Allergic phenotype identified on allergen testing is associated with proton pump inhibitor nonresponse in eosinophilic esophagitis.

BACKGROUND AND AIM: Food/environmental allergens have been associated with eosinophilic esophagitis (EoE); however, the correlation between allergy profiles and disease responsiveness to proton pump inhibitor (PPI) therapy remains unclear. We aimed to assess the association between food/environmental allergies identified on allergen testing and histologic response to PPI in patients with treatment-naive EoE. METHODS: Adults with newly diagnosed EoE who underwent formal testing for food/environmental allergies at a tertiary center were included. All patients underwent twice-daily PPI for 8 weeks with subsequent repeat endoscopy and biopsy to assess histologic response. Patients with <15 eosinophils/hpf on post-PPI mucosal biopsies were classified as responders (PPI-r-EoE), while those with ≥15 eosinophils/hpf were nonresponders (PPI-nr-EoE). RESULTS: Sixty-one patients met inclusion criteria (21 PPI-r-EoE vs 40 PPI-nr-EoE). Demographic, clinical, and endoscopic finding variables were similar between groups. Positive food allergen test was more prevalent among PPI-nr-EoE patients (82.5% vs 42.9%, P = 0.003). On multivariable analysis, positive food allergen testing remained an independent predictor for PPI nonresponse (aOR 0.15, CI: 0.04-0.58, P = 0.0006). Positive environmental allergen testing was highly prevalent, with no significant differences between groups (77.5% vs 95.2%, P = 0.14). However, higher number of positive environmental allergens (23.3% [≥5 allergens] vs 73.3% [<5 allergens], P = 0.003) and specific aeroallergens correlated with PPI-nr-EoE. CONCLUSION: Positive food allergy testing and increased environmental allergens predicted lower likelihood of histologic response to PPI in EoE. Our findings support an allergic phenotype of EoE that may less likely respond to PPI therapy. Formal allergen testing may play a role in therapy selection and tailored management in EoE.

Hospital Courses Differ Amongst Hip Fracture Patients With or Without Coronavirus-19 Positive Status Upon Admission.

INTRODUCTION: The purpose of this study was to compare the hospital course and disposition of COVID-19 positive versus negative patients following an operatively managed hip fracture. MATERIALS AND METHODS: This retrospective cohort study evaluated patients presenting to a university medical center with a hip fracture who underwent surgical management between February 1, 2020 and April 1, 2021. COVID-19 diagnosis was obtained using PCR testing. Hospital length of stay, disposition, readmission, and mortality were compared between patients with and without COVID-19. RESULTS: 399 total patients were identified who met inclusion criteria, with 14 patients who were COVID-positive (3.1%). There was a 6.1 day increase in length of hospital stay for COVID-19 positive patients compared to those who were COVID negative (p = 0.002), without significant changes in disposition, readmission rates, or mortality. CONCLUSIONS: A positive COVID-19 test at the time of admission can significantly increase hospital admission duration. LEVEL OF EVIDENCE: III, Retrospective Cohort Study.

The Relationship Between Testosterone Therapy and Rotator Cuff Tears, Repairs, and Revision Repairs.

INTRODUCTION: The purpose of this study was to evaluate rates of rotator cuff tears (RCTs), repairs (RCRs), and revision RCR in patients who were prescribed testosterone replacement therapy (TRT) and compare these patients with a control group. METHODS: The PearlDiver database was queried for patients who were prescribed testosterone for at least 90 days between 2011 and 2018 to evaluate the incidence of RCTs in this population. A second analysis evaluated patients who sustained RCTs using International Classification of Diseases, 9th/10th codes to evaluate these patients for rates of RCR and revision RCR. Chi square analysis and multivariate regression analyses were used to compare rates of RCTs, RCR, and subsequent or revision RCR between the testosterone and control groups, with a P -value of 0.05 representing statistical significance. RESULTS: A total of 673,862 patients with RCT were included for analysis, and 9,168 of these patients were prescribed testosterone for at least 90 days before their RCT. The TRT group had a 3.6 times greater risk of sustaining an RCT (1.14% versus 0.19%; adjusted odds ratio (OR) 3.57; 95% confidence interval (CI) 3.57 to 3.96). A 1.6 times greater rate of RCR was observed in the TRT cohort (TRT, 46.4% RCR rate and control, 34.0% RCR rate; adjusted OR 1.60; 95% CI 1.54 to 1.67). The TRT cohort had a 26.7 times greater risk of undergoing a subsequent RCR, irrespective of laterality, within 1 year of undergoing a primary RCR when compared with the control group (TRT, 47.1% and control, 4.0%; adjusted OR 26.4; 95% CI 25.0 to 27.9, P < 0.001). CONCLUSIONS: There is increased risk of RCTs, RCRs, and subsequent RCRs in patients prescribed testosterone. This finding may represent a musculoskeletal consequence of TRT and is important for patients and clinicians to understand. Additional research into the science of tendon injury in the setting of exogenous anabolic steroids remains of interest. LEVEL OF EVIDENCE: Level Ⅲ, retrospective cohort study.

Readability of Online Foot and Ankle Surgery Patient Education Materials.

Background. Online health education resources are frequently accessed by patients seeking information on orthopaedic conditions and procedures. The objectives of this study were to assess the readability of information provided by the American Orthopaedic Foot and Ankle Society (AOFAS) and compare current levels of readability with previous online material. Methods. This study examined 115 articles classified as "Conditions" or "Treatments" on FootCareMD.org. Readability was assessed using the 6 readability assessment tools: Flesch Reading Ease, Flesch-Kincaid Grade Level (FKGL), Gunning Fog Score, Simple Measure of Gobbledygook (SMOG) Index, Coleman-Liau Index, and the Automated Readability Index. Results. The mean readability score across all metrics ranged from 9.1 to 12.1, corresponding to a 9th- to 12th-grade reading level, with a mean FKGL of 9.2 ± SD 1.1 (range: 6.3-15.0). No articles were written below the recommended US sixth-grade reading level, with only 3 articles at or below an eighth-grade level. Treatment articles had higher mean readability grade levels than condition articles (P = .03). Conclusion. Although the volume and quality of the AOFAS resource Web site has increased, readability of information has worsened since 2008 and remains higher than the recommended reading level for optimal comprehension by the general population.Levels of Evidence: Level IV:Retrospective quantitative analysis.

Socioeconomic Disparities in the Utilization of Total Knee Arthroplasty.

BACKGROUND: Despite strong evidence supporting the efficacy of total knee arthroplasty (TKA), studies have shown significant socioeconomic disparities regarding who ultimately undergoes TKA. The purpose of the current study is to evaluate socioeconomic factors affecting whether a patient undergoes TKA after a diagnosis of osteoarthritis. METHODS: From 2011 to 2018, claims for adult patients diagnosed with knee osteoarthritis in the New York Statewide Planning and Research Cooperative System (SPARCS) database were analyzed. International Classification of Diseases (ICD), 9/10 CM codes were used to identify the initial diagnosis for each patient. ICD 9/10 PCS codes were used to identify subsequent TKA. Logistic regression analysis was performed to determine the effect of patient factors on the likelihood of having TKA. RESULTS: Of 313,794 osteoarthritis diagnoses, 33.3% proceeded to undergo TKA. Increased age (OR 1.007, P < .0001) and workers' compensation relative to commercial insurance (OR 1.865, P < .0001) had increased odds of TKA. Compared to White race, Asian (OR 0.705, P < .0001), Black (OR 0.497, P < .0001), and "other" race (OR 0.563, P < .0001) had lower odds of TKA. Hispanic ethnicity (OR 0.597, P < .0001) had lower odds of surgery. Compared to commercial insurance, Medicare (OR 0.876, P < .0001), Medicaid (OR 0.452, P < .0001), self-pay (OR 0.523, P < .0001), and "other" insurance (OR 0.819, P < .0001) had lower odds of TKA. Increased social deprivation (OR 0.987, P < .0001) had lower odds of TKA. CONCLUSION: TKA is associated with disparities among race, ethnicity, primary insurance, and social deprivation. Additional research is necessary to identify the cause of these disparities to improve equity in orthopedic care.

Preoperative Resilience and Early Postoperative Outcomes following Lumbar Spinal Fusion.

BACKGROUND: Previous studies identified a correlation between preoperative resilience scores and patient reported outcome measures in several surgical subspecialities. No previous studies, to our knowledge, have analyzed preoperative resilience and patient reported outcomes in lumbar spinal fusion. METHODS: Patients undergoing lumbar spinal fusion completed the Brief Resilience Scale (BRS) preoperatively, in addition to measures of disability (Oswestry Disability index [ODI]), quality of life (PROMIS global physical and mental health scales and EuroQol5), and leg and back pain (VAS) at pre- and 3-months postoperatively. The 3-month follow-up was selected due to the association with return to work. Multiple linear regression evaluated relationships between resilience and postoperative changes in outcomes measures, controlling for baseline values and body mass index, age, number of levels fused, and severity of comorbidities. RESULTS: Ninety-five participants (mean age 58 years, 56% male) completed the BRS preoperatively and outcome measures before and 3 months after lumbar fusion. On average, participants reported significant postoperative improvements on all outcome measures (P < 0.001). Higher preoperative resilience scores related to greater postoperative improvements in back and leg pain, global mental and physical health and EuroQol scores (P < 0.05), after controlling for baseline values and other covariates. Resilience scores did not significantly correlate with postoperative changes in ODI (P > 0.05). CONCLUSIONS: Preoperative resilience is associated with improvement in pain and physical and mental health quality of life during the early postoperative period following lumbar spinal fusion. Additional research is needed to determine if improvements are maintained beyond this interval and whether resilience can be modified to optimize outcomes.

Indolent Infection After Lumbar Interbody Fusion: An Under-recognized Cause of Pseudarthrosis, Which Can Be Successfully Treated With Anterior Revision Fusion.

INTRODUCTION: Bacterial infection is a common etiology for pseudarthrosis after transforaminal lumbar interbody fusion, although it is often difficult to identify because of a delayed presentation and normal laboratory values. The primary goal of this study was to present a series of cases demonstrating patients with infection-related pseudarthrosis successfully managed with anterior revision. METHODS: We retrospectively reviewed patients presenting to a single academic spine center who were found to have evidence of Cutibacterium acnes or coagulase-negative Staphylococcus infection on routine culturing of lumbar interbody fusion revisions from July 2019 to January 2021. All patients underwent salvage of a transforaminal lumbar interbody fusion pseudarthrosis through an anterior lumbar approach. RESULTS: A total of six patients managed for pseudarthrosis secondary to suspected infection were eligible for this study (mean age 64.8 years, range 54-70 years; mean body mass index, range 24.5-39.1). Persistent radiculopathy was the primary presenting symptom in all patients with a mean time to revision of 17 months. Coagulase-negative Staphylococcus was the primary pathogen, identified from intraoperative samples in 50% of the cases. All patients demonstrated a resolution of symptoms after placement of an anterior lumbar interbody cage, without intraoperative complications, and a subsequent antibiotic regimen. DISCUSSION: Indolent infection is an under-recognized cause of pseudarthrosis of the lumbar spine. Revision surgery through an anterior lumbar approach, which promotes ease of cage removal and optimized alignment and surface area available for revision fusion, is sufficient to manage pseudarthrosis due to infection.

Defining the contemporary epidemiology and return to play for high ankle sprains in the National Football League.

BACKGROUND: High ankle sprains and syndesmotic injuries are commonly sustained by National Football League players, yet there is apaucity of literature reporting the incidence, risk factors and return to play (RTP) rates for these injuries. The purpose of this study is to examine the epidemiology and trends in incidence of high ankle sprains across 11 NFL seasons. METHODS: Publicly available data from the 2009-2010 through 2019-20 seasons were reviewed to identify injuries and collect player characteristics and return to play. Incidence of high ankle injuries was calculated per 10,000 athlete-exposures. Linear regression was performed for incidence of injuries. Risk factors for failure to RTP were identified through multivariate logistic regression, controlling foryear of injury, player position, body mass index (BMI), age at injury, and years of experience before injury. RESULTS: A total of 533 high ankle sprains were identified in 498 players at an average age of 25.8 ± 3.1 and average BMI of 31.8 ± 4.6. The annual incidence of high ankle sprains in the NFL increased at alinear rate of 0.067per 10,000 player exposures (R2 = 0.3357) in 2009, to 1.75per 10,000 player exposures to 2.49 in 2019-20. Most injuries were in offensive players (304/533 injuries, 57.0%). Overall, 89.7% (478/533) of players returned to play; average RTP time was 80.5 ± 132.9 days. Defensive players had afaster RTP (68.1 ± 114.6 days) compared to offensive players (90.1 ± 144.8 days) (p = 0.084). Higher age at injury was found to increase the risk of failure to RTP (p = 0.0088). CONCLUSION: RTP rate was high following high ankle sprain aamongNFL players at 90%, with an average recovery period of 11 weeks. Defensive players experience RTP faster than offensive players. Future studies are needed to determine performance outcomes following RTP, along with which patients might benefit from surgery.

Socioeconomic Disparities in the Utilization of Total Hip Arthroplasty.

BACKGROUND: There is increasing focus on highlighting disparities in both access to and equity of care in orthopedics and understanding the impact disparities have on patient health. The purpose of the present study is to evaluate socioeconomic-related factors affecting whether a patient undergoes total hip arthroplasty (THA) after a diagnosis of osteoarthritis. METHODS: From 2011 to 2018, patients ≥40 years of age diagnosed with hip osteoarthritis were identified in the New York Statewide Planning and Research Cooperative System, a comprehensive all-payer database collecting preadjudicated claims in New York State. International Classification of Diseases, Ninth Revision/Tenth Revision codes were used to identify the initial diagnosis and subsequent THA. Logistic regression analysis was performed to determine the effect of patient factors on the likelihood of undergoing THA. RESULTS: Of 142,681 hip osteoarthritis diagnoses, 48.6% proceeded to THA. Compared to non-Hispanic white patients, Asian (odds ratio [OR] 0.65, P < .0001), Black (OR 0.51, P < .0001), and "Other" race (OR 0.54, P < .0001) had lower odds of THA. Hispanic patients (OR 0.55, P < .0001) had lower odds of surgery. Compared to commercial insurance, Medicare (OR 0.83, P < .0001), Medicaid (OR 0.49, P < .0001), Self-pay (OR 0.78, P < .0001), and workers' compensation (OR 0.71, P < .0001) had lower odds of THA. Having one or more Charlson Comorbidity Index (OR 0.45, P < .0001) was associated with lower odds of THA, as was increased social deprivation (OR 0.99, P < .0001). CONCLUSION: THA is associated with disparities among race, gender, primary insurance, and social deprivation. Additional research is necessary to identify the cause of these disparities to improve equity in patient care.

Lymphatic Injury with Lymph Fistula After Anterior Lumbar Fusion Managed with Vacuum-Assisted Closure: A Case Report.

CASE: A 40-year-old man underwent an L5-S1 anterior lumbar interbody fusion (ALIF) and subsequently developed abdominal distention and persistent wound drainage. During wound reexploration, a substantial lymphocele and lymphatic fistula tracking from the ALIF site were visualized and evacuated. The deep space was coated with fibrin sealant. A deep drain and wound vacuum were placed within the retroperitoneal cavity, leading to progressive recovery. CONCLUSION: Intraoperative lymphatic injury during anterior spinal surgery can progress to the development of a lymphocele and lymphatic fistula, manageable with an exploratory laparotomy, fibrin sealant, and the use of a wound vacuum to promote fistula sealing.

Malpractice Litigation Involving Chiropractic Spinal Manipulation.

OBJECTIVE: To evaluate the relationship between chiropractic spinal manipulation and medical malpractice using a legal database. METHODS: The legal database VerdictSearch was queried using the terms "chiropractor" OR "spinal manipulation" under the classification of "Medical Malpractice" between 1988 and 2018. Cases with chiropractors as defendants were identified. Relevant medicolegal characteristics were obtained, including legal outcome (plaintiff/defense verdict, settlement), payment amount, nature of plaintiff claim, and type and location of alleged injury. RESULTS: Forty-eight cases involving chiropractic management in the United States were reported. Of these, 93.8% (n = 45) featured allegations involving spinal manipulation. The defense (practitioner) was victorious in 70.8% (n = 34) of cases, with a plaintiff (patient) victory in 20.8% (n = 10) (mean payment $658,487 ± $697,045) and settlement in 8.3% (n = 4) (mean payment $596,667 ± $402,534). Overaggressive manipulation was the most frequent allegation (33.3%; 16 cases). A majority of cases alleged neurological injury of the spine as the reason for litigation (66.7%, 32 cases) with 87.5% (28/32) requiring surgery. C5-C6 disc herniation was the most frequently alleged injury (32.4%, 11/34, 83.3% requiring surgery) followed by C6-C7 herniation (26.5%, 9/34, 88.9% requiring surgery). Claims also alleged 7 cases of stroke (14.6%) and 2 rib fractures (4.2%) from manipulation therapy. CONCLUSIONS: Litigation claims following chiropractic care predominately alleged neurological injury with consequent surgical management. Plaintiffs primarily alleged overaggressive treatment, though a majority of trials ended in defensive verdicts. Ongoing analysis of malpractice provides a unique lens through which to view this complicated topic.

The Great Imposter: A Confusing Case of a Rare Renal Cell Carcinoma.

We report a 61-year-old male with sarcomatoid renal cell carcinoma (sRCC) in the context of multiple paraneoplastic syndromes, including thrombocytosis, leukemoid reaction, and paraneoplastic hepatopathy (Stauffer syndrome). The patient's clinical course was complicated by multiple medical challenges, extensive metastases, and persistent infection. This confusing presentation of a rare subtype of renal cell carcinoma (RCC) highlights the diverse and often misleading manifestations of this aggressive malignancy. Clinicians should be aware of the association between RCC, multiple paraneoplastic syndromes, and its propensity to present with systemic, non-renal symptoms.

Determinants of brain tumor malpractice litigation outcome and indemnity payments: a 29-year nationwide analysis.

OBJECTIVE: Medical malpractice litigation is a significant challenge in neurosurgery, with more than 25% of a neurosurgeon's career on average spent with an open malpractice claim. While earlier research has elucidated characteristics of litigation related to brain tumor treatment, factors impacting outcome and indemnity payment amount are incompletely understood. METHODS: The authors identified all medical malpractice cases related to brain tumors from 1988 to 2017 in VerdictSearch, a database of 200,000 cases from all 50 states. The outcome for each case was dichotomized from the perspective of the defendant physician as favorable (defendant victory) or unfavorable (plaintiff victory or settlement). Indemnity payments were recorded for cases that resulted in settlement or plaintiff victory. Univariate regression was used to assess the association between case characteristics and case outcome as well as indemnity payment amount. Subsequently, significant variables were used to generate multivariate models for each outcome. Statistical significance was maintained at p < 0.05. RESULTS: A total of 113 cases were analyzed, resulting most commonly in defendant (physician) victory (46.9%), followed by settlement and plaintiff victory (both 26.5%). The most common specialty of the primary defendant was neurosurgery (35.4%), and the most common allegation was improper diagnosis (59.3%). Indemnity payments totaled $191,621,392, with neurosurgical defendants accounting for $109,000,314 (56.9%). The average payments for cases with a plaintiff victory ($3,333,654) and for settlements ($3,051,832) did not significantly differ (p = 0.941). The highest rates of unfavorable outcomes were observed among radiologists (63.6%) and neurosurgeons (57.5%) (p = 0.042). On multivariate regression, severe disability was associated with a lower odds of favorable case outcome (OR 0.21, p = 0.023), while older plaintiff age (> 65 years) predicted higher odds of favorable outcome (OR 5.75, p = 0.047). For 60 cases resulting in indemnity payment, higher payments were associated on univariate analysis with neurosurgeon defendants (ß-coefficient = 2.33, p = 0.017), whether the plaintiff underwent surgery (ß-coefficient = 2.11, p = 0.012), and the plaintiff experiencing severe disability (ß-coefficient = 4.30, p = 0.005). Following multivariate regression, only medical outcome was predictive of increased indemnity payments, including moderate disability (ß-coefficient = 4.98, p = 0.007), severe disability (ß-coefficient = 6.96, p = 0.001), and death (ß-coefficient = 3.23, p = 0.027). CONCLUSIONS: Neurosurgeons were the most common defendants for brain tumor malpractice litigation, averaging more than $3 million per claim paid. Older plaintiff age was associated with case outcome in favor of the physician. Additionally, medical outcome was predictive of both case outcome and indemnity payment amount.

Malpractice claims associated with foot surgery.

Surgery of the foot constitutes a substantial portion of orthopedic procedures, performed by both orthopedic surgeons and doctors of podiatric medicine. Little research exists on the medicolegal implications of foot surgery amongst these specialties. This study seeks to investigate the different medical and legal factors associated with foot surgery-based malpractice litigation. Malpractice data between 2004 and 2017 was collected using the VerdictSearch legal database. Cases involving foot surgery were identified, and case information including physician specialty, procedure, medical outcome, verdict, and payment amount were obtained. A total of 72 cases were analyzed. A majority of lawsuits involved podiatrists (76.4%), with orthopedic surgeons accounting for 15.3%. Lawsuits against podiatrists primarily occurred over elective procedures (94.5%) and most frequently involved plaintiff complaints of persistent pain (41.8%) or deformation (27.3%). Podiatrist cases most often involved allegations of failure to treat (45.5%) or inappropriate surgical procedure (27.3%). Orthopedic surgeons saw higher rates of urgent cases (45.5%), with surgical complications (27.3%) occurring at higher rates than podiatrists. Despite different trends in case types, similar rates of plaintiff victories, and mean payments were seen between podiatrists (25.5%, $911,884 ± 1,145,345) and orthopedic surgeons (27.3%, $975,555 ± 448,795). This investigation is the first to analyze malpractice trends amongst podiatrists and orthopedic surgeons. Differing factors related to medical and legal outcomes can suggest quality improvement targets for both specialties. This data may assist in reducing malpractice risk and refining patient care, particularly with regards to outlining risks, benefits, and alternatives during pre-operative counselling.

Colorectal Cancer Litigation: 1988-2018.

INTRODUCTION: The purpose of this study was to examine colorectal cancer (CRC) malpractice suits over the past 20 years in the United States and evaluate the most common allegations, lawsuit outcomes, indemnity payment amounts, patient outcomes, and physician characteristics. METHODS: The malpractice section of VerdictSearch, a legal database, was queried for cases in which CRC was a principle component of the lawsuit. Legal notes were used to characterize plaintiff allegations, verdict, financial compensation, and case year. Clinical history for each case were analyzed for patient demographics, medical outcomes, and physician characteristics. RESULTS: A total of 240 CRC-related malpractice cases (1988-2018) were collected, resulting in defense (n = 101, 42.1%), plaintiff (n = 37, 15.4%), or settlement (n = 96, 40%) verdict. The primary defendants were often primary care physicians (n = 61, 25.4%) and gastroenterologists (n = 55, 22.9%). Most common plaintiff allegations are failure to perform diagnostic colonoscopy for patients with symptoms (n = 67, 27.9%), failure to perform screening colonoscopy according to screening guidelines (n = 46, 19.2%), or failure to detect CRC with colonoscopy (n = 45, 18.7%). A common alleged error in diagnosis before the median year of 2005 was failure to detect CRC by the noncolonoscopic methods (<2005: n = 22, 24.2%; >2005: n = 3, 3.09%). DISCUSSION: Plaintiff-alleged errors in diagnosis are consistently the most common reason for CRC malpractice litigation in the past 20 years, whereas specific diagnostic allegations (i.e., failure to screen vs failure to detect) and methods used for surveillance may vary over time. It is important to identify such pitfalls in CRC screening and explore areas for improvement to maximize patient care and satisfaction and reduce physician malpractice litigations.

Performance After Operative Versus Nonoperative Management of Shoulder Instability in the National Basketball Association.

BACKGROUND: Although nonoperative management after shoulder instability injury allows an athlete to return to play sooner than operative intervention, higher rates of recurrence have been observed after nonoperative management. However, no study has investigated the differences in performance of National Basketball Association (NBA) players after index shoulder instability events managed nonoperatively versus operatively. PURPOSE/HYPOTHESIS: The purpose of this study was to identify shoulder instability events in NBA athletes and assess differences in performance after injury with nonoperative versus operative management. We hypothesized that players who undergo operative intervention have reduced risk of recurrence and are able to continue their elite level of play as opposed to those who undergo nonoperative management. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Publicly available injury data from the 1986-1987 through 2017-2018 seasons were reviewed to identify NBA athletes sustaining a shoulder instability event. In addition to characteristics, player performance information, including games played, player efficiency rating (PER), and win shares, was analyzed before and for 3 seasons after injury. Statistical learning models were applied to identify performance variables that have the greatest predictive value to determine players who would benefit from surgery. RESULTS: A total of 60 players with shoulder instability events were identified between 1986 and 2018. After injury, 37 players (61.7%) eventually underwent surgery and 23 players (38.3%) did not. Players who were treated nonoperatively had significantly decreased PER, games played, and offensive win shares in the season after injury (P < .05). Players who underwent surgery did not see a decline in PER, games played, or win shares. Random forest modeling found that true shooting percentage and win shares per 48 minutes were the performance variables most predictive in determining which players would benefit from surgery after shoulder instability. CONCLUSION: Players who underwent surgical intervention for shoulder instability maintained their PER, games played, and win share performance characteristics, whereas players who did not undergo surgery had declines in these parameters. Given the demands of shoulder function in basketball and the risk of recurrence after an instability event, surgery enhances a player's opportunity to maintain a high level of performance after injury.

Global variability in orthopedic surgery training.

Medical and orthopedic training varies throughout the world. The pathways to achieve competency in orthopedic surgery in other countries differ greatly from those in the United States. This review summarizes international educational requirements and training pathways involved in the educational development of orthopedic surgeons. Understanding the differences in training around the world offers comparative opportunities which may lead to the improvement in education, training, and competency of individuals providing orthopedic care.

Malpractice Litigation Following Traumatic Fracture.

BACKGROUND: Poor clinical outcomes and adverse events following orthopaedic trauma are common, which may lead to litigation. To our knowledge, factors associated with litigation following fracture care have not previously been evaluated. METHODS: A retrospective review of fracture-related malpractice lawsuits from 1988 to 2015 was completed utilizing VerdictSearch (ALM Media Properties), a medicolegal database. Defendant and plaintiff characteristics along with fracture type, allegations, litigation outcomes, and the association of case characteristics with outcomes were analyzed. RESULTS: A total of 561 cases were evaluated; 360 cases were excluded, resulting in a total of 201 cases that were analyzed in detail. The mean age of the plaintiff was 43.1 years (standard deviation [SD],19.4 years). Twenty-four fracture types were represented among the analyzed cases. The most common fractures were of the radius (44), the femur (32), the tibia (30), the ulna (29), the humerus (26), the spine (24), the hip (17), and the fibula (15). Overall, 129 (64.2%) cases resulted in a defense verdict, 41 (20.4%) cases resulted in a plaintiff verdict, and 31 (15.4%) cases resulted in a settlement. For plaintiff verdicts, the mean indemnity payment was $3,778,657 (median, $753,057; range, $89,943 to $27,926,311). For settlements, the mean indemnity payment was $1,097,439 (median, $547,935; range, $103,541 to $9,445,113). The mean indemnity for plaintiff verdicts was significantly greater than the mean indemnity for settlements (p = 0.03). The presence of a neurological deficit was associated with a significantly greater likelihood of a favorable outcome for the plaintiff (52.8% for plaintiffs with neurological deficit versus 32.1% for plaintiffs without neurological deficit; p = 0.019). CONCLUSIONS: This study examined malpractice litigation following traumatic orthopaedic injuries. In cases with decisions for the plaintiff, indemnity payments were on average more than $2.5 million larger than payments for settlements. In fracture cases with neurological deficit, malpractice cases were more likely to result in a favorable outcome for the plaintiff.

Cholecystectomy-related malpractice litigation: predictive factors of case outcome.

Complications following cholecystectomy may lead to malpractice litigation. Little research exists regarding cholecystectomy-related malpractice, the complications that lead to litigation, and the outcomes of such cases. This study is a retrospective analysis utilizing the legal database Verdictsearch (ALM Media Properties, LLC, New York, NY). Medical malpractice cases between July 2004 and November 2017 were identified using the search term "gallbladder." Case information was recorded, including patient information, medical details, trial outcome, and resulting payments. Of 46 cases examined, 39 went to trial with a favorable plaintiff (patient) verdict in 43% (20/46) and a favorable physician verdict in 41% (19/46) of the cases. Only 7% (3/46) of the cases resulted in a settlement, with 4% (2/26) concluding in mixed verdicts or arbitration. The mean plaintiff victory payment was $723,844 ± $1,119,457, while the mean settlement payment was $1,350,000 ± $563,471. Intraoperative care was the most frequently litigated phase of care (67%, 31/46 cases). Problematic visualization of the surgical field was the most frequent intraoperative allegation (67.7%, 21/46 cases). Cases of problematic visualization often resulted in favorable plaintiff trial victory (66.7% vs. 19% in defendant victory). Only 9.5% of the problematic visualization cases settled. Bile duct injuries accounted for 43.5% of the injuries (plaintiff victory rate 60.0%; mean payment $736,434 ± $1,365,424). In cholecystectomy litigation, allegations of problematic intraoperative visualization are both the most common allegation and the most likely to end in physician loss. Bile duct injuries remain the most frequent patient injury leading to cholecystectomy litigation.