Differences in Primary Total Shoulder Arthroplasty Volume, Reimbursement, Practice Styles, and Patient Populations Based on Surgeon Gender: A Temporal Analysis.

BACKGROUND: Orthopedic surgery has previously been shown to have a shortage of female physicians and a gender pay gap. However, this has not been thoroughly evaluated in the setting of shoulder surgery. The primary purpose of this study was to evaluate differences in total shoulder arthroplasty (TSA) volume, reimbursement, surgeon billing practices, and patient populations between male and female surgeons from 2013 to 2021. METHODS: The Medicare Physician and Other Practitioners database, a publicly available dataset that includes 100% of services billed to Medicare Part B was utilized. The database was queried for all billing episodes of Current Procedural Terminology (CPT) code 23472, which encompasses both anatomic and reverse primary TSA. Procedural volume, average inflation-adjusted reimbursement per TSA, physician billing information, and the patient demographics of each surgeon who performed TSAs were collected. Welch's t-test and Kruskal-Wallis were utilized to compare male and female surgeons each year between 2013 and 2021. RESULTS: Between 2013 and 2021, the proportion of TSAs performed by female surgeons nationally increased from 1.8% to 2.9% (+1.1%). This increase was greatest in the Northeast (2.0% to 6.1%), while a decrease was seen in the Midwest (1.9% to 1.6%). In 2021, there was no significant difference between male and female surgeons in the average inflation-adjusted reimbursement per TSA ($1,144.00 vs $1,143.00, p=0.792) and the average number of TSAs performed per surgeon (26.6 vs 23.1, p=0.105). Female TSA surgeons, on average, had less Medicare beneficiaries (348 vs 462, p<0.001), performed fewer annual services (1,817 vs 3,630, p<0.001), and performed fewer unique services (60 vs 76, p<0.001) compared to male surgeons. A higher proportion of female surgeon's patient populations were non-White (24% vs 22%, p=0.028), female (61% vs 59%, p=0.001), and dual enrolled Medicare-Medicaid patients (13% vs 10%, p<0.001). However, there was no difference in the average patient complexity between male and female TSA surgeons based on hierarchical condition category (HCC) score (1.0783 vs 1.0732, p=0.228). CONCLUSION: Female representation within TSA surgery is increasing nationally, with the greatest representation in the Northeast and West and the lowest representation in the South and Midwest. Although female TSA surgeons perform a similar number of TSAs, receive comparable reimbursement per TSA, and have a similarly complex patient population as their male counterparts, they perform significantly fewer total and unique billable services annually. Additionally, female TSA surgeons tend to see more non-White, women, and dual Medicare-Medicaid enrolled patients.

Global Trends in Patellar Resurfacing From 2004 to 2022.

BACKGROUND: International rates of patellar resurfacing in primary total knee arthroplasty (TKA) are highly variable. This study sought to determine how trends in patellar resurfacing rates have changed between 2004 and 2022. In addition, we investigated how modern rates of revision have varied between resurfaced and unresurfaced patellae in primary TKA among national joint registries. METHODS: Data between 2004 and 2022 was obtained either from the publicly available joint registry annual reports, a literature review, or via direct correspondence with registry personnel in Sweden, New Zealand, Australia, the United States, Norway, the United Kingdom, the Netherlands, Switzerland, Canada, and India. Only English language national joint registries or data via direct correspondence with registry administrators were utilized. Additionally, the 10-year cumulative risk of revision TKA with and without patellar resurfacing was pulled from those registries that had this data available. RESULTS: There were persistent differences in the rates of patellar resurfacing among countries. Australia documented a 40% increase in patellar resurfacing rates, while other countries demonstrated modest or little change in resurfacing rates. This may indicate that surgeons are making the decision to resurface based on national TKA revision rates. The average rates of patellar resurfacing in primary TKA ranged from 4% in Sweden to 94% in the United States. Canada, the United States, Australia, and Switzerland documented a lower risk of revision when the patella was resurfaced, while Sweden, conversely, showed a higher risk of revision with resurfacing. CONCLUSIONS: Rates of patellar resurfacing in primary TKA were highly variable among countries, as were rates of change over time. It appears that the optimal patellar resurfacing strategy may depend mostly on unique patient factors and surgeon expertise. Future studies should attempt to elucidate the individual patient characteristics that contribute to increased risks of revision or anterior knee pain to determine who will most benefit from patellar resurfacing in primary TKA.

Acute minocycline administration reduces brain injury and improves long-term functional outcomes after delayed hypoxemia following traumatic brain injury.

Clinical trials of therapeutics for traumatic brain injury (TBI) demonstrating preclinical efficacy for TBI have failed to replicate these results in humans, in part due to the absence of clinically feasible therapeutic windows for administration. Minocycline, an inhibitor of microglial activation, has been shown to be neuroprotective when administered early after experimental TBI but detrimental when administered chronically to human TBI survivors. Rather than focusing on the rescue of primary injury with early administration of therapeutics which may not be clinically feasible, we hypothesized that minocycline administered at a clinically feasible time point (24 h after injury) would be neuroprotective in a model of TBI plus delayed hypoxemia. We first explored several different regimens of minocycline dosing with the initial dose 24 h after injury and 2 h prior to hypoxemia, utilizing short-term neuropathology to select the most promising candidate. We found that a short course of minocycline reduced acute microglial activation, monocyte infiltration and hippocampal neuronal loss at 1 week post injury. We then conducted a preclinical trial to assess the long-term efficacy of a short course of minocycline finding reductions in hippocampal neurodegeneration and synapse loss, preservation of white matter myelination, and improvements in fear memory performance at 6 months after injury. Timing in relation to injury and duration of minocycline treatment and its impact on neuroinflammatory response may be responsible for extensive neuroprotection observed in our studies.

Gut microbial dysbiosis after traumatic brain injury modulates the immune response and impairs neurogenesis.

The influence of the gut microbiota on traumatic brain injury (TBI) is presently unknown. This knowledge gap is of paramount clinical significance as TBI patients are highly susceptible to alterations in the gut microbiota by antibiotic exposure. Antibiotic-induced gut microbial dysbiosis established prior to TBI significantly worsened neuronal loss and reduced microglia activation in the injured hippocampus with concomitant changes in fear memory response. Importantly, antibiotic exposure for 1 week after TBI reduced cortical infiltration of Ly6Chigh monocytes, increased microglial pro-inflammatory markers, and decreased T lymphocyte infiltration, which persisted through 1 month post-injury. Moreover, microbial dysbiosis was associated with reduced neurogenesis in the dentate gyrus 1 week after TBI. By 3 months after injury (11 weeks after discontinuation of the antibiotics), we observed increased microglial proliferation, increased hippocampal neuronal loss, and modulation of fear memory response. These data demonstrate that antibiotic-induced gut microbial dysbiosis after TBI impacts neuroinflammation, neurogenesis, and fear memory and implicate gut microbial modulation as a potential therapeutic intervention for TBI.