Magnetic Resonance Imaging Analysis Demonstrates Improved Reliability in Measuring Shoulder Glenoid Bone Loss Using a Two-Thirds Glenoid Height Technique Compared to the "Best-fit Circle".

PURPOSE: To evaluate the superior to inferior glenoid height as a reliable reference in best-fit circle creation for glenoid anatomy. METHODS: The morphology of the native glenoid was evaluated using magnetic resonance imaging (MRI) in patients without shoulder instability. Using T1 sagittal MRI images, 2 reviewers independently estimated glenoid size using the two-thirds technique and the "best-fit circle" technique at 2 different times. A Student t-test was used to determine significant difference between the two methodologies. Inter- and intra-rater reliability were calculated using interclass and intraclass coefficients. RESULTS: This study included 112 patients. Using the results of glenoid height and "best-fit circle" diameter, the diameter of the "best-fit circle" was found to intersect the glenoid line at 67.8% of the glenoid height on average. We found no significant difference between the 2 measures of glenoid diameter (27.6 vs 27.9, P = .456). The interclass and intraclass coefficients for the two-third method were 0.85 and 0.88, respectively. The interclass and intraclass coefficients for the perfect circle methods were 0.84 and 0.73, respectively. CONCLUSIONS: We determined that the diameter of a circle placed on the inferior glenoid using the "best-fit circle" technique corresponds to 67.8% of the glenoid height. Additionally, we found that constructing a perfect circle using a diameter equal to two-thirds the height of the glenoid may improve intraclass reliability. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

How Does Orthopaedic Surgeon Gender Representation Vary by Career Stage, Regional Distribution, and Practice Size? A Large-Database Medicare Study.

BACKGROUND: Orthopaedic surgery has the lowest proportion of women surgeons in practice of any specialty in the United States. Preliminary studies suggest that patients who are treated by physicians of the same race, ethnicity, cultural background, or gender feel more comfortable with their care and may have better outcomes. Therefore, understanding the discrepancies in the diversity of the orthopaedic surgeon workforce is crucial to addressing system-wide healthcare inequities. QUESTIONS/PURPOSES: (1) Does a difference exist in gender representation among practicing orthopaedic surgeons across geographic distributions and years in practice? (2) Does a difference exist in gender representation among practicing orthopaedic surgeons with regard to rural-urban setting, group practice size, and years in practice? METHODS: Orthopaedic surgeons serving Medicare patients in 2017 were identified in the Medicare Physician and Other Supplier Public Use File and Physician Compare national databases. This dataset encompasses more than 64% of practicing orthopaedic surgeons, providing a low proportion of missing data compared with other survey techniques. Group practice size, location, and Rural-urban Commuting Area scores were compared across physician gender and years in practice. Linear and logistic regressions modeled gender and outcomes relationships adjusted by years in practice. Least-square means estimates for outcomes were calculated by gender at the median years in practice (19 years) via regression models. RESULTS: According to the combined Medicare databases used, 5% (1019 of 19,221) of orthopaedic surgeons serving Medicare patients were women; this proportion increased with decreasing years in practice (R 2 0.97; p < 0.001). Compared by region, the West region demonstrated the highest proportion of women orthopaedic surgeons overall (7% [259 of 3811]). The Midwest and South regions were below the national mean for proportions of women orthopaedic surgeons, both overall (5% [305 of 6666] and 5% [209 of 4146], respectively) and in the first 5 years of practice (9% [54 of 574] and 9% [74 of 817], respectively). Women worked in larger group practices than men (median [interquartile range] 118 physicians [20 to 636] versus median 56 [12 to 338]; p < 0.001, respectively). Both genders were more likely to practice in an urban setting, and when controlling for years in practice, there was no difference between men and women orthopaedic surgeons practicing in rural or urban settings (respectively, R 2 = 0.0004 and 0.07; p = 0.89 and 0.09). CONCLUSION: Among orthopaedic surgeons, there is only one woman for every 20 men caring for Medicare patients in the United States. Although gender representation is increasing longitudinally for women, it trails behind other surgical subspecialties substantially. Longitudinal mentoring programs, among other evidenced initiatives, should focus on the more pronounced underrepresentation identified in Midwestern/Southern regions and smaller group practices. Gender-based equity, inclusion, and diversity efforts should focus on recruitment strategies, and further research is needed to study how inclusion and diversity efforts among orthopaedic surgeons improves patient-centered care. LEVEL OF EVIDENCE: Level III, therapeutic study.

National and geographic trends in Medicare reimbursement rates for orthopedic shoulder and upper extremity surgery from 2000 to 2020.

BACKGROUND: There is a paucity of information regarding financial trends in orthopedic upper extremity surgery. If progress is to be made in advancing agreeable reimbursement models, a more comprehensive understanding of these trends is needed. The purpose of this study was to assess national and geographic trends in Medicare reimbursement rates for shoulder and elbow surgical procedures over the past 2 decades. METHODS: The 10 most billed Common Procedural Terminology (CPT) codes for both orthopedic shoulder surgery and elbow/upper arm surgery were determined. Medicare reimbursement data for these CPT codes were compiled between 2000 and 2020 and adjusted for inflation. The percentage change for each procedure and the average change in reimbursement each year were analyzed. Data from 2000, 2010, and 2020 were organized by state. The total percent change in physician fee and the percent change per year were tabulated for each CPT code using inflation-adjusted data and averaged by state. RESULTS: From 2000 to 2020, when corrected for inflation, shoulder and elbow procedures decreased on average by 29.3% and 24.5%, respectively. Shoulder procedures experienced a greater numerical yet statistically insignificant decline in mean reimbursement percent decrease (P = .16), average percent decrease per year (P = .11), a more negative compound annual growth rate (P = .14), and a greater R-squared value as compared with elbow and upper arm procedures. For shoulder procedures, the average percent difference in inflation-adjusted Medicare reimbursement rates from 2000 to 2020 varied from -22.6% in Alaska to -34.1% in Michigan; division data varied from -27.8% in the Mountain Division to -31.2% in the East North Central Division; and region data varied from -28.3% in the West to -30.5% in the Northeast. For elbow and upper arm procedures, the average percent difference in inflation-adjusted Medicare reimbursement rates from 2000 to 2020 varied from -17.6% in Alaska to -29.8% in Michigan; division data varied from -23.0% in the Mountain Division to -26.7% in the East North Central Division; and region data varied from -23.5% in the West to -25.7% in the Northeast. DISCUSSION: Inflation-adjusted Medicare reimbursement in upper extremity surgery has decreased markedly between 2000 and 2020. The degree of decrease varies geographically. If access to quality and sustainable surgical orthopedic care is to persist in the United States, increased awareness of these trends is important. The trends identified in this study can serve to customize regional health care policymaking.

Explaining Discrepancies Between Total and Segmental DXA and BIA Body Composition Estimates Using Bayesian Regression.

INTRODUCTION/BACKGROUND: Few investigations have sought to explain discrepancies between dual-energy X-ray absorptiometry (DXA) and bioelectrical impedance analysis (BIA) body composition estimates. The purpose of this analysis was to explore physiological and anthropometric predictors of discrepancies between DXA and BIA total and segmental body composition estimates. METHODOLOGY: Assessments via DXA (GE Lunar Prodigy) and single-frequency BIA (RJL Systems Quantum V) were performed in 179 adults (103 F, 76 M, age: 33.6 ± 15.3 yr; BMI: 24.9 ± 4.3 kg/m2). Potential predictor variables for differences between DXA and BIA total and segmental fat mass (FM) and lean soft tissue (LST) estimates were obtained from demographics and laboratory techniques, including DXA, BIA, bioimpedance spectroscopy, air displacement plethysmography, and 3-dimensional optical scanning. To determine meaningful predictors, Bayesian robust regression models were fit using a t-distribution and regularized hierarchical shrinkage "horseshoe" prior. Standardized model coefficients (ß) were generated, and leave-one-out cross validation was used to assess model predictive performance. RESULTS: LST hydration (i.e., total body water:LST) was a predictor of discrepancies in all FM and LST variables (|ß|: 0.20-0.82). Additionally, extracellular fluid percentage was a predictor for nearly all outcomes (|ß|: 0.19-0.40). Height influenced the agreement between whole-body estimates (|ß|: 0.74-0.77), while the mass, length, and composition of body segments were predictors for segmental LST estimates (|ß|: 0.23-3.04). Predictors of segmental FM errors were less consistent. Select sex-, race-, or age-based differences between methods were observed. The accuracy of whole-body models was superior to segmental models (leave-one-out cross-validation-adjusted R2 of 0.83-0.85 for FMTOTAL and LSTTOTAL vs. 0.20-0.76 for segmental estimates). For segmental models, predictive performance decreased in the order of: appendicular lean soft tissue, LSTLEGS, LSTTRUNK and FMLEGS, FMARMS, FMTRUNK, and LSTARMS. CONCLUSIONS: These findings indicate the importance of LST hydration, extracellular fluid content, and height for explaining discrepancies between DXA and BIA body composition estimates. These general findings and quantitative interpretation based on the presented data allow for a better understanding of sources of error between 2 popular segmental body composition techniques and facilitate interpretation of estimates from these technologies.

A Comprehensive Analysis of Medicare Reimbursement to Physicians for Common Arthroscopic Procedures: Adjusted Reimbursement Has Fallen Nearly 30% From 2000 to 2019.

PURPOSE: To analyze and objectively measure the trends in inflation-adjusted Medicare reimbursement rates for the 20 most commonly performed orthopaedic arthroscopic surgical procedures from 2000 to 2019. METHODS: The Centers for Medicare & Medicaid Services website was used to find the top 20 most commonly performed arthroscopic procedures using the Public Use File data file for calendar year 2017. By use of the Physician Fee Schedule Look-Up Tool, national reimbursement averages were calculated from 2000-2019 and data were analyzed. Averages were adjusted for inflation using the Consumer Price Index. Current Procedural Terminology codes that did not exist in 2000 were unable to be analyzed in this study. RESULTS: When adjusted for inflation, Medicare reimbursement for the 20 most commonly performed arthroscopic procedures from 2000-2019 has decreased substantially (-29.81%). The mean Medicare reimbursement to physicians was $906 in 2000 and $632 in 2019. During this same period, the annual change in the adjusted mean reimbursement rate for all included arthroscopic procedures was -1.8% whereas the average compound annual growth rate was -1.9%. CONCLUSIONS: This study shows that when adjusted for inflation, Medicare reimbursement to physicians has decreased by nearly 30% during the past 20 years for the most common arthroscopic procedures. CLINICAL RELEVANCE: This analysis will give orthopaedic surgeons and hospital administrators a better understanding of the financial trends surrounding one of the fastest-growing techniques in surgery. Additionally, these financial-trend data will be increasingly important as the population in the United States continues to age and new payment models are introduced.

Medical Malpractice Cases Involving Medical Students.

PURPOSE: This study uses a large national legal database to analyze characteristics of malpractice claims involving U.S. medical students. METHOD: The Westlaw database was searched in September 2023 for malpractice cases involving medical students from January 1, 1900, through September 1, 2023. Each case was independently reviewed by 2 authors, abstracting each variable. Categorical data were summarized as frequency of occurrence (i.e., number and percentage), and continuous data were summarized with means, medians, and ranges. All authors independently reviewed the dataset to identify potential themes and codes. RESULTS: There were 65 cases that met the inclusion criteria. Reported patient outcomes were death (19, 29%), pain (25, 38%), and disability (36, 55%). The most common specialties involved were emergency medicine (16, 25%), general surgery (14, 22%), and obstetrics and gynecology (13, 20%). The most common primary alleged errors attributed to students related to medical decision-making (30, 46%), procedural complication (24, 37%), and poor communication (11, 17%). Among 23 (35%) cases reporting year of training, 1 (4%) included a second-year student, 13 (57%) included third-year students, and 9 (39%) included fourth-year students. Of the 65 lawsuits, 28 (43%) resulted in a settlement or verdict against the medical student. The total amount paid in these cases was $78,192,612, with a mean (median) of $3,007,408 ($1,050,000) per case. Of these 28 cases, 14 (50%) cited minimal or no physician supervision. CONCLUSIONS: Medical malpractice claims involving medical students are rare but commonly relate to medical decision-making, procedural complication, and poor communication, with a lack of supervision being frequently cited. These results can be used to guide students and supervising physicians on how to avoid scenarios that may increase vulnerability to medical malpractice lawsuits.

All-Arthroscopic Falciform Portal Biceps Tenodesis.

Biceps tenodesis has been proven to be an effective treatment for biceps tendon and superior labral pathology. Many techniques including both open and arthroscopic approaches have been reported. Open techniques afford management of the entire proximal biceps tendon but are limited by wound healing issues, increased bleeding, and increased surgical time. Arthroscopic tenodesis offers benefits in terms of surgical efficiency, cosmesis, and bleeding risk. However, standard arthroscopic tenodesis only addresses intra-articular biceps pathology. In this report we describe an all-arthroscopic biceps tenodesis technique at the suprapectoral region of the humerus using knotless suture anchor fixation.

Patellar Resurfacing Is Not a Risk Factor for Postoperative Patella Baja in Total Knee Arthroplasty.

Background: Patella baja is a known complication of total knee arthroplasty (TKA). There is a limited understanding of the association between patellar resurfacing and the incidence of patella baja. We aimed to compare rates of patella baja between unresurfaced and resurfaced patellas in patients undergoing TKA. Methods: A retrospective review of patients who underwent TKA between October 2009 and January 2020 was performed. Patients were included if they had at least one preoperative radiograph and a 1-year follow-up radiograph. Blackburne-Peel index (BPI) and Insall-Salvati ratios (ISRs) were measured on preoperative and 1-year postoperative radiographs and were used to define patella baja vs pseudopatella baja. Statistical analysis was performed using a linear model analysis of variance and the Fisher's exact test. Results: Three hundred eighteen TKAs were included, with 176 being resurfaced and 142 unresurfaced patellas. Of the resurfaced group, 4% (7/176) had true patella baja, compared to 5.6% (8/142) of the unresurfaced patellas. Of the resurfaced patellas, 8% (14/176) had pseudopatella baja, compared to 7% (10/142) in the unresurfaced group. Patellar resurfacing was not associated with a higher incidence of patella baja (P = .60) or pseudopatella baja (P = .83). Lower preoperative ISRs (P = .04) and BPIs (0.03) were highly predictive of a higher incidence of patella baja post-TKA. Conclusions: Patellar resurfacing in TKA is not associated with a higher incidence of patella baja in TKA when compared to unresurfaced patellas. Lower preoperative ISRs and BPIs are highly predictive of a higher incidence of postoperative patella baja.

Patient Interest in Quadriceps Autograft Anterior Cruciate Ligament Reconstruction Is Increasing Over Other Autograft Options: A 12-Year Google Trends Analysis.

Purpose: To use Google trends to explore differences in public interest among types of anterior cruciate ligament (ACL) autografts, specifically quadriceps tendon, patellar tendon, and hamstring tendon autografts, between 2008 and 2019. Methods: Data were obtained by querying Google Trends for key terms and phrases for online search data ranging from January 2008 to December 2019. Relative search volumes were created based on searches related to ACL reconstruction with comparative analysis generated for search terms related to quadriceps ACL, patellar tendon ACL, and hamstring ACL autografts. Statistical analysis included linear regression analysis, comparison of quarterly search volume trends over time, and comparison of cumulative annual search volumes for 2008 versus 2019. Results: Linear models for respective search terms were statistically significant for the quadriceps (P < .001) and patellar (P = .007) tendon autograft groups but not the hamstring group (P = .129). The quadriceps autograft group demonstrated a 12-year search volume trend change of 0.56, which was significantly greater than the hamstring (0.07; P < .001) and patellar tendon (0.168; P < .001) groups. There was no significant difference in the trend change between hamstring and patellar tendon groups (P = .20). Percent change in cumulative relative annual search volumes between 2008 and 2019 was 112% for the quadriceps tendon group, 12.9% for the hamstring group, and 18.6% for the patellar tendon group. Conclusions: This study indicates a consistently increasing public interest in quadriceps tendon autograft for ACL reconstruction. The quadriceps autograft group demonstrated a significantly greater 12-year online search volume, greater linear correlation, and larger percent change between 2008 and 2019 compared with patellar tendon or hamstring autograft groups. Clinical Relevance: Awareness of patient perceptions has value in informing shared decision-making, aligning patient expectations, and guiding areas of future research. Each of these has an impact on patient care. Being aware of patient interest and expectations is particularly important in areas with controversial or emerging research.

Arthroscopic Posterior Capsular Release Improves Range of Motion and Outcomes for Flexion Contracture After Anterior Cruciate Ligament Reconstruction in Athletes.

Purpose: To assess outcomes of arthroscopic posterior capsular release among athletes for loss of terminal extension following anterior cruciate ligament (ACL) reconstruction. Methods: A retrospective review of prospectively collected data was performed for patients undergoing arthroscopic posterior capsular release for knee extension loss following ACL reconstruction between January 2014 and December 2019. Procedure indications included extension loss greater than 10° at least 3 months after ACL reconstruction that was refractory to physical therapy. Patients were included if they were involved in either high school or college athletics, had complete outcomes of interest, and had at least 2 years of follow-up. Prospectively collected outcomes included preoperative and postoperative measurement of knee extension, International Knee Documentation Committee score, Lysholm score, return to sport data, and complications. Results: Eighteen athletes with minimum 2 years of follow-up who underwent posterior capsular release following ACL reconstruction performed by a single surgeon were included in the analysis. Patients underwent surgery at an average of 16 weeks after ACL reconstruction. Knee extension improved an average of 13.8° at 2 years' follow-up (prerelease mean extension deficit 15.1°, postrelease mean extension deficit 1.3°, P < .005). Improvements in the International Knee Documentation Committee score averaged 21.7 at 6 months and 35.0 at 24 months, both of which were statistically significant (P < .001). Similarly, differences in Lysholm included a significant improvement of 23.0 and 34.2 at 6 months and 2 years, respectively (P < .001). In total, 77.8% returned to sport at an average of 9.8 months from their primary ACL surgery and 6.5 months following posterior capsular release surgery. No infections or neurovascular complications were observed. One patient required secondary release to achieve adequate extension. Conclusions: For athletes with persistent knee extension loss after ACL reconstruction, knee extension was significantly improved at 2 years following arthroscopic posterior capsular release. Substantial improvements in patient-reported outcomes also were seen. In addition, subjects demonstrated a high rate of return to sport and return to preinjury performance levels. Level of Evidence: Level IV, therapeutic case series.

Characterization of neurosurgery fellowship directors: strengths and room for improvement.

BACKGROUND: While many current and aspiring neurosurgeons are looking to supplement their clinical practices with leadership positions, there has not been research characterizing current leadership positions such as fellowship directors (FDs) in neurosurgery to provide insight into objective qualities that distinguish these individuals from the rest of the workforce. This study aims to outline the current characterization of spine, endovascular, pediatric, and stereotactic and functional neurosurgery fellowship directors. METHODS: A list of accredited neurosurgical fellowship programs located within the US and their respective directors was acquired through the AANS Neurosurgical Fellowship Training Program Directory. This study obtained educational, demographic, institutional, research, and professional background variables through curriculum vitae, institutional profiles, personal websites, emails, and the Scopus database. RESULTS: Of the 152 FDs analyzed, 143 (94%) were male, 9 (6%) were female, and the mean age was 52.2±8.5 years. The mean Scopus H-index and mean total citations for all FDs was 27±15.7 and 3782.1±4526.7, respectively. Furthermore, the majority of FDs were Caucasian (69.1%), followed by Asian (20.4%), Black or African American (5.3%), and Hispanic or Latino (5.3%). The mean number of years as FD was 8.9±7.2. CONCLUSIONS: This analysis showed neurosurgery fellowship directors are primarily Caucasian males. Neurosurgery training pedigree seems to play a role in FD attainment. In addition, these directors are largely distinguished by their research productivity. This analysis serves as an insight into the current climate for students aspiring to serve as academic leaders in the field of neurosurgery.

Public Interest in Shoulder Platelet-Rich Plasma Injections Is Increasing: A 10-Year Google Trends Analysis.

Purpose: To quantify and analyze public interest trends in platelet-rich plasma (PRP) therapy for shoulder pathology between 2011 and 2020 using Google Trends data. Methods: Google Trends data were queried for online search data ranging from January 2011 to December 2020. Various combinations of terms related to PRP and shoulder pathology were queried. Terms related to corticosteroid therapy in association with shoulder pathology were also generated for comparative analysis. Analyses were performed regarding trends in online search volumes. Results: Linear models were generated to evaluated trends in the volume of online searches for PRP and corticosteroid therapy for shoulder pathology. For both the PRP and steroid groups, linear models showed a statistically significant increase in search volume for the period studied (P < .001). The PRP group showed a significantly greater growth rate than the steroid group (P < .001). There were no statistically significant differences in online search volume when compared between different geographic and socioeconomic locations. Conclusions: This study indicates consistently increasing public interest in PRP injections in the shoulder. The rate of online search volume growth of PRP is significantly greater than that of corticosteroid injections for the period studied. Clinical Relevance: Awareness of patient perceptions has value in informing shared decision making, aligning patient expectations, and guiding areas of future research. Each of these has an impact on patient care. Being aware of patient interest and expectations is particularly important in areas with controversial or emerging research.

The Most Cited and Influential Publications Relating to Ice Hockey Since 2000 Focus Primarily on Concussion and Traumatic Brain Injuries.

Purpose: To determine the most frequently cited articles relating to ice hockey since 2000 and conduct a bibliometric analysis of these publications. Methods: The Clarivate Web of Knowledge database was used to gather data and generate a list of publications relating to "ice hockey" on June 20, 2022. Articles were filtered by the total number of citations accrued and were included or excluded on the basis of relevance to ice hockey; no date of publication, language, or journal restrictions. After the 50 most highly cited articles were identified, articles published before the year 2000 were excluded to avoid bias. The information analyzed from each article included author name (first and last), publication year, country of origin, institutional affiliation (of the first and last author), journal name, research design, main research topic, competition level, and the level of evidence. Results: Ultimately, 46 studies were included in this analysis. The total number of citations was 8,267 times with an average of 179.7 citations per article. The most cited article was cited 926 times. The articles came from 5 different countries, with the United States and Canada comprising 27 and 13 articles, respectively. All articles were published in English. The American Journal of Sports Medicine published the greatest number of articles. The most studied topic was concussion/traumatic brain injury (n = 26). Professional hockey was the most studied level of competition (n = 15), while college followed (n = 13). Three institutions, University of Calgary, Dartmouth School of Medicine, and University of North Carolina at Chapel Hill were responsible for 32.6% of the top articles (n = 15). Conclusions: The majority of the most cited articles relating to ice hockey are cohort studies, review articles, and epidemiological studies originating from the United States or Canada. The majority of publications included in the analysis focused on concussion and traumatic brain injury prevalence, identification, diagnosis, outcomes, and prevention, as well as the most studied level of competition was professional, but the greatest number of participants arose from the youth and high school level. Level of Evidence: Level IV, cross-sectional study.

Bibliometric Analysis of the Top 50 Most Influential Studies on Patellar Tendon Injury.

Background: There is a wide range of literature on patellar tendon injury, making it increasingly difficult to stay informed on the most influential studies in this field. It is essential to be familiar with the foundational articles of patellar tendon injury research to understand the current state of the literature and deliver high quality care. Purpose: To objectively identify the 50 most influential articles relating to patellar tendon injury and conduct a bibliometric analysis to identify key features of these articles. Study Design: Cross-sectional study. Methods: The Clarivate Analytics Web of Knowledge database was utilized to gather metrics on the 50 most cited articles on patellar tendon injury on June 27, 2022. The information extracted from each article included publication year, number of citations, author information, article type, level of evidence, country of origin, journal name, study focus, and industry influence. Results: The top 50 studies were cited a total of 8543 times and published between 1977 and 2015. The majority of articles were published after 2003, and the majority of citations were accrued after 2011. The most prevalent article types were cohort studies (n = 23), and the majority of studies were of evidence level 2 (n = 14) or 4 (n = 13). Australia and the United States (US) each published the most studies (n = 11). Only 4 (8%) studies focused on patellar tendon rupture, and 12 (24%) of the top 50 studies were associated with industry. Conclusion: The majority of the top 50 most influential articles in patellar tendon injury were published and accumulated citations in the past 10 to 20 years. Non-US countries, institutions, and journals published many of the top 50 studies, reflecting a global interest and commitment to research in this field. Patellar tendon rupture and surgical repair represents a minority of research in the top 50 studies and could be a point of growth in the future.

The Effect of Amniotic Tissue on Spinal Interventions: A Systematic Review.

BACKGROUND: Amniotic membrane tissue has been thought to potentiate healing in many soft tissue conditions. Specifically, recent studies have shown its therapeutic potential for treatment in the setting of spinal pathologies. The purpose of this study is to thoroughly review the existing scientific literature and evidence concerning the clinical use of amniotic membrane-derived biologic agents on postoperative outcomes following spinal surgery. METHODS: A systematic review was conducted following preferred reporting items for systematic reviews and meta-analyses guidelines using PubMed, Embase, and Cochrane databases up to December 2020 to identify animal and clinical studies examining the therapeutic potential for amniotic membrane tissue in the setting of spinal pathologies (including disc herniation, prevention of epidural fibrosis, and spinal fusion). Studies were broken down into 2 categories: experimental model type and the type of amnion product being analyzed. RESULTS: A total of 12 studies (4 clinical studies and 8 studies utilizing animal models) met inclusion criteria. Additionally, the major types of amnion product were divided into cryopreserved/freeze-dried amniotic membrane, human amniotic fluid, human amniotic membrane, cross-linked amniotic membrane, and amnion-derived epithelial cells. While heterogeneity of study design precludes definitive specific results reporting, most studies showed positive benefits on healing/outcomes with amniotic augmentation. Specifically, amnion products have shown promising effects in reducing epidural adhesions and scar tissue after spine surgery, improving spinal fusion rate and postoperative pain scores, and promoting better functional outcomes after spine surgery. CONCLUSIONS: A review of the limited number of reported studies revealed a wide variety of amniotic membrane preparations, treatment regimens, and indications, which limit definitive conclusions. To date, while there is no definitive clinical proof that amniotic tissues enhance tissue repair or regeneration, the aggregate results demonstrate promising basic science and outcomes potential in spinal surgery. Further study is warranted to determine whether this application is appropriate in the clinical setting. CLINICAL RELEVANCE: This systematic review provides a summary of the existing literature regarding the use of amniotic membrane preparations, treatment regimens, and indications within spinal surgery. With the growing popularity and utilization of biologic agents such as amniotic membrane-derived products in orthopedic and neurologic surgery, this systematic review gives physicians a concise summary on the outcomes and indications associated with amniotic membrane products.

Large Variation in Listed Chargemaster Price for Total Joint Arthroplasty Among Top Orthopaedic Hospitals in the United States.

BACKGROUND: Chargemasters are lists of all services offered by a hospital and their associated cost. This study analyzes chargemaster data to determine price differences among different hospitals for total joint arthroplasty. METHODS: In May 2020, the chargemaster data for highly rated orthopaedic hospitals were accessed, and the diagnostic-related group (DRG) codes related to primary and revision total joint arthroplasty were analyzed (DRGs 466, 467, 468, 469, and 470). The prices listed for each hospital were averaged, and descriptive statistics were calculated. Furthermore, Medicare reimbursement was collected. A subanalysis was performed to determine relationships between geographic and demographic information. RESULTS: The median price for a major hip or knee joint arthroplasty without complications was $68,016 (range: $39,927 to $195,264). The median price of a revision of hip or knee arthroplasty without complications was $90,966 (range: $58,967 to $247,715). The cost of living in the city in which the hospitals are located was weakly correlated with procedure pricing, whereas the median income had no notable relationship to chargemaster pricing. CONCLUSION: The published cost of DRG codes in arthroplasty is widely variable among the top 20 US orthopaedic hospitals, with little correlation to the cost of living or median income of the area.

Bibliometric Analysis of the Top 50 Most Cited Studies on Achilles Tendon Pathology.

Background: The development of Achilles tendon treatment modalities has been rapid, and it is increasingly difficult for clinicians to stay up to date with the most influential studies in this field. In order to fully understand the current state of the literature regarding Achilles tendon injury, it is invaluable to be familiar with the foundational articles and studies upon which the field is built. Purpose: To objectively determine the 50 most frequently cited studies in Achilles tendon pathology and to conduct a bibliometric analysis. Study Design: Cross-sectional study. Methods: The Clarivate Analytics Web of Knowledge database was used to gather data and metrics of Achilles tendon research. The 50 most cited articles were selected for analysis from an initial 17,244 identified articles. The information extracted for each article included author name, publication year, country of origin, journal name, study type, and level of evidence. Results: For these 50 studies, the total number of citations was calculated to be 13,159, with a mean of 263.2 citations per paper. The most cited article collected 657 citations. The publication dates of the 50 studies included in this analysis spanned 41 years (1972-2013). The largest number of articles were published by Swedish authors (n = 14); however, many other countries were represented, including Canada and Finland (n = 6 articles each). The most prevalent study designs were cohort studies (n = 13) with level 4 evidence studies being the most common (n = 14). Conclusion: Among the 50 most influential articles in Achilles tendon pathology, the study designs most commonly used were cohort studies and review articles. Sweden was the country of origin for the most studies included on this list, which reflects this country's interest and commitment to researching Achilles tendon injuries and treatments.