INTRODUCTION:Osteogenesis imperfecta (OI) is a type I collagen disorder. Fragile and deformed bones increase fracture risk with noninvasive blood pressure (NIBP) cuff use. Patients with OI require multiple surgeries, with blood loss and pain medications risking hypotension. There is not currently a widely accepted protocol for NIBP measurements in patients with OI. We designed a protocol demonstrating the safe implementation of "busting the myth" that this is not feasible. METHODS:We prospectively enrolled patients with OI undergoing spine or extremity procedures. Inclusion criteria were approval by an orthopaedic surgeon, age 1 to 35 years, and postoperative admittance to a non-intensive care unit (ICU). To minimize fracture risk and detect hypotension, low maximum inflation pressures were used: 120 mmHg-neonatal/infant/pediatric-sized cuffs; 140 mmHg-adult cuffs. Blood pressure (BP) measurements were taken per standard institutional postoperative care: no more than every 4 hours for 24 hours and every 8 hours or less thereafter. Upper extremity BP was measured manually by registered nurses who inspected the limb and inquired regarding signs of fracture (pain with palpation and bruising) before and after each measurement. RESULTS:Fifty participants were enrolled (median age 12.5 years; 25 girls). Most had moderate (48%) or severe (42%) disease. Twenty-eight patients underwent extremity surgery, and 22 underwent spine surgery. Thirty-three percent of the humeri used were rodded, with an average of 9.5 BP measurements taken postoperatively. Clinical assessment revealed that no fractures occurred. Two participants (4%) withdrew for reasons unrelated to BP cuff complications. CONCLUSION:Noninvasive BP measurements may be safely obtained in the postoperative period for patients with OI. This study was conducted in a system with a high volume of OI care, and OI-specialized orthopaedic surgeons screened the patients. Within these limitations, we recommend manual cuff use and careful fracture monitoring. This protocol may help patients with OI across other hospitals avoid postoperative arterial catheters and ICU admission and could facilitate preventive care for cardiovascular disease.
Family planning and maternity leave concerns contribute to reasons why the percentage of women in orthopedic surgery is disproportionally and consistently low. Without institutional policies, these stressors are often placed on the pregnant resident in training. The establishment of formal department policies allows for clear, universal expectations, which helps decrease negative peer perception and overall dissatisfaction. This practice not only supports current trainees but can also help attract more diverse applicants to create a sustainable workforce. This is the first of a two-part paper that outlines key evidence-based considerations for pregnancy during residency. Importantly, we address the balance of early disclosure with confidentiality, call schedules, medical appointments, and return-to-work considerations, including lactation policies. Creation of these formal guidelines will require an investment in the department but can lay the foundation for a new generation of surgeons who thrive both at home and in the operating room.
Introduction: There are limited opportunities for orthopaedic trainees to practice placing Kirschner wires for fracture fixation outside the operating room. We created an inexpensive, low-fidelity simulator to meet this need. Methods: The simulator is composed of a bone model, soft-tissue model, light fixture “radiograph,” and an electronic component and costs US$53. Validation evidence relevant to test content was evaluated by five fellowship-trained pediatric orthopaedic surgeons using a Likert scale to assess the physical characteristics of the models and their ability to result in transfer of skills to the operating room. Results: Model 3 had the highest average score for feel of the near (3.4) and far (3.4) cortex. Model 2 had the highest average score for feel of the medullary canal (3.2) and pin visualization (2.6). The simulator had high scores for ease of use and implementation and was rated highly for its ability to support residents' learning to triangulate to a defined target (4.8) and improve motor skills (4.4). Discussion: We were able to create an inexpensive, low-fidelity simulator with potential for high transferability, which can be used by orthopaedic surgery residents to improve their motor skills in a low risk, high-reward environment.
BACKGROUND:Percutaneous kyphoplasty is routinely indicated in elderly patients with osteoporotic vertebral compression fractures (VCFs) who have failed conservative management. Although it can effectively stabilize the vertebra and alleviate pain, kyphoplasty has been associated with various complications, including pulmonary embolism and adjacent level fractures. However, there is a lack of consensus on whether office-based kyphoplasty is safer than inpatient or outpatient ambulatory surgery center (outpatient-ASC)-based kyphoplasty. METHODS:PearlDiver was queried to identify adults undergoing percutaneous kyphoplasty for new age-related osteoporotic VCF between 2016 to 2022. Patients were stratified by service location (ie, inpatient, outpatient-ASC, outpatient office) and matched 1:1 by age, sex, and Charlson Comorbidity Index. Medical complications 90 days after the procedure were compared. RESULTS:In total, 71,084 patients underwent kyphoplasty for osteoporotic VCFs between 2016 to 2022. The mean age was 74.3 years, 76.2% were female, and mean Charlson Comorbidity Index was 3.5. The proportion of annual kyphoplasty cases performed in the outpatient-office setting increased markedly from 21.7% in 2016 to 29.6% in 2022 ( P = 0.002). After matching, 11,340 patients remained in each cohort. Multivariate logistic regression analyses revealed that the inpatient cohort had the highest odds of acute kidney injury, cardiac arrest, deep vein thrombosis, pneumonia, transfusion, urinary tract infection, site complications, wound complications, and readmissions (all P < 0.004). Both the inpatient and the outpatient-ASC cohorts had higher odds of infection than the outpatient-office cohort ( P < 0.001). Finally, the outpatient-office cohort had the highest odds of nerve injury and secondary fractures ( P < 0.004). DISCUSSION:In this retrospective cohort study of kyphoplasty performed for osteoporotic VCFs, office-based kyphoplasty procedures were observed to have a lower rate of medical complications compared with inpatient or outpatient-ASC-based kyphoplasty procedures. These findings suggest that office-based kyphoplasty may represent an appropriate treatment setting for carefully selected patients with osteoporotic VCFs.
Glucagon-like peptide 1 (GLP-1) receptor agonists (GLP-1 RAs) are used in diabetic patients for glycemic control. Yet, there has been a notable rise in their use for weight loss management in obese patients. This review critically appraises current evidence on perioperative implications of GLP-1 receptor agonists in TJA patients. The review discusses GLP-1 RA implications and use (physiology, pharmacology, pharmacodynamics, mechanisms of actions, and commonly used GLP-1 Ras), complications and adverse effects, considerations for the anesthesiologist, considerations for the TJA surgeon, and current clinical practice recommendations in 2025.
INTRODUCTION:Total ankle arthroplasty (TAA) has become a viable alternative to ankle arthrodesis (AA) in recent years. However, implant longevity is a concern because malalignment of either the tibial or talar implants has been shown to predispose to premature wear and necessary revision surgery. Thus, customized surgical tools such as computer navigation and patient-specific instrumentation have been used to theoretically improve intraoperative alignment of implants. The primary outcome of this study is to compare alignment between a computer-assisted navigation (CAN) system for TAA, a preexisting patient-specific instrumentation (PSI) system, and SRG fluoroscopic techniques. METHODS:TAA was done on 36 artificial ankle joint specimens by a single surgeon: 12 using CAN, 12 with PSI, and 12 with SRG instrumentation. All specimens were scanned both preoperatively and postoperatively using a high-precision 3D scanning tool. Resections and implant placements were then analyzed in 3D processing software and compared between surgical modalities. Statistical analysis included one-way ANOVA with associated Tukey tests to assess for differences between groups. RESULTS:We found that tibial resections were overall most accurate using CAN, with tibial slope measurements demonstrating significant improvements over PSI (P < 0.001) and conventional instrumentation (P < 0.001). PSI was more accurate than SRG when considering the axial cut height of the tibial resection (P < 0.001). In the talar resections, CAN was statistically superior to SRG methods in two of three measured categories (slope: P < 0.001, axial cut height: P < 0.001). However, PSI fared better than CAN in those same categories (slope: P = 0.002, axial cut height: P < 0.001). Employment of the CAN system also decreased implant placement variability (CAN: ± 0.47 mm, ± 0.62 deg; PSI: ± 0.63 mm, ± 1.03 deg; SRG: ± 0.73 mm, ± 1.21 deg). CONCLUSION:In this laboratory-based TAA study, we found that both CAN and PSI demonstrated advantages over SRG instrumentation regarding implant placement accuracy. Tibial resections were found to be overall most accurate under CAN guidance, and talar resections were found to be overall most accurate under PSI guidance. In addition, the observed reduction in implant placement variability has potential positive implications for surgeons. However, as this study was conducted on artificial specimens, effects of soft tissue and preoperative deformities or pathologies were not considered. Future studies should include cadaveric specimens with various pathologies to better simulate conditions encountered in an operating room. LEVEL OF EVIDENCE:Level II - Lesser Quality RCT or Prospective Comparative Study.
BACKGROUND:Accurate Evaluation and Management (E/M) coding depends on the precise documentation of medical decision making. Advances in artificial intelligence have introduced ambient listening technology as a novel documentation tool. Despite its rapid adoption, the effect of ambient listening technology on E/M code selection, coding accuracy, and downstream financial implications remains poorly defined. This study aimed to evaluate the effect of ambient listening technology on E/M code selection, coding concordance, and associated revenue implications within an orthopaedic surgery practice. METHODS:A comparative cross-sectional analysis was done of all outpatient E/M services at a single academic medical center. Providers were required to have a minimum of 20 encounters documented using ambient listening technology and traditional dictation for the same encounter type. The final analytic cohort included 7,236 encounters. A randomized subset of 200 encounters (100 ambient listening and 100 traditional) underwent blinded, independent audit by an experienced orthopaedic coding auditor. Outcomes included concordance between provider-selected and auditor-determined E/M levels, weighted coding discrepancies, accuracy rates, and modeled revenue effect. RESULTS:Encounters documented with ambient listening technology were associated with higher E/M levels than those documented with traditional dictation, as assessed by both auditors (3.24 vs 2.96) and providers (3.11 vs 2.82). Overall coding accuracy was 68% for ambient listening and 74% for dictation, while focused review of higher-level ambient listening encounters demonstrated 81.3% accuracy. Revenue modeling projected a potential annual increase of $232,313 if dictation-based encounters achieved E/M distributions observed with ambient listening. CONCLUSION:Ambient listening-generated documentation meaningfully influences E/M code determination in orthopaedic outpatient practice, supporting higher and more appropriate E/M level selection compared with dictation. Although distinct error patterns persist, ambient listening was associated with reduced undercoding and measurable financial impact. These findings position ambient listening technology as a clinically and financially consequential documentation modality, warranting thoughtful implementation and continued coding oversight.
Primary elbow osteoarthritis is a functionally limiting condition, predominantly affecting middle-aged men engaged in repetitive manual labor, and is characterized by pain, stiffness, and mechanical symptoms. Evaluation involves a detailed history focusing on pain, loss of motion, and mechanical symptoms, followed by clinical examination for range of motion deficits, crepitus, and instability. Radiographic assessment, including standard radiographs and, when indicated, computed tomography imaging, is essential for staging disease severity, identifying osteophytes, capsular contracture, and joint space narrowing. Initial management is nonsurgical, emphasizing activity modification, NSAIDs, physical therapy, and intra-articular corticosteroid injections. When conservative measures fail, surgical options include arthroscopic or open débridement, osteocapsular arthroplasty, and procedures such as the Outerbridge-Kashiwagi technique. Both arthroscopic and open approaches reliably improve pain, range of motion, and functional scores, with low complication rates. However, open procedures may yield greater flexion gains in select cases. Nonarthroplasty options for primary elbow arthritis encompass a spectrum from conservative management to arthroscopic and open surgical débridement, with treatment tailored to disease severity, patient age, and functional demands.
Subchondral bone impaction at the level of the radial neck, usually present at the anterior or lateral quadrant, can be an associated feature in radial head fractures. Buttress plating principles suggest that subchondral zones of impaction are best supported by an implant positioned directly on the site of impaction to resist secondary collapse. The anatomical considerations limit the standard radial head plating technique to a narrow safe zone. Therefore, irrespective of the zone of impaction, the standard plating zone remains the same, which may not provide the best possible mechanical construct for radial head fractures where the zone of impaction lies outside the safe zone for plating. In this study, the authors present an alternate subchondral shelf plating technique performed through the zone of impaction. The technique involves supporting the disimpacted radial head using a bent mini-fragment plate that acts as a shelf along with supplemental fixation. The shelf plate remains extra-articular, recessed below the radial head and the proximal radioulnar joint, with scope for impingement-free fixation along the entire circumference of the radial head. The technique was used in 13 adult patients and yielded excellent outcomes. Radiological healing was achieved in all patients with maintenance of reduction. The mean Mayo Elbow Performance Score and the quick DASH score were 96.5 ± 6.5 and 4.9 ± 3.3, respectively, at a mean follow-up of 20 ± 8 months.
Mid-shaft clavicle fractures in the adult and postpubescent adolescent population are a common injury treated by orthopaedic surgeons. This injury has a notable burden of disease due to its prevalence, effect on the patient, and effect on the society through cost of treatment and time lost from social activity. Determining surgical and nonsurgical care for a clavicle fracture can represent a clinical challenge. To assist clinicians with this treatment decision, the American Academy of Orthopaedic Surgeons has developed and adopted an appropriate use criteria to recommend nonsurgical and surgical treatment based on a variety of patient and injury characteristics. These criteria are available online and through phone-based applications. This article aims to illustrate how the criteria may be applied in clinical practice.
Introduction: Proper nutrition is a well-established variable in recovery from orthopaedic surgery. The purpose of this study was to explore patient perception of preoperative nutrition before elective shoulder surgery. We hypothesized that patients have a positive attitude toward preoperative nutrition, with interest in receiving nutritional guidance from their healthcare provider. Methods: A prospective survey study of 100 patients scheduled for elective shoulder surgery was conducted. All surveys were completed in the preoperative period, with questions designed to evaluate a patient's knowledge and perceptions regarding nutrition, as it relates to their recovery. Survey questions assessed (1) how patients perceive their personal daily nutrition, (2) the importance of quality nutrition with respect to postoperative recovery, and (3) their ability to self-implement nutrition strategies and/or those provided to them. Results: The majority of surveyed patients ( n = 80; 80%) agreed that nutrition is an important part of recovering from orthopaedic shoulder surgery, with most patients ( n = 77; 77%) supporting the idea that a formal preoperative nutrition plan would help contribute to postoperative recovery. However, only 40 patients (40%) believed that they understood which foods to eat, 28 (28%) believed that they knew which supplements to take, and 46 (46%) planned to take supplements without instruction. Family support was found to be associated with patient confidence in ( P = 0.003) and adherence to ( P = 0.023) a preoperative nutrition plan. Conclusion: This study found that there is a clear disconnect between patient perspectives and practical knowledge when it comes to perioperative nutrition before shoulder surgery. Nevertheless, most patients display a positive attitude toward following a nutrition plan if provided by a healthcare provider, and if family support is present. These data indicate the need for established perioperative nutrition plans to aid in effectively optimizing patient nutrition before elective shoulder surgery.
The American Academy of Orthopaedic Surgeons (AAOS) has developed an Appropriate Use Criteria (AUC) for the Treatment of Mid-Shaft Clavicle Fractures. Evidence-based information, in conjunction with the clinical expertise of physicians, was used to develop criteria to determine the appropriateness of surgical and nonsurgical treatment in patients who have suffered a mid-shaft clavicle fracture. The Appropriate Use Criteria for the Treatment of Mid-Shaft Clavicle Fractures were derived by identifying clinical indications typical of patients who have suffered a mid-shaft clavicle fracture. These indications were most often variables observable by the clinician, including symptoms or results of diagnostic tests. In addition, "human factor" (eg, activity level or demographic variables) can be considered. The 96 patient scenarios and two treatments were developed by the writing panel, a group of clinicians who are specialists in this Appropriate Use Criteria topic. Next, a separate, multidisciplinary rating panel (made up of specialists and nonspecialists) rated the appropriateness of treatment for each patient scenario using a 9-point scale to designate a treatment as "Appropriate" (median rating, 7 to 9), "May Be Appropriate" (median rating, 4 to 6), or "Rarely Appropriate" (median rating, 1 to 3).
Background: Diabetes mellitus (DM) is a well-established risk factor for complications after surgical fixation of ankle fractures. Elevated hemoglobin A1c (HbA1c) has been associated with worse outcomes; however, it remains unclear whether HbA1c alone predicts perioperative risk independent of a formal DM diagnosis and treatment status. This study evaluated whether elevated preoperative HbA1c (≥8.0%) in patients without a documented diagnosis or pharmacologic treatment of DM is associated with increased early postoperative complications compared with patients with established DM. Methods: The American College of Surgeons National Surgical Quality Improvement Program database (2021 to 2024) was queried for patients undergoing open reduction and internal fixation of ankle fractures. Patients were stratified into four cohorts based on diabetes diagnosis/treatment status and glycemic control: (1) undiagnosed/untreated, HbA1c < 8.0%; (2) undiagnosed/untreated, HbA1c ≥ 8.0%; (3) diagnosed/treated, HbA1c < 8.0%; and (4) diagnosed/treated, HbA1c ≥ 8.0%. Propensity score matching (1:1) on age and sex yielded 388 matched patients (n = 97 per group). Primary outcomes were 30-day mortality, readmission, and revision surgery. Secondary outcomes included surgical site infection, organ-space infection, and medical complications. Multivariable logistic regression adjusted for residual differences in body mass index and comorbidities. Results: Thirty-day mortality was rare (0.8%) and did not differ between groups ( P = 0.381). Significant differences were observed in revision surgery ( P = 0.006), superficial surgical site infection ( P = 0.003), and organ space infection ( P = 0.019). Patients with diagnosed/treated uncontrolled DM had higher odds of these complications compared with those with elevated HbA1c but no documented DM diagnosis or treatment (undiagnosed/untreated uncontrolled) (all P < 0.05). Conclusion: Patients with poorly controlled established diabetes had higher rates of early postoperative complications after ankle fracture open reduction and internal fixation compared with those with elevated HbA1c but no earlier diabetes diagnosis or treatment. Assessment of the presence and treatment status of diabetes may provide more meaningful perioperative risk stratification than HbA1c level alone. Level of Evidence: Level III, retrospective cohort study.
Background: Unimalleolar, bimalleolar, and trimalleolar ankle fractures and syndesmosis injuries represent a spectrum of increasing instability and surgical complexity. Although the work Relative Value Unit (wRVU) system is designed to account for surgical time and technical complexity, previous studies suggest a mismatch between procedural complexity and proportional reimbursement rate. Our study aims to evaluate whether current wRVU allocation across ankle fracture types adequately reflects procedural complexity and to assess whether more complex cases are relatively undercompensated. Methods: The national surgical quality improvement program (NSQIP) database (2021 to 2024) was queried for patients undergoing open reduction and internal fixation for ankle fractures and syndesmosis injuries, using current procedural terminology (CPT) codes. Cases involving tibial shaft or pilon fractures or multiple CPT codes were excluded. Compensation metrics included surgical time, total wRVUs, wRVUs per hour (wRVU/hr), and hourly reimbursement rate ($/hr). 1:1 propensity score matching was done based on age, sex, American Society of Anesthesiologists class, and inpatient versus outpatient status. Analysis of covariance was subsequently used to adjust for preoperative comorbidities and postoperative complications affecting compensation metrics. Results: Among 17,833 cases, 779 patients per group were identified after propensity score matching. Surgical time (minutes) increased significantly with complexity (unimalleolar: 64.1 ± 35.5; syndesmosis: 64.2 ± 37.9; bimalleolar: 83.5 ± 43.6; trimalleolar: 105.0 ± 53.6; P < 0.001). Although trimalleolar ankle fractures generated the highest total wRVUs (11.7), wRVU/hr decreased as complexity increased (unimalleolar: 10.7 ± 6.3; syndesmosis: 11.3 ± 6.9; bimalleolar: 9.9 ± 5.4; trimalleolar: 8.7 ± 5.5; P = 0.006). Hourly reimbursement rate ($/hr) followed a similar inverse pattern (unimalleolar: 361.9 ± 214.2; syndesmosis: 382.0 ± 234.4; bimalleolar: 335.4 ± 182.6; trimalleolar: 296.1 ± 188.7; P = 0.006). Conclusion: Our study suggests that the current compensation structure for ankle fracture and syndesmosis fixation procedures may not adequately reflect the surgical time and effort required for more complex injuries. Additional evaluation of wRVU allocation for ankle fracture and syndesmosis injury management may be necessary to ensure that compensation more accurately aligns with physician time and effort. Level of Evidence: Level III.
BACKGROUND:Unrestricted kinematic alignment (KA) in total knee arthroplasty (TKA) seeks to restore patient-specific limb geometry and ligamentous balance, yet uncertainty persists regarding patellofemoral (PF) complications and postoperative interventions. Comparative evidence centered on objective mechanical outcomes remains limited, and prior meta-analyses have included heterogeneous alignment strategies or mixed implant constructs. The purpose of this study was to compare unrestricted KA with mechanical alignment (MA) in primary TKA with respect to PF safety, postoperative motion, and intraoperative soft-tissue release requirements. METHODS:A systematic review and meta-analysis was conducted in accordance with PRISMA guidelines. Randomized and comparative observational studies directly comparing unrestricted KA with MA in primary TKA were eligible without language or date restrictions. Studies were required to report at least 1 predefined objective outcome: postoperative flexion, terminal extension, manipulation under anesthesia (MUA), PF complications, intraoperative soft-tissue releases, or all-cause revision surgery. Data were extracted in duplicate, and random-effects models were used for pooled analyses. Risk of bias was assessed using ROB2 for randomized trials and ROBINS-I for observational studies, and certainty of evidence was graded using GRADE methodology. RESULTS:Seven studies (five randomized trials and two comparative cohorts) comprising 1,068 primary TKAs met inclusion criteria. Compared with MA, KA resulted in greater postoperative flexion (mean difference [MD], 4.58°; 95% confidence intervals (CI), 1.83° to 7.32°; moderate certainty) and slightly improved terminal extension (MD, -0.99°; 95% CI, -1.86° to -0.12°; moderate certainty). KA required substantially fewer intraoperative soft-tissue releases (risk ratio [RR], 0.34; 95% CI, 0.24 to 0.49; moderate certainty). No significant differences were observed for PF complications (RR, 1.90; 95% CI, 0.63 to 5.74; low certainty), MUA (RR, 0.47; 95% CI, 0.09 to 2.44; low certainty), or all-cause revision surgery (RR, 1.96; 95% CI, 0.75 to 5.14; low certainty). Sensitivity analyses demonstrated stable effect direction across fixed-effects and random-effects models. DISCUSSION:Unrestricted KA TKA improves postoperative flexion, slightly enhances extension, and markedly reduces soft-tissue releases without increasing early PF complications, MUA, or revision surgery compared with MA TKA. Longer term randomized studies are needed to refine PF-specific risk estimates and assess survivorship. LEVEL OF EVIDENCE:II.
Background: Patients with spinopelvic risk factors such as lumbar fusion or stiff spine exhibit a 5- to 10-fold increased risk of dislocation following total hip arthroplasty (THA), primarily due to altered spinopelvic mechanics that influence cup positioning. The utilization of robotic-assisted THA facilitates personalized planning, enhancing component placement in this high-risk population. This study aims to compare rates of implant-related and medical complications between robotic-assisted and manual THA in these high-risk patients. Methods: Data were retrospectively obtained from the TriNetX Research Network. Patients with prior lumbar fusion or spinal conditions associated with stiffness or malalignment, and who subsequently underwent THA, were identified using ICD-10 and CPT codes. Procedure codes defined robotic-assisted and manual THA. After 1:1 propensity score matching for age, sex, body mass index, smoking status, and other comorbidities, outcomes were compared at 3, 6, 12 months and 2 years. A subgroup analysis compared both groups in spinal fusion (SF) and nonfusion (no-SF/stiff spine) patients. Results: After 1:1 propensity score matching, each cohort included 2,147 patients. At 3 months, robotic THA was associated with lower prosthetic complications (1.4 vs 2.7%; odds ratio [OR]: 1.86, 95%; P = 0.01) and postoperative blood transfusion (0.9 vs. 1.8%; OR: 2.02, P = 0.01). At 1 year, dislocation was reduced (0.9 vs. 1.8%; OR: 2.07; P = 0.01). Revisions were also lower at 1 and 2-year follow-up in the robotic group (1.7 vs. 2.7%, OR: 1.61; 2.0 vs 3.7%, OR: 1.86; all P < 0.05; respectively), and the manual group had 1.9 times the hazard of having revision surgery at 2 years (HR: 1.9, 95%; P = 0.02). In no-SF patients, robotic THA was associated with markedly lower rates of prosthetic complications and revision surgery. Conclusion: Robotic-assisted THA was associated with fewer complications than manual THA in patients with lumbar fusion or clinically relevant spinal stiffness, a population at elevated risk for instability after THA. Precision-based implant positioning may improve outcomes in patients with altered spinopelvic mobility, including those without spinal fusion.
BACKGROUND:As the cost of anatomic total shoulder arthroplasty (aTSA) continues to rise, there is increasing pressure to optimize value through cost-effective care strategies. Patient-level value analysis (PLVA) is an emerging method that quantifies value as the change in patient-reported outcomes (PROs) relative to total cost. Although PLVA has been applied to other orthopaedic procedures, it has not been used to evaluate aTSA. This study aimed to assess 1-year value delivery in aTSA and identify characteristics that influence cost and outcomes. METHODS:A retrospective cohort study was conducted using prospectively collected patient-reported outcome registries at one healthcare institution. Patients undergoing primary unilateral aTSA for osteoarthritis between 2018 and 2022 were included. Patients were excluded if they lacked preoperative or 1-year American Shoulder and Elbow Surgeons (ASES) scores or experienced complications or revisions. Episode-of-care (EOC) costs were calculated using time-driven activity-based costing (TDABC), including direct and indirect care costs. The value quotient (Vq) was defined as the change in ASES score divided by total EOC cost, multiplied by 100. Multivariate regression was used to assess predictors of cost, outcome, and value. RESULTS:A total of 139 patients met inclusion criteria. The mean age was 67.8 years, and 54.4% were female. The average 1-year ASES improvement was 32.1 ± 24.9, and the mean EOC cost was $13,301±$3,137. Implants accounted for 49% of the total EOC cost. Surgeries in the ASC setting predicted lower cost (β = -$2,847; P < 0.001), whereas inpatient stay and SNF discharge were associated with higher costs. The average value quotient was 0.23 ± 0.19 for each patient. CONCLUSION:Cost variability in aTSA is driven by surgical setting, implant selection, and discharge disposition. Higher costs do not correspond to better outcomes, highlighting opportunities to improve value by targeting modifiable cost drivers, particularly implant prices and use of postacute care facilities.
BACKGROUND:Although female representation at national orthopaedic society meetings has increased in recent years, women remain disproportionately more likely to deliver nontechnical presentations. Examining patterns in speaker roles provides a measurable way to assess progress toward equitable representation by sex in academic orthopaedic settings. QUESTIONS/PURPOSES:This study aimed to (1) evaluate trends in female speaker representation at the Orthopaedic Trauma Association (OTA) Annual Meeting from 2014 to 2024 and (2) assess sex-based differences in speaker roles, including the likelihood of delivering technical versus nontechnical presentations. PATIENTS AND METHODS:Speaker names, session titles, and roles (speaker, moderator, or committee member) were extracted from OTA Annual Meeting programs spanning 2014 to 2024. Sessions were classified as technical or nontechnical, and speaker sex was determined through publicly available information. A total of 514 sessions were analyzed, including 390 technical and 124 nontechnical sessions. Trends in speaker roles by sex were assessed over time, and odds ratios (ORs) were calculated to evaluate the likelihood of men versus women delivering technical presentations. RESULTS:Female representation increased across all roles over the study period. The proportion of female speakers rose from 8.85% in 2014 to 22.22% in 2024, and the proportion of female moderators increased from 4.84% to 12.99%. Four women served as committee members since 2021, with one serving as cochair. Men were significantly more likely to give technical talks in 2024 (OR 2.8, 95% CI, 1.47-5.41, P = 0.0018) and 2021 (OR 3.0, 95% CI, 1.59-5.87, P = 0.0009). CONCLUSION:Female representation at the OTA Annual Meeting has increased substantially over the past decade, mirroring trends observed in other orthopaedic subspecialty societies. However, sex-based differences in the distribution of technical versus nontechnical presentations were observed in multiple years. Continued efforts are needed to promote equitable access to academic and leadership roles for women in orthopaedic trauma. LEVEL OF EVIDENCE:Level III (retrospective observational study).
INTRODUCTION:The existing literature on anterior cervical diskectomy and fusion (ACDF) predominantly focuses on 1- and 2-level procedures, leaving limited data comparing outcomes of 3- versus 4-level standalone ACDFs. Thus, the aim of this study was to compare surgical outcomes and patient-reported outcome measures (PROMs) of 3- versus 4-level ACDF. METHODS:Patients who underwent 3- or 4-level ACDF within a single academic health system (2014 to 2020) were retrospectively identified. Surgical outcomes and PROMs were evaluated, including the 0 to 10 numeric rating scale for neck and arm pain, Short Form-12, Modified Japanese Orthopaedic Association (mJOA), and Neck Disability Index (NDI). Patients were excluded if they did not have complete preoperative or 1-year postoperative mJOA scores, underwent ACDF for tumor/trauma/infection, or had concomitant posterior cervical fusion. RESULTS:A total of 256 patients were included (46 4-level ACDFs). Patients undergoing 4-level ACDF had higher BMI (30.8 vs. 28.9; P = 0.032) and a greater prevalence of myelopathy (45.7% vs. 33.3%; P = 0.018) but were otherwise demographically similar to 3-level ACDF patients. Four-level ACDF patients had a higher dysphagia rate (20% vs. 8.6%; P = 0.033) and a higher 30-day ED visit rate (6.5% vs. 0%; P = 0.005) but similar readmission rates and all other surgical outcomes. Patients with 4-level ACDF had better 6-month NDI scores but worse 1-year mJOA scores. All other PROM comparisons and deltas were similar at all time points. CONCLUSION:Patients undergoing 4-level ACDF had higher BMI and a greater prevalence of myelopathy than those undergoing 3-level ACDF; 4-level ACDF was associated with a higher rate of dysphagia and early postoperative ED utilization, but not readmissions. The groups otherwise did similarly with respect to surgical outcomes and PROM improvements. These findings suggest that extending fusion from three to four levels was not associated with increased surgical risk or inferior short-term functional or pain outcomes compared with 3-level ACDF.
Identifying the correct etiology of total hip arthroplasty (THA) failure is the critical first step in determining the most appropriate course of treatment. In many cases, the cause of failure may not be evident. Thus, a systematic approach to the failed THA is paramount to identifying the correct diagnosis. Many studies provide a detailed understanding of why THAs fail. However, a concomitant methodology to distinguish one failure modality from another is not readily available. In addition, the diagnosis of one mode of failure may lead a surgeon to inadvertently overlook other potential coexisting mode(s) of failure. In this article, we present a systematic approach for determining the cause of THA failure. The essence of this review article lies in the comprehensive worksheet that provides a clear framework to evaluate patients presenting with a failed or painful THA, especially in the absence of obvious causes. A systematic approach minimizes the chances of excluding pertinent information and concomitant modes of failure, which may lead to an inaccurate diagnosis and high likelihood of failure following revision surgery. This simple guide is intended to help residents, fellows, and surgeons in practice to avoid overlooking concomitant etiologies in a failed THA and thereby improve the chances of successful outcomes.
