Amputation or Reconstruction? Development and Validation of a Patient Decision Aid for Treatment of Severe Lower-Extremity Trauma.

BACKGROUND: Our goal was to develop and validate the Severe Lower-Extremity Trauma decision aid (SLETRA) to help patients make treatment decisions aligned with their values regarding amputation versus reconstruction. METHODS: We recruited 62 adults (41 women) from a foot and ankle practice at a US academic hospital from June to August 2020. We excluded patients who could not read in English and who lacked internet service access. Patients completed an 8-question knowledge test regarding the risks, benefits, and outcomes of treatment options before and after reviewing SLETRA. The survey presented a hypothetical case of severe lower-extremity trauma. Respondents, imagining themselves as patients, indicated whether they would choose amputation or reconstruction. We evaluated knowledge scores (maximum, 8 points); decisional conflict scores (maximum, 400 points, with higher scores indicating greater respondent difficulty in decision making); ratings of factors influencing the decision; and SLETRA helpfulness (maximum, 7 points). Pre- and post-test knowledge scores were compared using paired Student's t-tests; Alpha = 0.05. RESULTS: Mean and standard deviation knowledge scores improved from 5.2 ± 1.6 (pre-test) to 6.7 ± 1.6 (post-test) (p < 0.001). Mean decisional conflict score was 223 ± 16, reflecting moderate difficulty. Factors affecting treatment choice were risk of complications (n = 29), recovery time (n = 27), and future prosthesis use (n = 27). No respondent had difficulty understanding SLETRA. Mean helpfulness score was 5.6 ± 0.16, reflecting considerable benefit. CONCLUSION: The SLETRA decision aid is a helpful, understandable tool that significantly improves patient knowledge regarding treatment options for severe lower-extremity trauma.

Issues in Ethics in Orthopaedic Surgery Following the COVID-19 Pandemic.

The COVID-19 pandemic has caused changes in health care as well as human suffering, and consideration of the principles of ethics can build a foundation to consider dilemmas that have arisen. Diversity, equity, and inclusion have become key issues. Simulation training and the related ethics of its application have taken on new meaning. Access to health care continues to evolve and will need further evaluation in the years following the COVID-19 pandemic.

Medicaid Insurance is Associated With Decreased MRI Use for Ankle Sprains Compared With Private Insurance: A Retrospective Database Analysis.

BACKGROUND: Advanced imaging modalities are expensive, and access to advanced imaging services may vary by socioeconomic factors, creating the potential for unwarranted variations in care. Ankle sprains are a common injury for which variations in MRI use can occur, both via underuse of indicated MRIs (appropriate use) and overuse of nonindicated MRIs (inappropriate use). High-value, equitable healthcare would decrease inappropriate use and increase appropriate use of MRI for this common injury. It is unknown whether socioeconomic factors are associated with underuse of indicated MRIs and overuse of nonindicated MRIs for ankle sprains. QUESTIONS/PURPOSES: Using ankle sprains as a paradigm injury, given their high population incidence, we asked: (1) Does MRI use for ankle sprains vary by insurance type? (2) After controlling for relevant confounding variables, did patients who received an MRI have higher odds of undergoing ankle surgery? METHODS: Between 2011 and 2019, a total of 6,710,223 patients were entered into the PearlDiver Mariner Patient Records Database with a diagnosis of ankle sprain. We considered patients with continuous enrollment in the database for at least 1 year before and 2 years after the diagnosis as potentially eligible. Based on that, 68% (4,567,106) were eligible; a further 20% (1,372,478) were excluded because of age younger than 18 years, age at least 65 years with Medicaid insurance, or age < 65 years with Medicare insurance. Another 0.1% (9169) had incomplete data, leaving 47% (3,185,459) for analysis here. Patients with Medicaid insurance differed from patients with Medicare Advantage or private insurance with respect to age, gender, region, and comorbidity burden. The primary outcome was ankle MRI occurring within 12 months after diagnosis. The use of ankle surgery after MRI in each cohort was measured as a secondary outcome. We used multivariable logistic regression models to evaluate the association between insurance type and MRI use while adjusting for age, gender, region, and comorbidity burden. Separate multivariable regression models were created to evaluate the association between receiving an MRI and subsequent ankle surgery for each insurance type, adjusting for age, gender, region, and comorbidity burden. Within 12 months of an ankle sprain diagnosis, 1% (3522 of 339,457) of patients with Medicaid, 2% (44,793 of 2,627,288) of patients with private insurance, and 1% (1660 of 218,714) of patients with Medicare Advantage received an MRI. RESULTS: After controlling for age, gender, region, and comorbidity burden, patients with Medicaid had lower odds of receiving an MRI within 12 months after ankle sprain diagnosis than patients with private insurance (odds ratio 0.60 [95% confidence interval 0.57 to 0.62]; p < 0.001). Patients with Medicaid who received an MRI had higher adjusted odds of undergoing subsequent ankle surgery (OR 23 [95% CI 21 to 26]; p < 0.001) than patients with private insurance (OR 12.7 [95% CI 12 to 13]; p < 0.001). CONCLUSION: Although absolute MRI use was generally low, there was substantial relative variation by insurance type. Given the high incidence of ankle sprains in the general population, these relative differences can translate to tens of thousands of MRIs. Further studies are needed to evaluate the reasons for decreased appropriate MRI use in patients with Medicaid and overuse of MRI in patients with private insurance. The establishment of clinical practice guidelines by orthopaedic professional societies and more stringent gatekeeping for MRI use by health insurers could reduce unwarranted variations in MRI use. LEVEL OF EVIDENCE: Level III, prognostic study.

Strategies for Reducing Perioperative Opioid Use in Foot and Ankle Surgery: Education, Risk Identification, and Multimodal Analgesia.

There remains a high prevalence and substantial risks of opioid utilization amongst orthopedic patients. The goal of this review is to discuss strategies for responsible opioid use in the perioperative setting following foot and ankle orthopedic surgeries. We will highlight 1) education interventions, 2) risk identification, and 3) non-opioid alternatives for postoperative pain management.

Ethical Considerations Surrounding Surgeon Ownership of Ambulatory Surgery Centers.

As surgical care continues to transition to an outpatient setting, ambulatory surgery centers (ASCs) present favorable options for physician investment. As of 2017, more than 90% of ASCs have at least some physician ownership, with 64% solely physician-owned. Yet, physician ownership creates an inherent conflict of interest known as dual agency, where clinicians have a personal financial stake in addition to their obligation towards patient well-being. Here, we assess the ethical considerations surrounding dual agency in the setting of ASCs through the lens of beneficence, nonmaleficence, autonomy, and justice. We further propose strategies for appropriate navigation of such situations, including disclosure of ownership status, instruction on unfamiliar techniques, and adherence to accepted clinical practice guidelines for materials selection and surgical indications.

COVID-19 and the orthopaedic surgeon: who gets redeployed?

The COVID-19 pandemic has increased demand for physicians, leading to widespread redeployment of specialty physicians to care for patients with COVID-19. These redeployments highlight an important question: How do physicians balance competing obligations to their own health, their own patients, and society during a public health crisis? How can physicians, specifically subspecialists, navigate this tension? In this article, we analyse a clinical scenario in which an orthopaedic sports surgeon is redeployed to care for patients with COVID-19. This case raises questions about physicians' obligations to their own patients compared with society at large, the relative value of specialty physicians during a global pandemic, and the ethical permissibility of compulsory redeployment. Using the orthopaedic surgery specialty as a model, we build a redeployment framework for surgical specialists that is both ethical and equitable. We argue that although orthopaedic surgeons have a moral obligation to participate in physician redeployment schemes, the scope of this obligation is limited and contingent on the following conditions: (1) the number of local COVID-19 cases is high; (2) obligations to their own patients or orthopaedic patients requiring urgent or emergency care have been fulfilled; (3) their value as physicians exceeds their value as specialists because of the pandemic climate; (4) voluntary redeployments are exhausted before compulsory redeployments are implemented; and (5) redeployment would not put the physicians at unreasonable risk of harm.

Restarting Orthopaedic Care in a Pandemic: Ethical Framework and Case Examples.

The question about how to resume typical orthopaedic care during a pandemic, such as coronavirus disease 2019, should be framed not only as a logistic or safety question but also as an ethical question. The current published guidelines from surgical societies do not explicitly address ethical dilemmas, such as why public health ethics requires a cessation of nonemergency surgery or how to fairly allocate limited resources for delayed surgical care. We propose ethical guidance for the resumption of care on the basis of public health ethics with a focus on clinical equipoise, triage tiers, and flexibility. We then provide orthopaedic surgery examples to guide physicians in the ethical resumption of care.

How Do Medical Students Perceive Diversity in Orthopaedic Surgery, and How Do Their Perceptions Change After an Orthopaedic Clinical Rotation?

BACKGROUND: A diverse physician workforce improves the quality of care for all patients, and there is a need for greater diversity in orthopaedic surgery. It is important that medical students of diverse backgrounds be encouraged to pursue the specialty, but to do so, we must understand students' perceptions of diversity and inclusion in orthopaedics. We also currently lack knowledge about how participation in an orthopaedic clinical rotation might influence these perceptions. QUESTIONS/PURPOSES: (1) How do the perceptions of diversity and inclusion in orthopaedic surgery compare among medical students of different gender identities, races or ethnicities, and sexual orientations? (2) How do perceptions change after an orthopaedic clinical rotation among members of demographic groups who are not the majority in orthopaedics (that is, cis-gender women, underrepresented racial minorities, other racial minorities, and nonheterosexual people)? METHODS: We surveyed students from 27 US medical schools who had completed orthopaedic rotations. We asked about their demographic characteristics, rotation experience, perceptions of diversity and inclusion in orthopaedics, and personal views on specialty choice. Questions were derived from diversity, equity, and inclusion climate surveys used at major academic institutions. Cis-gender men and cis-gender women were defined as those who self-identified their gender as men or women, respectively, and were not transgender. Forty-five percent (59 of 131) of respondents were cis-men and 53% (70 of 131) were cis-women; 49% (64 of 131) were white, 20% (26 of 131) were of underrepresented racial minorities, and 31% (41 of 131) were of other races. Eighty-five percent (112 of 131) of respondents were heterosexual and 15% (19 of 131) reported having another sexual orientation. We compared prerotation and postrotation perceptions of diversity and inclusion between majority and nonmajority demographic groups for each demographic domain (for example, cis-men versus cis-women). We also compared prerotation to postrotation perceptions within each nonmajority demographic group. To identify potential confounding variables, we performed univariate analysis to compare student and rotation characteristics across the demographic groups, assessed using an alpha of 0.05. No potential confounders were identified. Statistical significance was assessed at a Bonferroni-adjusted alpha of 0.0125. Our estimated response percentage was 26%. To determine limitations of nonresponse bias, we compared all early versus late responders and found that for three survey questions, late responders had a more favorable perception of diversity in orthopaedic surgery, whereas for most questions, there was no difference. RESULTS: Before rotation, cis-women had lower agreement that diversity and inclusion are part of orthopaedic culture (mean score 0.96 ± 0.75) compared with cis-men (1.4 ± 1.1) (mean difference 0.48 [95% confidence interval 0.16 to 0.81]; p = 0.004), viewed orthopaedic surgery as less diverse (cis-women 0.71 ± 0.73 versus cis-men 1.2 ± 0.92; mean difference 0.49 [95% CI 0.20 to 0.78]; p = 0.001) and more sexist (cis-women 1.3 ± 0.92 versus cis-men 1.9 ± 1.2; mean difference 0.61 [95% CI 0.23 to 0.99]; p = 0.002), believed they would have to work harder than others to be valued equally (cis-women 2.8 ± 1.0 versus cis-men 1.9 ± 1.3; mean difference 0.87 [95% CI 0.45 to 1.3]; p < 0.001), and were less likely to pursue orthopaedic surgery (cis-women 1.4 ± 1.4 versus cis-men 2.6 ± 1.1; mean difference 1.2 [95% CI 0.76 to 1.6]; p < 0.001). Before rotation, underrepresented minorities had less agreement that diversity and inclusion are part of orthopaedic surgery culture (0.73 ± 0.72) compared with white students (1.5 ± 0.97) (mean difference 0.72 [95% CI 0.35 to 1.1]; p < 0.001). Many of these differences between nonmajority and majority demographic groups ceased to exist after rotation. Compared with their own prerotation beliefs, after rotation, cis-women believed more that diversity and inclusion are part of orthopaedic surgery culture (prerotation mean score 0.96 ± 0.75 versus postrotation mean score 1.2 ± 0.96; mean difference 0.60 [95% CI 0.22 to 0.98]; p = 0.002) and that orthopaedic surgery is friendlier (prerotation 2.3 ± 1.2 versus postrotation 2.6 ± 1.1; mean difference 0.41 [95% CI 0.14 to 0.69]; p = 0.004), more diverse (prerotation 0.71 ± 0.73 versus postrotation 1.0 ± 0.89; mean difference 0.28 [95% CI 0.08 to 0.49]; p = 0.007), less sexist (prerotation 1.3 ± 0.92 versus postrotation 1.9 ± 1.0; mean difference 0.63 [95% CI 0.40 to 0.85]; p < 0.001), less homophobic (prerotation 2.1 ± 1.0 versus postrotation 2.4 ± 0.97; mean difference 0.27 [95% CI 0.062 to 0.47]; p = 0.011), and less racist (prerotation 2.3 ± 1.1 versus postrotation 2.5 ± 1.1; mean difference 0.28 [95% CI 0.099 to 0.47]; p = 0.003). Compared with before rotation, after rotation cis-women believed less that they would have to work harder than others to be valued equally on the rotation (prerotation 2.8 ± 1.0 versus postrotation 2.5 ± 1.0; mean difference 0.31 [95% CI 0.12 to 0.50]; p = 0.002), as did nonheterosexual students (prerotation 2.4 ± 1.4 versus postrotation 1.8 ± 1.3; mean difference 0.56 [95% 0.21 to 0.91]; p = 0.004). Underrepresented minority students saw orthopaedic surgery as less sexist after rotation compared with before rotation (prerotation 1.5 ± 1.1 versus postrotation 2.0 ± 1.1; mean difference 0.52 [95% CI 0.16 to 0.89]; p = 0.007). CONCLUSION: Even with an estimated 26% response percentage, we found that medical students of demographic backgrounds who are not the majority in orthopaedics generally perceived that orthopaedic surgery is less diverse and inclusive than do their counterparts in majority groups, but these views often change after a clinical orthopaedic rotation. CLINICAL RELEVANCE: These perceptions may be a barrier to diversification of the pool of medical student applicants to orthopaedics. However, participation in an orthopaedic surgery rotation is associated with mitigation of many of these negative perceptions among diverse students. Medical schools have a responsibility to develop a diverse workforce, and given our findings, schools should promote participation in a clinical orthopaedic rotation. Residency programs and orthopaedic organizations can also increase exposure to the field through the rotation and other means. Doing so may ultimately diversify the orthopaedic surgeon workforce and improve care for all orthopaedic patients.

Should "Pain Clearance" Be Routine for Elective Surgery?

For elective surgery, preoperative planning for patients with comorbidities tends to address risk stratification, cardiac clearance, and anticoagulation. This commentary suggests that chronic opioid use should be normalized as a comorbidity requiring "pain clearance" prior to elective surgery. Doing so would likely enhance team communication, optimize patient care, decrease stigma, and facilitate care transitioning and long-term planning.

Patient Selection After Mandatory Bundled Payments for Hip and Knee Replacement: Limited Evidence of Lemon-Dropping or Cherry-Picking.

BACKGROUND: On April 1, 2016, the Centers for Medicare & Medicaid Services (CMS) introduced bundled-payment programs for hip replacement and knee replacement (HKR) in selected metropolitan statistical areas (MSAs) to decrease the costs and cost variability of HKR and to increase the quality of care. Early program analyses showed cost savings; however, studies also demonstrated a trend toward the selection of healthier patients for HKR performed under the bundled system. We compared the characteristics of patients who underwent HKR before implementation of the bundled-payment system (pre-policy) with those of patients who underwent HKR after implementation (post-policy). METHODS: Patients who underwent HKR from 2015 to 2016 were identified from Medicare inpatient claims files. After matching for MSA characteristics, we used a difference-in-difference design to evaluate changes in patient case mix from pre-policy to post-policy by comparing Medicare beneficiaries receiving HKR in bundled MSAs (bMSAs) with those receiving HKR in non-bundled MSAs (nbMSAs). The main characteristics of interest were race, dual eligibility (for Medicare and Medicaid), tobacco use, obesity, presence of diabetes with or without complications, and Charlson Comorbidity Index (CCI) value. We also evaluated pre-policy to post-policy changes in patient case mix by comparing Medicare beneficiaries in bMSAs who underwent HKR compared with those who underwent hip hemiarthroplasty. Hip hemiarthroplasty was used as a control to determine whether there were changes in access to HKR. RESULTS: We found significant differences in the unadjusted baseline characteristics between the bMSA and nbMSA cohorts, both for unmatched and matched samples. We found no significant post-policy changes in the characteristics of patients undergoing HKR. Patients undergoing hemiarthroplasty had significantly higher CCI values than did those undergoing HKR in bMSAs post-policy, although the difference was small (0.36-point higher CCI value; p < 0.01). Patients undergoing hemiarthroplasty were also 2.4% more likely to have diabetes mellitus without complications compared with those who underwent HRK post-policy (p < 0.01). CONCLUSIONS: In contrast to previous investigators, we found little to no significant change in the characteristics (including race, dual eligibility, tobacco use, obesity, presence of diabetes with or without complications, and CCI value) of Medicare beneficiaries who underwent HKR after the initiation of the CMS mandatory bundled-payment policy.

Are There Gender-based Differences in Language in Letters of Recommendation to an Orthopaedic Surgery Residency Program?

BACKGROUND: Letters of recommendation are considered one of the most important factors for whether an applicant is selected for an interview for orthopaedic surgery residency programs. Language differences in letters describing men versus women candidates may create differential perceptions by gender. Given the gender imbalance in orthopaedic surgery, we sought to determine whether there are differences in the language of letters of recommendation by applicant gender. QUESTIONS/PURPOSES: (1) Are there differences in word count and word categories in letters of recommendation describing women and men applicants, regardless of author gender? (2) Is author gender associated with word category differences in letters of recommendation? (3) Do authors of different academic rank use different words to describe women versus men applicants? METHODS: Using a linguistic analysis in a retrospective study, we analyzed all letters of recommendation (2834 letters) written for all 738 applicants with completed Electronic Residency Application Service applications submitted to the Johns Hopkins Orthopaedic Surgery Residency program during the 2018 to 2019 cycle to determine differences in word category use among applicants by gender, authors by gender, and authors by academic rank. Thirty nine validated word categories from the Linguistic Inquiry and Word Count dictionary along with seven additional word categories from previous publications were used in this analysis. The occurrence of words in each word category was divided by the number of words in the letter to obtain a word frequency for each letter. We calculated the mean word category frequency across all letters and analyzed means using non-parametric tests. For comparison of two groups, a p value threshold of 0.05 was used. For comparison of multiple groups, the Bonferroni correction was used to calculate an adjusted p value (p = 0.00058). RESULTS: Letters of recommendation for women applicants were slightly longer compared with those for men applicants (366 ± 188 versus 339 ± 199 words; p = 0.003). When comparing word category differences by applicant gender, letters for women applicants had slightly more "achieve" words (0.036 ± 0.015 versus 0.035 ± 0.018; p < 0.0001). Letters for men had more use of their first name (0.016 ± 0.013 versus 0.014 ± 0.009; p < 0.0001), and more "young" words (0.001 ± 0.003 versus 0.000 ± 0.001; p < 0.0001) than letters for women applicants. These differences were very small as each 0.001 difference in mean word frequency was equivalent to one more additional word from the word category appearing when comparing three letters for women to three letters for men. For differences in letters by author gender, there were no word category differences between men and women authors. Finally, when looking at author academic rank, letters for men applicants written by professors had slightly more "research" terms (0.011 ± 0.010) than letters written by associate professors (0.010 ± 0.010) or faculty of other rank (0.009 ± 0.011; p < 0.0001), a finding not observed in letters written for women. CONCLUSIONS: Although there were some minor differences favoring women, language in letters of recommendation to an academic orthopaedic surgery residency program were overall similar between men and women applicants. CLINICAL RELEVANCE: Given the similarity in language between men and women applicants, increasing women applicants may be a more important factor in addressing the gender gap in orthopaedics.