/rural environment. Most female PDs (89%) were at university-based hospitals. Of PDs at osteopathic-focused programs, 28% had an MD/PD. No program with an allopathic focus had a DO/PD. Lastly, 38% of PDs worked at the center where they completed residency. (Journal of Surgical Orthopaedic Advances 31(4):252–255, 2022)

Key words: orthopaedics, program director, medical education, resident education

The Associations of Spine Surgeon Training, Office Wait Times, and Social Media Presence with Reviews on Physician Rating Websites - Andrew J. Sama, BA; Nicholas C. Schiller, MS; Johnathon R. McCormick, MD; Kevin J. Bondar, BS; Deborah J. Li, MD; Jose A. Canseco, MD; and Chester J. Donnally III, MD

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This study evaluated the associations of demographics and social media (SM) usage on physician review websites for spine surgeons in New Jersey and Pennsylvania. Three physician rating websites were accessed to obtain training history, number of ratings/reviews, and overall rating (0–5). Surgeon web pages and publicly searchable SM accounts on Facebook (FB), Twitter (T), and/or Instagram (IG) were recorded. Of 246 spine surgeons included, 95.9% had a personal/institutional website while 12.2% were present on at least one SM platform. Physician age was inversely correlated with Healthgrades.com (HG), Vitals.com (V), and Google.com (G) ratings (p < 0.0001). Physicians with SM had higher ratings on HG (p = 0.006) and V (p = 0.006). Spine surgeons with SM received more ratings, comments, and higher scores than those without SM. All review sites agree that SM presence correlated with the number of ratings and comments across physician review websites, suggesting SM may influence patient feedback. (Journal of Surgical Orthopaedic Advances 31(4):256–262, 2022)

Key words: online patient ratings, orthopaedic ratings, physician review websites, social media, spine surgery, wait-times

The Association of H-index and Academic Rank Among Full-time Academic Foot and Ankle Surgeons Affiliated with Fellowship Programs - John P. Scanaliato, MD; Clare K. Green, BS; Michael M. Polmear, MD; Justin D. Orr, MD; and John C. Dunn, MD

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The purpose of this study is to investigate the association between Hirsch index (h-index) and academic rank among foot and ankle surgeons affiliated with American Orthopaedic Foot and Ankle Society (AOFAS) fellowship programs. The total number of publications, academic rank, years in practice, fellowship training pedigree, and h-indices of 176 foot and ankle surgeons from 48 AOFAS fellowship programs were recorded, and statistical analysis was performed. We found a strong association between total number of publications and h-index. Number of publications, h-index and training program affiliation were associated with higher academic rank, except at the chair/director position. Overall, h-index is a stronger predictor of academic rank than number of publications. The results of this study suggest that h-index and total number of publications are associated with a higher academic rank for full-time foot and ankle fellowship affiliated surgeons. (Journal of Surgical Orthopaedic Advances 31(4):263–267, 2022)

Key words: academic productivity, academic rank, h-index, hirsch index

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