Improved patient reported outcomes with the direct anterior approach versus the posterior approach for total hip arthroplasty in the early post-operative period.

BACKGROUND: Patients undergoing total hip arthroplasty (THA) with the direct anterior approach (DAA) may experience faster recovery but may also have better baseline health than those who undergo THA with the posterior approach (PA). This study aimed to compare patient-reported outcome measures (PROMs) between the DAA and PA while controlling for baseline factors. METHODS: This is a secondary data analysis from a prospective cohort study of patients utilizing a smartphone-based care management platform following THA. The primary outcomes were HOOS JR and EQ-5D-5L through 1 year and change from baseline. Longitudinal regression models were created to control for baseline characteristics and investigate the impact of surgical approach on PROMs. RESULTS: Of 1364 THAs evaluated, 731 (53.6%) were female, and 840 (61.6%) used the PA. Patients in the PA group were of similar age but had higher body mass index and comorbidity scores. Pre-operative HOOS JR and EQ-5D-5L were comparable, but higher post-operatively in the DAA group through 6 months (p = 0.03 and p = 0.005). At 1 year post-operatively, HOOS JR and EQ-5D-5L did not vary between groups (p = 0.48 and p = 0.56), nor did changes from baseline (p = 0.47 and p = 0.11). After controlling baseline characteristics, DAA was significantly associated with higher average HOOS JR through 6 months (p = 0.03) and EQ-5D-5L through 3 months (p = 0.005), but not at 12 months (p = 0.89 and p = 0.56). CONCLUSION: THA patients undergoing DAA demonstrate earlier improvements in HOOS JR and EQ-5D-5L. However, these differences may not be clinically significant and are not evident at 1-year post-operative. Patient selection and surgeon training may continue to affect outcomes by surgical approach.

The Rising Quality of Randomized Controlled Trials in The Journal of Bone & Joint Surgery: An Updated Analysis from 2014 to 2022.

Background: Previous reports found that 40% of randomized controlled trials (RCTs) published in The Journal of Bone & Joint Surgery (JBJS) from 1988 to 2000 and 47% of those published from 2001 to 2013 were of high quality. The purpose of this study was to assess the quality of RCTs published from 2014 to 2022 in JBJS and to compare these findings with those of prior analyses in order to identify trends over time and areas for continued improvement. Methods: PubMed was searched for the term "randomized controlled trial" to identify studies published in JBJS from 2014 to 2022. Each included RCT was evaluated with use of the Detsky score and a risk-of-bias assessment modified from the Cochrane tool. These evaluations were then compared with previous evaluations of RCTs from the 1988 to 2000 and 2001 to 2013 periods with use of independent-sample t tests. A transformed Detsky score of >75% and a modified risk-of-bias score of ≥8 were defined as being indicative of high quality. Results: A total of 218 RCTs were published in JBJS from 2014 to 2022. An a priori sample size was calculated in 183 studies (83.9%). A total of 152 (83.1%) of the 183 studies enrolled the calculated number of patients, of which 126 (82.9%) maintained an adequate number at the time of final follow-up. Most RCTs were conducted at a single center (146 of 218; 67%), evaluated a surgical intervention (162 of 218; 74%), and reported positive results (142 of 218; 65%). The mean transformed Detsky score was 85% ± 10% (95% confidence interval, 83.7% to 86.3%), with 82% of trials (179 of 218) scored as high quality. The mean transformed Detsky score from 2014 to 2022 was higher than that from 1988 to 2000 and that from 2001 to 2013 (85% versus 76% and 68%, respectively; p < 0.001). The mean modified risk-of-bias score was 7 ± 1, with 42% of trials (92 of 218) scored as high quality. RCTs published from 2014 to 2022 had a higher mean modified risk-of-bias score than those published from 2001 to 2013 (7 ± 1 versus 6 ± 1; p < 0.001). Compared with the 2001 to 2013 and 2014 to 2022 periods, the 1988 to 2000 period had a greater proportion of trials that reported positive results (51% and 65% versus 82%, respectively; p < 0.001) and that included data from multiple centers (31% and 33% versus 67%; p < 0.001). Conclusions: The quality of RCTs published in JBJS from 2014 to 2022 has improved from that reported previously, as demonstrated by the increases in the modified risk-of-bias score and transformed Detsky score from prior periods. This may be the result of journal policies such as the requirements of CONSORT adherence and prospective trial registration. Investigators should focus on improving the clarity of reporting, limiting attrition bias, and making efforts to blind support staff in order to increase the quality of future RCTs. Clinical Relevance: Improving the quality of RCTs is crucial given their potential to influence current clinical practice.

YouTube videos on ulnar collateral ligament reconstruction are highly variable in terms of reliability and quality: A quantitative analysis.

Background: Ulnar collateral ligament reconstruction (UCLR) is commonly performed on adolescent athletes, who often turn to online sources such as YouTube for health information. The purpose of this study was to retrospectively review the accuracy, reliability, and quality of UCLR videos using validated scoring instruments. Methods: YouTube was queried for "Tommy John surgery," "UCL reconstruction," and "ulnar collateral ligament reconstruction." After categorization by physician, nonphysician/trainer, patient or commercial source, videos were assessed for reliability and quality using the Journal of the American Medical Association (JAMA) benchmark criteria (0-4) and DISCERN tool (16-80). Results: 104 videos were included in the final analysis. 74% of videos (77/104) were made by physicians. The mean JAMA and DISCERN scores for all videos were 3.1 ± 0.8 and 46.1 ± 8.5, respectively. The majority of videos were rated as "fair" based on DISCERN score (56/104, 53.8%). JAMA scores were significantly higher for physician videos compared to nonphysician videos (3.3 ± 0.8 vs 2.6 ± 0.7, p < 0.0001), but no such difference was found for DISCERN scores (46.3 ± 7.7 vs 45.3 ± 10.57, p = 0.43). Conclusion: Physicians should be cognizant of the quality and reliability of YouTube videos when instructing patients on information sources related to UCLR.

No difference in abstract publication rates between the open and closed American Shoulder and Elbow Surgeons meetings from 2013 to 2019.

BACKGROUND: The American Shoulder and Elbow Surgeons (ASES) society has advanced the practice of shoulder and elbow care through the exhibition of research at academic meetings. The ASES annual meeting is a closed (member-only) conference annually held in October, while the specialty day is an open (non-members included) event that takes place during the American Academy of Orthopaedic Surgeons (AAOS) meeting week in March. This study aims to compare the rate of publication for abstracts presented at the open and closed ASES meetings from 2013 to 2019. METHODS: The ASES website was searched to obtain the annual meeting and specialty day program agendas from 2013 to 2019. A standardized search protocol was employed to identify conference abstracts that went on to be published. Publications associated with an ASES abstract were analyzed through several variables including the time to publication, journal impact factor (JIF), and level of evidence. RESULTS: There was no difference between the rates of publication of the open (76.5%, 121/158) and closed (75.3%, 223/296) meetings (P = .904). The median time to publication significantly differed between the open (7 months, 95% confidence interval [CI]: 5.0-10.0) and closed (11 months, 95% CI: 9.0-13.0) meetings (P = .02). There was no difference between the median JIF between the open (2.69, 95% CI: 2.41-2.81) and closed (2.73, 95% CI: 2.41-2.81) meetings. The distribution of the level of evidence in published articles comparing the open and closed meetings did not differ significantly (P = .446). DISCUSSION: The overall quality of academic research presented at orthopedic subspecialty conferences can be objectively evaluated through abstract publication rates. Our analysis demonstrates that there is not a single significant difference among the publication rates, median JIF, and level of evidence distribution between the ASES open and closed meetings from 2013 to 2019. Impactful research is showcased at both the open and closed meetings. Societies that limit submissions from members only at annual meetings can consider soliciting research from non-members. While the quality of research would not decline if non-ASES members were invited to participate, the presence of a closed annual meeting may be a valuable tool for societies to expand their reach through member-exclusive benefits.

Poor evidence is used to support commercial payers' coverage policies for shoulder arthroplasty.

BACKGROUND: The incidence of shoulder arthroplasty has continued to increase over the past decade. In response, commercial payers have implemented strategies to control the medical requirement of these surgeries in attempt to contain the growing costs. For example, most payers require a prolonged trial of conservative management prior to shoulder arthroplasty for patients who may otherwise be surgical candidates. However, little is known regarding the evidence used to support these indications. The purpose of this study was to analyze the references used by commercial payers to substantiate their coverage policies for shoulder arthroplasty. METHODS: Ten of the leading commercial payers for total shoulder arthroplasty were identified. Publicly available coverage policies were searched on the internet or requested directly from the payer via email or telephone. Cited references were reviewed independently by two authors for type of document, level of evidence, and mention of the efficacy of conservative management. RESULTS: A total of 5 coverage policies were obtained with 118 references. The most common reference type was primary journal article (n = 70; 59.3%) followed by review or expert opinion articles (n = 35; 29.7%). Most references were of level IV evidence (n = 60; 52.2%), with only 6 (5.2%) of level I or II evidence. Only 4 (3.5%) references mentioned the efficacy of conservative management in patients who may be candidates for shoulder arthroplasty. CONCLUSION: The majority of references used to substantiate the coverage policies for shoulder arthroplasty among major commercial payers within the United States are of low scientific evidence and fail to demonstrate the success of required nonoperative intervention strategies. Our study underscores the need for high-quality, comparative trials that evaluate the outcomes of conservative management vs. shoulder arthroplasty in end-stage glenohumeral osteoarthritis patients in order to determine the most cost-effective treatment algorithm.

Prospective registration of randomized clinical trials for total shoulder arthroplasty is low: a systematic review.

BACKGROUND: Prospective trial registration has become an important means of improving the transparency and reproducibility of randomized controlled trials (RCTs) and is recommended by the Journal of Shoulder and Elbow Surgery (JSES) per the Consolidated Standards of Reporting Trials (CONSORT) guidelines. Herein, we performed a cross-sectional evaluation of RCTs published in JSES from 2010 to present to determine the prevalence of trial registration and consistency of outcome reporting. METHODS: The electronic database PubMed was searched to identify all RCTs on total shoulder arthroplasty (TSA) published in JSES from 2010 to 2022 using the search terms "randomized controlled trial" AND "shoulder" AND "arthroplasty OR replacement." RCTs were considered to be registered if they provided a registration number. For articles that were registered, authors also extracted the registry name, registration date, date of first enrollment, date of last enrollment, and if the primary outcomes reported in the registry were either (1) omitted, (2) newly introduced in the publication, (3) reported as a secondary outcome or vice versa, or (4) varied in timing of assessment compared to the publication. "Early" RCTs were considered those published from 2010 to 2016, whereas "later" RCTs were from 2017 to 2022. RESULTS: Fifty-eight RCTs met inclusion criteria. There were 16 early RCTs and 42 later RCTs. Twenty-three of the 58 (39.7%) studies were registered, with 9 of 22 with an available registry (40.9%) of those being enrolled prior to patient enrollment. Nineteen of the registered studies (82.6%) provided the name of the registry and a registration number. The proportion of later RCTs that were registered was not significantly different from the early RCTs (45.2% vs. 25.0%, P = .232). Seven RCTs (31.8%) had at least 1 inconsistency compared with the registry. The most common discrepancy was the timing of the assessment (ie, follow-up period) reported in the publication vs. the registry. DISCUSSION: Although JSES recommends prospective trial registration, less than half of shoulder arthroplasty RCTs are registered and more than 30% registered trials have at least 1 inconsistency with their registry record. More rigorous review of trial registration and accuracy is necessary to limit bias in published shoulder arthroplasty RCTs.

Differences in the Academic Attributes of Matched and Unmatched Orthopaedic Surgery Residency Applicants are Narrowing.

Orthopaedic surgery remains one of the most competitive residency specialties, with the number of applicants outpacing the availability of residency positions each year. The purpose of this study was to analyze present-day orthopaedic surgery match data, identify differences between matched and unmatched applicants, and compare our findings to previous trends. Methods: Applicant data from the National Resident Matching Program from 2016 to 2022 were analyzed. The number of matched and unmatched US allopathic senior orthopaedic applicants relative to the number of available positions was used to determine respective match rates. Performance metrics and applicant characteristics were compared by match status. Trends were compared with those of previous analysis from 2006 to 2014. Results: The number of applicants increased from 863 in 2016 to 1,068 in 2022. The match rate decreased from 75% in 2016 to 66% in 2022 (p < 0.0001). Matched applicants had a higher number of contiguous ranks (12.3 vs. 6.5; p < 0.001), United States Medical Licensing Examination (USMLE) Step-1 score (248 vs. 240; p < 0.001), USMLE Step-2 score (255 vs. 247; p < 0.001), Alpha Omega Alpha (AOA) membership (38% vs. 13%; p < 0.001), and enrollment at a top 40 National Institutes of Health (NIH)-funded medical school (34% vs. 24%, p < 0.001). Compared with 2006 to 2014 data, a smaller percentage of matched applicants were enrolled in a top 40 NIH-funded medical school (34% vs. 37%, p = 0.013). The mean differences in USMLE Step-1 score (16 vs. 8.25 points, p < 0.001) and USMLE Step-2 score (16 vs. 8.25 points, p = 0.002) in favor of matched applicants nearly halved compared with that in 2006 to 2014. In addition, there was no longer a significant difference in the number of research products (abstracts, presentations, posters, and publications) between matched and unmatched applicants (p = 0.309). Conclusions: Differences in the academic attributes of matched and unmatched orthopaedic surgery applicants have become less profound over time, making it increasingly difficult to predict a successful match based on USMLE Step scores, AOA membership, research productivity, and medical school research reputation. Future studies should evaluate differences in subjective metrics (e.g., away rotation and interview performance and letters of recommendation) by match status.

National Institutes of Health Funding to Departments of Orthopaedic Surgery at U.S. Medical Schools from 2015 to 2021.

BACKGROUND: National Institutes of Health (NIH) funding of orthopaedic surgery departments has historically lagged behind that of other surgical disciplines. In this study, we present an updated analysis of NIH grants awarded to orthopaedic surgery departments at U.S. medical schools and an evaluation of the characteristics of NIH-funded principal investigators (PIs). METHODS: The NIH Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER) database was queried for grants awarded to orthopaedic surgery departments in the 2015 to 2021 fiscal years. Funding totals were calculated for 4 categories: award mechanism, awarding institute, recipient institute, and PI. Trends in funding from 2015 to 2021 were determined and compared with the annual NIH budget. Funding awarded to orthopaedic surgery departments was compared with awards received by other surgical specialties in 2021. The characteristics of NIH-funded PIs and co-PIs were evaluated. Funding awarded to orthopaedic surgery departments in 2021 was compared with funding in 2014 as reported in a previous study. RESULTS: In 2021, 287 grants were awarded to 187 PIs at 47 orthopaedic surgery departments for a total of $104,710,841, representing 0.4% of the overall NIH budget. The top 5 departments earned $41,750,321 (39.9%) of the total NIH funding for orthopaedic surgery. From 2015 to 2021, total funding increased by 79.7% (p < 0.001), but the rate of increase was not significantly different from that of the overall annual NIH budget (p = 0.469). In 2021, grants were most commonly awarded via the R01 mechanism (70.0% of total funding), with a median annual award of $397,144 (interquartile range [IQR], $335,017 to $491,248). The majority of grants (70.0%) supported basic science research, followed by translational (12.2%), clinical (9.4%), and educational (8.4%) research. NIH funding did not vary by the gender of the PI (p = 0.505), and the proportion of female PIs was significantly greater in 2021 than in 2014 (33.9% versus 20.5%, p = 0.009). Compared with other surgical departments, orthopaedic surgery departments ranked second-lowest in terms of the total NIH funding received in 2021. CONCLUSIONS: NIH funding to orthopaedic surgery departments continues to be limited and lags behind that of other surgical subspecialties, which may create challenges in addressing the rising burden of musculoskeletal disease in the U.S. These findings highlight the importance of efforts to identify barriers to grant procurement in orthopaedic surgery.

A critical appraisal of Evicore's guidelines for advanced diagnostic imaging of the spine for lower extremity pain with neurological features.

Background: This analysis aims to evaluate the methodological quality of Evicore's spinal imaging guidelines for lower extremity pain with neurological features with or without lower back pain by leveraging the AGREE II tool. The AGREE II tool provides a framework to assess guideline development. It is well validated and has been used to evaluate many other guidelines previously. Methods: Five appraisers used the AGREE II appraisal tool to conduct a comprehensive review of Evicore's spinal imaging guidelines for lower extremity pain with neurological features. Appraisers provided an overall assessment of the guidelines as well as specific scores pertaining to domains including scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. Results: Appraisers assigned numerical grades of 2, 2, 2, 3 and 4 (out of 7 total points, with 7 being the highest) for overall quality of the guidelines. Three appraisers recommended use of the guideline with modifications and two appraisers did not recommend the guideline. The AGREE II ratings had good reliability across the different raters [intraclass correlation coefficient (ICC) =0.881, 95% confidence interval (CI): 0.77, 0.94]. Conclusions: Evicore's guidelines would greatly benefit from increased identification and diversification of guideline development parties and stakeholders, increased rigor of development including a more robust discussion of the body of evidence and its strengths and limitations, and incorporation of more explicit suggestions for implementation of guideline recommendations by healthcare providers.

Perioperative risk stratification tools for shoulder arthroplasty: a systematic review.

BACKGROUND: Risk stratification tools are being increasingly utilized to guide patient selection for outpatient shoulder arthroplasty. The purpose of this study was to identify the existing calculators used to predict discharge disposition, postoperative complications, hospital readmissions, and patient candidacy for outpatient shoulder arthroplasty and to compare the specific components used to generate their prediction models. METHODS: This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocol. PubMed, Cochrane Library, Scopus, and OVID Medline were searched for studies that developed calculators used to determine patient candidacy for outpatient surgery or predict discharge disposition, the risk of postoperative complications, and hospital readmissions after anatomic or reverse total shoulder arthroplasty (TSA). Reviews, case reports, letters to the editor, and studies including hemiarthroplasty cases were excluded. Data extracted included authors, year of publication, study design, patient population, sample size, input variables, comorbidities, method of validation, and intended purpose. The pros and cons of each calculator as reported by the respective authors were evaluated. RESULTS: Eleven publications met inclusion criteria. Three tools assessed patient candidacy for outpatient TSA, 3 tools evaluated the risk of 30- or 90-day hospital readmission and postoperative complications, and 5 tools predicted discharge destination. Four calculators validated previously constructed comorbidity indices used as risk predictors after shoulder arthroplasty, including the Charlson Comorbidity Index, Elixhauser Comorbidity Index, modified Frailty Index, and the Outpatient Arthroplasty Risk Assessment, while 7 developed newcalculators. Nine studies utilized multiple logistic regression to develop their calculators, while 1 study developed their algorithm based on previous literature and 1 used univariate analysis. Five tools were built using data from a single institution, 2 using data pooled from 2 institutions, and 4 from large national databases. All studies used preoperative data points in their algorithms with one tool additionally using intraoperative data points. The number of inputs ranged from 5 to 57 items. Four calculators assessed psychological comorbidities, 3 included inputs for substance use, and 1 calculator accounted for race. CONCLUSION: The variation in perioperative risk calculators after TSA highlights the need for standardization and external validation of the existing tools. As the use of outpatient shoulder arthroplasty increases, these calculators may become outdated or require revision. Incorporation of socioeconomic and psychological measures into these calculators should be investigated.

Medical malpractice litigation after total shoulder arthroplasty: a comprehensive analysis based on the Westlaw legal database.

INTRODUCTION: Orthopedic surgery is one of the most common subspecialties subject to medical malpractice claims. Although total shoulder arthroplasty (TSA) is associated with favorable patient outcomes and relatively low complication rates, surgeons performing this procedure may be subject to malpractice litigation leading to significant economic and psychological burden on the provider. The purpose of this study is to characterize and describe malpractice claims against orthopedic surgeons performing TSA using the Westlaw legal database. METHODS: The Westlaw legal database was queried for all cases related to TSA using the terms "malpractice" AND "shoulder replacement" OR "shoulder arthroplasty." Cases were excluded if the defendant was not an orthopedic surgeon, the procedure involved was not a TSA, or if the patient was a minor. Patient demographics, causes cited for litigation, case outcomes, and indemnity payments were analyzed to determine common factors that lead plaintiffs to pursue legal action. RESULTS: Thirty-five TSA cases were identified that met inclusion criteria. The mean plaintiff age was 55 years with 63.6% female. The most common category of negligence alleged was intraoperative error, which occurred in 25 claims (71%). The most common types of damages incurred were nerve injury (23%), functional limitation (20%), and infection (17%). Overall, 27 cases (77%) resulted in a defense verdict. Four cases (11%) resulted in settlements and 4 cases (11%) resulted in plaintiff verdicts. The average inflation-adjusted monetary award in these cases was $1,619,919 (standard deviation, $1,689,452). DISCUSSION: This study provides a comprehensive summary of malpractice claims and associated outcomes in TSA. Given the rapidly increasing rate of TSA in the United States and the burden of associated malpractice claims, understanding potential legal implications of TSA is of great value to orthopedic surgeons. Intraoperative error was the category of negligence cited most commonly in TSA malpractice claims. Nerve injury, functional limitation, and infection were the most commonly cited specific damages. These findings highlight the need for orthopedic surgeons to educate patients regarding potential postoperative complications while continuing to focus on minimizing their occurrence.

Evaluation of the National Institutes of Health-Supported Relative Citation Ratio Among Fellowship-Trained American Orthopaedic Joint Reconstruction Surgery Faculty: A New Bibliometric Measure of Scientific Influence.

BACKGROUND: The relative citation ratio (RCR), a novel National Institutes of Health-Supported measure of research productivity, allows for accurate interdisciplinary comparison of publication influence. This study evaluates the RCR of fellowship-trained adult reconstructive orthopaedic surgeons with the goal of analyzing potentially influential physician demographics. METHODS: Adult Reconstruction Accreditation Council for Graduate Medical Education fellowship-trained faculty for orthopaedic residency programs were identified via departmental websites. The National Institutes of Health's iCite database was retrospectively reviewed for mean RCR, weighted RCR, and publication count by surgeon. Multivariate analyses were performed using the Wilcoxon rank-sum tests and analyses of variance testing to compare sex, career length, academic rank, and professional degrees in addition to an MD or DO. Significance was considered P < .05. RESULTS: A total of 488 fellowship-trained adult reconstruction faculty from 144 programs were included in the analysis. Overall, the faculty recorded a median RCR of 1.65 (interquartile range: 1.01-2.28) and a median weighted RCR of 16.59 (interquartile range: 3.98-61.92). The weighted RCR and total number of publications were associated with academic rank and career longevity, while the mean RCR was associated with academic rank. The median RCR ranged from 1.12 to 1.87 for all subgroups. CONCLUSION: Adult reconstruction faculty are exceptionally productive and generate highly impactful studies as evidenced by the high median RCR value relative to the National Institutes of Health standard value of 1.0. Our data have important implications in the assessment of grant outcomes, promotion, and continued evaluation of research influence within the hip and knee community.

Nephron sparing surgery outcomes in Wilms' tumor: is it ready for primetime?

PURPOSE: Radical nephrectomy is the gold standard in Wilms tumor (WT) treatment and is combined with adjuvant treatment in early stage disease or performed after neo adjuvant therapy in advanced disease. With the development of novel adjuvant and neoadjuvant therapeutic strategies, there is increasing interest in organ preserving procedures in several adult malignancies. Potential long-term complications of living with a single kidney include hyperfiltration syndrome, hypertension, and fluid retention. If NSS (Nephron Sparing Surgery) were to be adopted for the treatment of WT it would be necessary to preserve the gains in Overall Survival (OS) seen with current treatment protocols. With this in mind we undertook a study of outcomes of NSS performed in the USA using a large population-based registry. METHODS: We retrospectively queried the SEER Research Plus 18-registries Database 2010-2018 for patients 18 years old or younger with Wilms tumor as determined by ICD-O-3 code 8960. Clinical and demographic data was extracted, and statistical analysis was performed in GraphPad PRISM 9 with bivariate analysis and log-rank analysis to determine survival. RESULTS: 1087 patients with Wilms tumor were identified. 73 (6.72%) underwent nephron-sparing surgery. The final cohort consisted of 45 patients (64%) who underwent unilateral NSS and 25 patients (36%) who underwent bilateral NSS. Three were excluded from analysis due to non-renal origin of tumor. Mean age was 3.214 years (std dev 3.807). Demographics were similar between the groups, apart from younger age associated with bilateral tumor (p = 0.0441). No differences were found between radiation use (p = 0.4280), chemotherapy use (p = 0.5479), tumor size (p = 0.2186), positive regional lymph nodes (p = 0.707). Log-rank analysis demonstrated that cancer-specific survival was not significantly different between unilateral and bilateral NSS or radical nephrectomy (p = 0.4539). CONCLUSION: NSS may preserve renal function long-term, an important consideration in the pediatric population. Prospective study is necessary to select the appropriate patient subsets who may benefit from NSS in WT.

Evaluating the Academic Influence of Orthopedic Surgeons in Spinal Literature Through Relative Citation Ratio.

INTRODUCTION:  The innovative iCite tool applies the relative citation ratio (RCR) to gauge the time and field-adjusted scientific influence of a publication. This study examines scholarly effects on spine surgery to distinguish the impact made by orthopedic surgeons, neurosurgeons, and several other specialists. MATERIALS AND METHODS:  From 2013 to 2017, 100 of the highest RCR-rated articles were gathered for each of the following terms: cervical disc herniation (CDH), lumbar disc herniation (LDH), lumbar spinal stenosis (LSS), neurogenic claudication (NC), radiculopathy (RAD), and sciatica (SC). The first, second, and last authors were queried for background and academic qualifications and placed into the following specialty categories: orthopedic surgery, neurosurgery, pain management, medicine, and others. To provide an alternative degree of influence, the Scopus database was employed to classify the h-index associated with each author. RESULTS:  Across the six search terms, there were 526 orthopedic surgeons among 1,730 authors (30.4%), with the highest representation in LSS (118/290, 40.7%), and the lowest in SC (45/286, 15.7%). Orthopedics was the most influential specialty across all six research terms by median RCR (p = 0.012). Compared to their neurosurgical counterparts, orthopedic authors had a greater influence in CDH (3.93 vs. 2.63, p = 0.0492), LDH (5.10 vs. 4.99, p = 1.0000), NC (2.16 vs. 1.40, p = 0.2370), and SC (3.35 vs. 3.04, p = 0.5285), but had a lower influence in LSS (5.13 vs. 5.32, p = 0.7736) and RAD (5.03 vs. 6.05, p = 0.3938). CONCLUSION:  Orthopedic surgeons lead other specialties when determining scholarly influence through RCR across six of the pre-designated research domains within spine surgery. For orthopedics, a modest influence in LSS and RAD may suggest potential areas of future focus. The use of bibliometrics to analyze available literature enables us to identify other specialties that have contributed to our field and promote interdisciplinary collaboration.

Pudendal Neurapraxia After Proximal Hamstring Repair: A Case Report.

CASE: The pudendal nerve lies near the origin of the hamstring muscles, placing it at increased risk of injury during proximal hamstring tendon repair. In this study, we report on a 56-year old man who experienced intermittent unilateral testicular pain after a proximal hamstring tendon repair presumably due to pudendal nerve neurapraxia. At the 1-year follow-up, he continued to experience discomfort in the pudendal nerve distribution but reported significant improvement in symptoms and complete resolution of hamstring pain. CONCLUSION: Although the risk of pudendal nerve injury during proximal hamstring tendon repair is rare, surgeons should be aware of this potential complication.