OBJECTIVE:When patients with non-traumatic lower extremity conditions express concerns regarding symptoms of the contralateral lower extremity they may be communicating fear of painful movement. Among people seeking specialty care for unilateral non-traumatic lower extremity conditions, we studied the relationship between magnitude of incapability and pain intensity in the contralateral and ipsilateral limbs and thoughts and feelings about sensations. METHODS:Patients seeing a musculoskeletal specialist for any unilateral non-traumatic lower extremity condition were enrolled. We used multivariable analysis to identify aspects of unhelpful thinking and feelings of distress associated with contralateral and ipsilateral pain intensity and magnitude of capability accounting for demographic factors. RESULTS:Greater pain intensity in the contralateral limb, greater pain intensity in the ipsilateral limb, and higher magnitude of incapability were all associated with greater distress regarding symptoms. CONCLUSIONS:When patients voice concerns about pain in the contralateral limb, they may be signaling feelings of worry or despair regarding symptoms. PRACTICE IMPLICATIONS:Concerns about pain in the contralateral limb can prompt clinicians to explore feelings of worry or despair regarding symptoms, an important and modifiable aspect of musculoskeletal illness.

Loss of the entire extensor mechanism of the knee presents a major reconstructive challenge. We encountered a patient who was missing the patellar tendon, patella, and quadriceps tendon following a remote trauma. A prior attempt at allograft reconstruction failed due to infection and dehiscence at the allograft-muscle connection. To avoid an allograft, we reconstructed the entire knee extensor mechanism with an ipsilateral functional free gracilis transfer, maintaining the enthesis at the tibia, rerouting the muscle across the anterior knee, and attaching the origin to the fascia lata. We vascularized the muscle with the descending branch of the lateral circumflex femoral vessels and innervated the muscle with a motor branch of the femoral nerve. The transfer was successful, with the patient able to ambulate without a brace by 6 months and to perform squats by 9 months. Complications commonly seen with allograft were obviated, and functional recovery was excellent.

INTRODUCTION:Delays in time to surgery (TTS) for patients with a hip fracture negatively affect patient outcomes, including mortality. Surgery within 24 to 48 hours of admission for a hip fracture markedly reduces these risks; however, attempts at improving TTS after hip fracture have had mixed results. Drivers of delays in TTS across different settings in the United States are not well described. Therefore, the aim of this study was to identify drivers of delays in TTS for patients with a hip fracture from different settings to inform where patient- and context-specific improvements in TTS may be implemented. METHODS:Semistructured interviews were completed using the Consolidated Framework for Implementation Research and Theoretical Domains Framework. Interviews were completed with stakeholders involved in hip fracture care between June 2023 and October 2023. Transcripts were analyzed iteratively through a combined inductive and deductive approach. The data were analyzed to synthesize overarching themes related to drivers of delays of TTS. RESULTS:A total of 25 stakeholders, 24 orthopaedic surgeons, and 1 nurse practitioner, from 22 different hospital systems across the United States participated in semistructured interviews. Eight themes of drivers of delayed TTS emerged: (1) patient health; (2) structural drivers of health; (3) care coordination; (4) prioritization; (5) improvement climate; (6) availability; (7) incentive structure; and (8) empowerment. CONCLUSION:Eight major themes related to drivers in TTS for patients with a hip fracture were identified across hospital systems. These findings inform the process of identifying site-specific drivers of delayed TTS at individual health systems and implementing targeted improvement programs for TTS for patients with a hip fracture.

Abstract Background Patients recovering from lower extremity injuries often interpret discomfort associated with increased use of the uninjured leg as a potential indication of harm. If expressed concerns regarding contralateral leg pain are associated with unhelpful thinking regarding symptoms, they can signal orthopaedic surgeons to gently reorient these thoughts to help improve comfort and capability during recovery. Questions/purposes We asked: (1) Among people recovering from isolated traumatic lower extremity injury, is pain intensity in the uninjured leg associated with unhelpful thoughts and feelings of distress regarding symptoms, accounting for other factors? (2) Are pain intensity in the injured leg, magnitude of capability, and accommodation of pain associated with unhelpful thoughts and feelings of distress regarding symptoms? Methods Between February 2020 and February 2022, we enrolled 139 patients presenting for an initial evaluation or return visit for any traumatic lower extremity injury at the offices of one of three musculoskeletal specialists. Patients had the option to decline filling out our surveys, but because of the cross-sectional design, required fields on the electronic survey tools, and monitored completion, there were few declines and few incomplete surveys. The median age of participants was 41 years (IQR 32 to 58), and 48% (67 of 139) were women. Fifty percent (70 of 139) injured their right leg. Sixty-five percent (91 of 139) had operative treatment of their fracture. Patients completed measures of pain intensity in the uninjured leg, pain intensity in the injured leg, lower extremity–specific magnitude of capability, symptoms of depression, symptoms of health anxiety, catastrophic thinking, and accommodation of pain. Multivariable analysis sought factors independently associated with pain intensity in the uninjured leg, pain intensity in the injured leg, magnitude of capability, and pain accommodation, controlling for other demographic and injury-related factors. Results Greater pain intensity in the uninjured leg (regression coefficient [RC] 0.09 [95% CI 0.02 to 0.16]; p < 0.01) was moderately associated with more unhelpful thinking regarding symptoms. This indicates that for every one-unit increase in unhelpful thinking regarding symptoms on the 17-point scale we used to measure pain catastrophizing, pain intensity in the uninjured leg increases by 0.94 points on the 11-point scale that we used to measure pain intensity, holding all other independent variables constant. Greater pain intensity in the injured leg (RC 0.18 [95% CI 0.08 to 0.27]; p < 0.01) was modestly associated with more unhelpful thinking regarding symptoms. Greater pain accommodation (RC -0.25 [95% CI -0.38 to -0.12]; p < 0.01) was modestly associated with less unhelpful thinking regarding symptoms. Greater magnitude of capability was not independently associated with less unhelpful thinking regarding symptoms. Conclusion A patient’s report of concerns regarding pain in the uninjured limb (such as, “I’m overcompensating for the pain in my other leg”) can be considered an indicator of unhelpful thinking regarding symptoms. Orthopaedic surgeons can use such reports to recognize unhelpful thinking and begin guiding patients toward healthier thoughts and behaviors. Level of Evidence Level II, prognostic study.

Background Approximately 20% to 50% of patients develop persistent pain after traumatic orthopaedic injuries. Psychosocial factors are an important predictor of persistent pain; however, there are no evidence-based, mind-body interventions to prevent persistent pain for this patient population. Questions/purposes (1) Does the Toolkit for Optimal Recovery after Injury (TOR) achieve a priori feasibility benchmarks in a multisite randomized control trial (RCT)? (2) Does TOR demonstrate a preliminary effect in improving pain, as well as physical and emotional function? Methods This pilot RCT of TOR versus a minimally enhanced usual care comparison group (MEUC) was conducted among 195 adults with an acute orthopaedic traumatic injury at risk for persistent pain at four geographically diverse Level 1 trauma centers between October 2021 to August 2023. Fifty percent (97 of 195) of participants were randomized to TOR (mean age 43 ± 17 years; 67% [65 of 97] women) and 50% (98) to MEUC (mean age 45 ± 16 years; 67% [66 of 98] women). In TOR, 24% (23 of 97) of patients were lost to follow-up, whereas in the MEUC, 17% (17 of 98) were lost. At 4 weeks, 78% (76 of 97) of patients in TOR and 95% (93 of 98) in the MEUC completed the assessments; by 12 weeks, 76% (74 of 97) of patients in TOR and 83% (81 of 98) in the MEUC completed the assessments (all participants were still included in the analysis consistent with an intention-to-treat approach). The TOR has four weekly video-administered sessions that teach pain coping skills. The MEUC is an educational pamphlet. Both were delivered in addition to usual care. Primary outcomes were feasibility of recruitment (the percentage of patients who met study criteria and enrolled) and data collection, appropriateness of treatment (the percent of participants in TOR who score above the midpoint on the Credibility and Expectancy Scale), acceptability (the percentage of patients in TOR who attend at least three of four sessions), and treatment satisfaction (the percent of participants in TOR who score above the midpoint on the Client Satisfaction Scale). Secondary outcomes included additional feasibility (including collecting data on narcotics and rescue medications and adverse events), fidelity (whether the intervention was delivered as planned) and acceptability metrics (patients and staff), pain (numeric rating scale), physical function (Short Musculoskeletal Function Assessment questionnaire [SMFA], PROMIS), emotional function (PTSD [PTSD Checklist], depression [Center for Epidemiologic Study of Depression]), and intervention targets (pain catastrophizing, pain anxiety, coping, and mindfulness). Assessments occurred at baseline, 4 and 12 weeks. Results Several outcomes exceeded a priori benchmarks: feasibility of recruitment (89% [210 of 235] of eligible participants consented), appropriateness (TOR: 73% [66 of 90] scored > midpoint on the Credibility and Expectancy Scale), data collection (79% [154 of 195] completed all surveys), satisfaction (TOR: 99% [75 of 76] > midpoint on the Client Satisfaction Scale), and acceptability (TOR: 73% [71 of 97] attended all four sessions). Participation in TOR, compared with the MEUC, was associated with improvement from baseline to postintervention and from baseline to follow-up in physical function (SMFA, baseline to post: -7 [95% CI -11 to -4]; p < 0.001; baseline to follow-up: -6 [95% CI -11 to -1]; p = 0.02), PROMIS (PROMIS-PF, baseline to follow-up: 2 [95% CI 0 to 4]; p = 0.045), pain at rest (baseline to post: -1.2 [95% CI -1.7 to -0.6]; p < 0.001; baseline to follow-up: -1 [95% CI -1.7 to -0.3]; p = 0.003), activity (baseline to post: -0.7 [95% CI -1.3 to -0.1]; p = 0.03; baseline to follow-up: -0.8 [95% CI -1.6 to -0.1]; p = 0.04), depressive symptoms (baseline to post: -6 [95% CI -9 to -3]; p < 0.001; baseline to follow-up: -5 [95% CI -9 to -2]; p < 0.002), and posttraumatic symptoms (baseline to post: -4 [95% CI -7 to 0]; p = 0.03; baseline to follow-up: -5 [95% CI -9 to -1]; p = 0.01). Improvements were generally clinically important and sustained or continued through the 3 months of follow-up (that is, above the minimum clinically important different [MCID] of 7 for the SMFA, the MCID of 3.6 for PROMIS, the MCID of 2 for pain at rest and pain during activity, the MCID of more than 10% change in depressive symptoms, and the MCID of 10 for posttraumatic symptoms). There were treatment-dependent improvements in pain catastrophizing, pain anxiety, coping, and mindfulness. Conclusion TOR was feasible and potentially efficacious in preventing persistent pain among patients with an acute orthopaedic traumatic injury. Using TOR in clinical practice may prevent persistent pain after orthopaedic traumatic injury. Level of Evidence Level I, therapeutic study.

OBJECTIVES: To seek the factors associated with timing, staging, and type of surgery in the management of multiligament knee injuries. METHODS: Design: Cross-sectional scenario-based experiment. Setting: Fifteen fictional patient scenarios with randomized elements. Participants: Fracture surgeons of the Science of Variation Group, an international collaborative of musculoskeletal surgeons who studies variation in care, were invited to participate. Surgeons with limited experience treating multiligament knee injuries were asked to self-exclude. Outcome Measures and Comparisons: Surgeon recommendations for operative treatment, timing of surgery, and use of open surgery in addition to arthroscopy were measured. Patient factors (age, time from injury, contralateral fracture, knee dislocation, combinations of ruptured ligaments, and preexisting osteoarthritis) and surgeon factors (gender, practice location, years of experience, and supervision of trainees) associated with surgeon recommendations were assessed. RESULTS: Eighty-five surgeons participated, of which most were men (89%) and practiced in the United States (44%) or Europe (38%). Operative treatment was less likely among older patients (odds ratio [OR] = 0.051) and preexisting osteoarthritis (OR = 0.32) and more likely in knee dislocation (OR = 1.9) and disruption of anterior cruciate ligament, posterior cruciate ligament, and lateral collateral ligament with or without medial collateral ligament (MCL; OR = 5.1 and OR = 3.1, respectively). Disruption of anterior cruciate ligament, posterior cruciate ligament, and medial collateral ligament was associated with shorter time to surgery (β = −11). Longer time to surgery was associated with contralateral fracture (β = 9.2) and surgeons supervising trainees (β = 23) and practicing in Europe (β = 13). Surgeon factors accounted for more variation in timing than patient and injury factors (5.1% vs. 1.4%, respectively). Open surgery was more likely in patients with lateral collateral ligament injury (OR = 2.9 to 3.3). CONCLUSIONS: The observation that surgeons were more likely to operate in younger patients with more severe injury has face validity, while the finding that surgeon factors accounted for more variation in timing of surgery than patient or injury factors suggests that treatment variation is based on opinion more so than evidence. LEVEL OF EVIDENCE: Prognostic Level V. See Instructions for Authors for a complete description of levels of evidence.

The chemical analysis and antibacterial activity of three types of propolis collected three different races of Apis mellifera bee in the same apiary were investigated. Propolis samples were investigated by GC/MS, 48 compounds were identified 32 being new for propolis. The compounds identified indicated that the main plant sources of propolis were Populus alba, Populus tremuloides and Salix alba. The antimicrobial activity against Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa and Candida albicans was evaluated. Ethanolic extracts of propolis samples showed high antibacterial activity against Gram-positive cocci (Staphylococcus aureus), but had a weak activity against Gram-negative bacteria (Escherichia coli and Pseudomonas aeruginosa) and yeast (Candida albicans). Propolis sample collected by Apis mellifera caucasica showed a higher antibacterial activity than collected by Apis mellifera anatolica and Apis mellifera carnica.

The Toolkit for Optimal Recovery (TOR) is a mind-body program for patients with acute orthopedic injuries who are at risk for persistent pain/disability. In preparation for a multisite feasibility trial of TOR at three orthopedic trauma centers, we aim to qualitatively identify barriers and facilitators to study implementation and strategies to mitigate the implementation barriers and leverage facilitators.We conducted 18 live video focus groups among providers and three one-on-one interviews with department chiefs at Level 1 trauma centers in three geographically diverse sites (N = 79 participants). Using a content analysis approach, we detected the site-specific barriers and facilitators of implementation of TOR clinical trial. We organized the data according to 26 constructs of the Consolidated Framework for Implementation Research (CFIR), mapped to three Proctor implementation outcomes relevant to the desired study outcomes (acceptability, appropriateness, and feasibility). Across the three sites, we mapped six of the CFIR constructs to acceptability, eight to appropriateness, and three to feasibility. Prominent perceived barriers across all three sites were related to providers' lack of knowledge/comfort addressing psychosocial factors, and organizational cultures of prioritizing workflow efficiency over patients' psychosocial needs (acceptability), poor fit between TOR clinical trial and the fast-paced clinic structure as well as basic needs of some patients (appropriateness), and limited resources (feasibility). Suggestions to maximize the implementation of the TOR trial included provision of knowledge/tools to improve providers' confidence, streamlining study recruitment procedures, creating a learning collaborative, tailoring the study protocol based on local needs assessments, exercising flexibility in conducting research, dedicating research staff, and identifying/promoting champions and using novel incentive structures with regular check-ins, while keeping study procedures as nonobtrusive and language as de-stigmatizing as possible. These data could serve as a blueprint for implementation of clinical research and innovations in orthopedic and other medical settings.

Background Despite the pivotal role of psychosocial factors in pain and disability after orthopedic injury, there are no evidence-based preventive interventions targeting psychosocial factors in patients with acute orthopedic injuries. We developed the first mind-body intervention focused on optimizing recovery and improving pain and disability in patients with acute orthopedic injuries who exhibit high levels of catastrophic thinking about pain and/or pain anxiety (Toolkit for Optimal Recovery [TOR] after orthopedic injury). In a pilot single-site randomized controlled trial (RCT), the TOR met a priori set benchmarks for feasibility, acceptability, and satisfaction. The next step in developing TOR is to conduct a multisite feasibility RCT to set the stage for a scientifically rigorous hybrid efficacy-effectiveness trial. Objective The objective of this study is to conduct a rigorous multisite feasibility RCT of TOR to determine whether the intervention and study methodology meet a priori set benchmarks necessary for the successful implementation of a future multisite hybrid efficacy-effectiveness trial. In this paper, we describe the study design, manualized treatments, and specific strategies used to conduct this multisite feasibility RCT investigation. Methods This study will be conducted at 3 geographically diverse level 1 trauma centers, anonymized as sites A, B, and C. We will conduct a multisite feasibility RCT of TOR versus the minimally enhanced usual care (MEUC) control (60 patients per site; 30 per arm) targeting a priori set feasibility benchmarks. Adult patients with acute orthopedic injuries who endorse high pain catastrophizing or pain anxiety will be recruited approximately 1-2 months after injury or surgery (baseline). Participants randomized to the TOR will receive a 4-session mind-body treatment delivered via a secure live video by trained clinical psychologists. Participants randomized to the MEUC will receive an educational booklet. Primary outcomes include feasibility of recruitment, appropriateness, feasibility of data collection, acceptability of TOR (adherence to sessions), and treatment satisfaction across all sites. We will also collect data on secondary implementation outcomes, as well as pain severity, physical and emotional function, coping skills, and adverse events. Outcomes will be assessed at baseline, posttreatment, and at the 3-month follow-up. Results Enrollment for the RCT is estimated to begin in June 2021. The target date of completion of the feasibility RCT is April 2024. The institutional review board approval has been obtained (January 2020). Conclusions This investigation examines the multisite feasibility of TOR administered via live videoconferencing in adult patients with acute orthopedic injuries. If feasible, the next step is a multisite, hybrid efficacy-effectiveness trial of TOR versus MEUC. Preventive psychosocial interventions can provide a new way to improve patient and provider satisfaction and decrease suffering and health care costs among patients with orthopedic injuries who are at risk for chronic pain and disability. International Registered Report Identifier (IRRID) PRR1-10.2196/28155

OBJECTIVES:Requests for opioid pain medication more than a few weeks after surgery are associated with greater symptoms of depression and cognitive biases regarding pain such as worst-case thinking and fear of painful movement. We sought factors associated with patient desire for more opioid medication and satisfaction with pain alleviation at suture removal after lower extremity surgery.DESIGN:Cross sectional study.SETTING:Enrollment occurred at 1 of 4 orthopaedic offices in an urban setting.PATIENTS/PARTICIPANTS:At suture removal after lower extremity surgery, 134 patients completed questionnaires measuring catastrophic thinking, ability to reach goals and continue normal activities in spite of pain, symptoms of depression, and magnitude of physical limitations.MAIN OUTCOME MEASUREMENTS:Psychological factors associated with questionnaire-reported patient desire for another opioid prescription, satisfaction with postoperative pain alleviation, and the self-reported number of pills remaining from original opioid prescription.RESULTS:In logistic regression, smoking and greater catastrophic thinking were independently associated with desire for opioid refill (R2 = 0.20). Lower satisfaction with pain alleviation was associated with greater catastrophic thinking (R2 = 0.19). The size of surgery (large vs. medium/small procedure) was not associated with pain alleviation or satisfaction with pain alleviation.CONCLUSIONS:The association between unhelpful cognitive bias regarding pain and request for more opioids reinforces the importance of diagnosing and addressing common misconceptions regarding pain in efforts to help people get comfortable.LEVEL OF EVIDENCE:Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:We compared the amount of variation in Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF) Computer Adaptive Test (CAT) accounted for by The Tampa Scale for Kinesiophobia (TSK) and its short form (TSK-4) independent of other factors. Questionnaire coverage, reliability, and validity were compared for both TSK and TSK-4 using mean scaled scores, internal consistency, floor and ceiling effects, interquestionnaire correlations, and collinearity with other measures as the Pain Catastrophizing Scale short form (PCS-4), PROMIS Depression CAT, and PROMIS Pain Interference (PROMIS PI) CAT.METHODS:One hundred forty eight consecutive new or return patients were enrolled. Patients were seen in an outpatient setting in several orthopaedic clinics in a large urban area. All patients completed the TSK, PROMIS PF CAT, PROMIS PI CAT, PROMIS Depression CAT, and PCS-4.RESULTS:Greater fear of movement (higher TSK) was associated with worse physical function (lower PROMIS PF CAT) and the full TSK explained more variation in physical function than the short form (TSK-4). In contrast to prior studies PCS-4 was not independent of TSK. Flooring and ceiling effects were seen with TSK-4. Worse physical function was associated with older age, traumatic condition, and more symptoms of depression.CONCLUSION:The short form of the Tampa Scale for Kinesiophobia can be used as a brief screening measure in patient care and research in order to identify an independent influence of kinesiophobia on lower extremity specific limitations. Additional study is needed to determine whether there is utility in screening for both TSK and PCS or if one or the other provides sufficient information about cognitive biases regarding pain to guide treatment with cognitive behavioral therapy and related techniques.

The rise of patient-reported outcome (PRO) measurement across medicine has been swift and now extends to the world of orthopedic trauma. However, PRO measures (PROMs) applied to trauma patients pose special considerations; measuring "episodes of care" is less straightforward, injuries are heterogeneous in their severity, and the patient's initial visit is "postinjury." Obtaining baseline scores and assessing the impact of a traumatic event on mental health are key considerations. Currently, few, if any, trauma registries include PROs; though general and condition-specific PROMs plus the patient empowerment measure of Patient Activation represent meaningful inputs for the clinical decision-making process. To be useful in trauma care, PROMs should be psychometrically sound and validated, be used for capturing function, screen for mental state and substance use, and give the clinician a sense of the patient's "activation" (engagement in their own health). Although the implementation of routine PRO collection can seem daunting, clinicians can use a multitude of electronic resources to access validated measures and simplify the implementation process. Computer-adaptive testing has evolved to help minimize patient burden, and PROM collection must maximize efficiency. Once established as part of your practice, PROs become an important tool to track recovery, identify mental health issues, engage in the prevention of future injury, and enable care of the whole patient.

Value in healthcare can be defined as health outcomes that matter to patients divided by the cost incurred to achieve those outcomes [8]. Value is increased by improving health outcomes, reducing costs, or both. One way to increase value is to reduce implant-related costs, provided that doing so does not compromise pain reduction, functional gains, or other improvements in endpoints that matter to patients. In a 2014 paper, Egol and colleagues [3] outlined six strategies for reducing trauma implant-related healthcare costs. Of those strategies, the use of generic fracture implants stands out for its relative simplicity, provided that generic implants are functionally equivalent to conventional implants. Indeed, if researched and implemented correctly, the use of generic implants has the potential to improve value and have wide application across orthopaedic subspecialties. Surprisingly, clinical research comparing conventional and generic orthopaedic implants is relatively limited. One study [1] found that generic sacroiliac screws could result in cost savings of USD 327 per procedure over conventional screws in patients who were otherwise similar in terms of age, sex, fracture pattern complication rate, and radiographic outcomes. The authors reported similarfindings for screws used for the internal fixation of femoral neck fractures. Another study [7] reported savings of USD 1197 per procedure (a 56% reduction) when generic locking plates were compared to conventional ones for fractures of the proximal humerus, distal radius, proximal tibia, tibial pilon, and ankle, with no increase in complications or surgical time. Findings in arthroplasty are a bitmore complicated, if still quite preliminary. WhileWaddell and colleagues [9] found that generic total hip implants were comparable to more-expensive prostheses at 2-year followup with respect to clinical endpoints, Hothi and colleagues [5] identified potentially important design differences between branded and generic stems in terms of trunnion surface roughness and mass, but not volume. Greater trunnion roughness (as was found in the generic stem) has been associated with greater corrosion at the head-stem junction [5, 11]. The mass and volume findings suggest different material densities, manufacturing processes, and possibly mechanical properties between the two stem designs of uncertain clinical significance. These findings led Haddad [4] to caution against rushing to adopt generic implants and to urge clinicians instead to conduct a “full and thorough stepwise evaluation” before considering them for routine care. We agree that for joint replacements, the adoption of generic implants should be more cautious. Yet this caution should be tempered by the need to provide value-based care, which incorporates consideration of cost. The use of generic implants remains limited despite the evidence that simple generic implants such as plates and screws are functionally equivalent to (and less expensive than) conventional implants. A 2016 survey of A note from the Editor-in-Chief: We are pleased to present to readers of Clinical Orthopaedics and Related Research the latest Value-based Healthcare column (formerly Orthopaedic Healthcare Worldwide). Valuebased Healthcare explores strategies to enhance the value of musculoskeletal care by improving health outcomes and reducing the overall cost of care delivery. We welcome reader feedback on all of our columns and articles; please send your comments to eic@ clinorthop.org. One author (KJB) is Chair of the American Joint Replacement Registry Steering Committee. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. K. J. Bozic MD, MBA (✉), Dell Medical School at the University of Texas at Austin 1701 Trinity Street, Austin, TX 78712. Email: kevin.bozic@austin.utexas.edu V. H. Waldrop, Medical Student, Dell Medical School at The University of Texas at Austin, Austin, TX. D. Laverty, Clinical Assistant Professor, Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, TX. K. Bozic, Chair, Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, TX.