Eccentric Hamstring Strength Imbalance among Football and Soccer Athletes.

OBJECTIVES: Hamstring strain injuries (HSI) are common among football and soccer athletes. Eccentric strength imbalance is considered a contributing factor for HSI. There is, however, a paucity of data on hamstring imbalances of soccer and American football athletes as they age and advance in skill level. High school athletes will display greater interlimb discrepancies compared with collegiate and professional athletes. In addition, soccer athletes will exhibit greater hamstring asymmetry than American football athletes. METHODS: Hamstring testing was performed on soccer and American football athletes using the NordBord Hamstring Testing System (Vald Performance, Albion, Australia). Age, sex, weight, sport specialization, and sport level were recorded. Maximum hamstring forces (N), torque (N · m), and work (N · s) were measured. Hamstring imbalance (%) was calculated by dividing the absolute value of the difference in leg forces divided by their sum. One-way analysis of variance and independent sample t tests compared measurements between athlete groups. RESULTS: A total of 631 athletes completed measurements, including 88 high school male soccer, 25 college male soccer, 23 professional male soccer, 83 high school female soccer, 28 college female soccer, 288 high school football, and 96 college football athletes. High school soccer players displayed significantly greater imbalances for torque (P = 0.03) and work (P < 0.01) than football athletes. Imbalances for maximum force (P = 0.035), torque (P = 0.018), and work (P = 0.033) were significantly higher for male soccer athletes in high school compared with college- and professional-level athletes. Female high school soccer players had significantly higher imbalance in torque (P = 0.045) and work (P = 0.001) compared with female collegiate soccer players. Football athletes did not experience significant changes in force imbalances between skill levels. CONCLUSIONS: High school soccer athletes exhibit greater hamstring imbalances than football athletes. Higher levels of play in soccer, for both male and female athletes, correlate with less hamstring asymmetry.

Elective Hand Surgery Is Delayed among Private Insurance Holders.

OBJECTIVES: Patients with private healthcare plans often defer nonemergent or elective procedures toward the end of the year once they have met their deductible. No previous studies have evaluated how insurance status and hospital setting may affect surgical timing for upper extremity procedures. Our study aimed to evaluate the influence of insurance and hospital setting on end-of-the-year surgical cases for elective carpometacarpal (CMC) arthroplasty, carpal tunnel, cubital tunnel, and trigger finger release, and nonelective distal radius fixation. METHODS: Insurance provider and surgical dates were gathered from two institutions' electronic medical records (one university, one physician-owned hospital) for those undergoing CMC arthroplasty, carpal tunnel release, cubital tunnel release, trigger finger release, and distal radius fixation from January 2010 to December 2019. Dates were converted into corresponding fiscal quarters (Q1-Q4). Using the Poisson exact test, comparisons were made between the case volume rate of Q1-Q3 and Q4 for private insurance and then for public insurance. RESULTS: Overall, case counts were greater in Q4 than the rest of the year at both institutions. There was a significantly greater proportion of privately insured patients undergoing hand and upper extremity surgery at the physician-owned hospital than the university center (physician owned: 69.7%, university: 50.3%; P < 0.001). Privately insured patients underwent CMC arthroplasty and carpal tunnel release at a significantly greater rate in Q4 compared with Q1-Q3 for both institutions. Publicly insured patients did not experience an increase in carpal tunnel releases during the same period at both institutions. CONCLUSIONS: Privately insured patients underwent elective CMC arthroplasty and carpal tunnel release procedures in Q4 at a significantly greater rate than publicly insured patients. This finding suggests private insurance status, and potentially deductibles, influence surgical decision making and timing. Further work is needed to evaluate the impact of deductibles on surgical planning and the financial and medical impact of delaying elective surgeries.

Bioactive Knee Sleeve for Osteoarthritis: A Small Cohort Study.

OBJECTIVES: Osteoarthritis (OA) is one of the most prevalent musculoskeletal ailments worldwide. Numerous conservative therapies exist, but evidence for such treatments remains conflicting. Recently, there has been growing interest surrounding bioactive sleeves for managing knee arthritis; however, the literature on their efficacy for relieving pain and improving function in the setting of knee OA is limited. As such, we sought to investigate the effect of a bioactive sleeve on patient-reported outcome measures in a small cohort of patients with OA. METHODS: Patients with knee OA were given a bioactive sleeve (Reparel, Chico, CA) and asked to refrain from lifestyle modifications and intraarticular corticosteroid injections. Lysholm Knee Score, Oxford Knee Score, Knee Injury and OA Outcome Score (KOOS), Single Assessment Numeric Evaluation, and Visual Analog Scale score were obtained at baseline, 2 weeks, 6 weeks, and 3 months. OA severity was evaluated using the Kellgren and Lawrence (KL) classification system. The Wilcoxon signed rank test was used to compare baseline patient-reported outcomes with 2-week, 6-week, and 3-month time points. Bivariate correlation was used to evaluate the relation between patient-reported outcome measures and KL classification. RESULTS: The cohort was composed of 14 participants-4 males and 10 females-with a mean age of 62.2 ± 13.2 years and a body mass index of 33.7 ± 5.8. The average KL grade was 2.9 (range 2-4). KOOS pain, symptoms, activities of daily living, and quality of life increased significantly at 2 weeks, 6 weeks, and 3 months. KOOS sport and recreation significantly increased at 3 months. The Oxford Knee Score was significantly greater at 2 weeks, 6 weeks, and 3 months. The Lysholm Knee Score was significantly greater at 6 weeks and 3 months. The Single Assessment Numeric Evaluation attained significant improvement at 3 months, and the Visual Analog Scale improvement was significant at 2 weeks. No statistically significant difference was attained with University of California at Los Angeles activity score. Outcome scores did not correlate with KL classification. CONCLUSIONS: These data suggest that a bioactive sleeve may improve patient-reported pain, symptoms, and function in the setting of knee OA. Further research is needed to better understand the role of bioactive sleeves for patients with knee arthritis.

COVID-19 Impact on Orthopedic Surgeons: Elective Procedures, Telehealth, and Income.

OBJECTIVES: The purpose of this study was to investigate the response in orthopedic surgery to the coronavirus disease 2019 (COVID-19) pandemic across the United States by surveying surgeons about their care setting, timing of restrictions on elective surgery, use of telehealth, and estimated economic impact. METHODS: A survey was distributed via REDCap through state orthopedic organizations between April and July 2020. The 22-question digital survey collected information regarding restrictions on elective procedures, location of care, utilization of telehealth, and estimated reductions in annual income. RESULTS: In this study, 192 participants responded to the survey (average age 49.9 ± 11.0 years, 92.7% male). Responses primarily originated from Alabama (30.2%), Georgia (30.2%), and Missouri (16.1%). The remainder of the responses were grouped into the category "other." Respondents did not vary significantly by state in operative setting or income type (salary, work relative value units, or collections). Most of the participants documented elective procedure restrictions in hospital and ambulatory settings. The highest frequency of closures occurred between March 18 and 20 (47% in hospital, 51% in ambulatory). Of the participants, financial loss estimates varied across states (P = 0.005), with 50% of physicians claiming >50% losses of income in Alabama (24% Georgia, 10% Missouri, 31% other). Regarding telehealth, practices set up for these services before 2020 varied across states. None of the orthopedic practices in Alabama had telehealth before the COVID-19 pandemic (Missouri 25%, Georgia 9%, other 8%, P = 0.06); however, respondents generally were split when considering the anticipation of implementing telehealth into routine practice. CONCLUSIONS: Most practices did implement restrictions for elective clinic visits and procedures early during the pandemic. COVID-19 ultimately will result in a large revenue loss for elective orthopedic practices. Services such as telehealth may help offset these losses and help deliver orthopedic care to patients remotely.

Is outpatient shoulder arthroplasty safe? A systematic review and meta-analysis.

BACKGROUND: Amid rising health care costs and recent advances in surgical and anesthetic protocols, the rate of outpatient joint arthroplasty has risen steadily in recent years. Although the safety of outpatient total knee arthroplasty and total hip arthroplasty has been well established, outpatient shoulder arthroplasty is still in its infancy. The purpose of this study was to synthesize the current literature and provide further data regarding the outcomes and safety of outpatient shoulder arthroplasty. METHODS: A systematic review was conducted following the standard PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included were studies that evaluated the outcomes of patients undergoing outpatient total shoulder arthroplasty (TSA) or reverse TSA. Meta-analysis was conducted using Mantel-Haenszel statistics to generate odds ratios (ORs) and their corresponding 95% confidence intervals (CIs) comparing outpatient and inpatient shoulder arthroplasty. RESULTS: Twelve studies were included, with a total of 194,513 patients, of whom 7162 were outpatients. Of the studies, 8 were level III and 4 were level IV. The average age of the outpatients was 66.6 years, and the average age of the inpatients was 70.1 years. The overall OR for complications was significantly lower in outpatients (OR, 0.40; 95% CI, 0.35-0.45) than in inpatients. There was no significant difference in rates of 90-day readmission (OR, 0.88; 95% CI, 0.75-1.03), revision (OR, 0.96; 95% CI, 0.65-1.41), and infection (OR, 0.93; 95% CI, 0.64-1.35) when comparing outpatients with inpatients. CONCLUSION: Outpatient TSA, in an appropriately selected patient population, is safe and results in comparable patient outcomes to those of inpatient shoulder arthroplasty. Given the expected increase in the number of patients requiring TSA, surgeons, hospital administrators, and insurance carriers should strongly consider the merits of a cost- and care-efficient approach to total shoulder replacement.

Quality Improvement Tools in Total Joint Arthroplasty: A Systematic Review.

Systems review and quality improvement (QI) is a significant need within orthopaedic surgery. The focus of this paper is to systematically review QI principles utilized in total joint arthroplasty to determine most successful QI tools. A systematic search on MEDLINE/Pubmed, Embase, Cochrane Library and other sources was conducted from September 1991 through October 2018. The three primary improved outcomes from each article were recorded along with the date, author and subspecialty. Thirty-four eligible studies related to joint arthroplasty were identified for inclusion in the systematic review. The most common outcomes that were improved in these publications were: length of stay (LOS), cost, medication management, and patient education. Lean, clinical care pathways (CCP), plan-do-check-act (PDCA), and shared decision-making improved those metrics. Four metrics were found that were consistently improved by certain quality improvement tools: LOS, cost, medication management, and patient education. Further research is warranted to continue to build a framework for quality improvement in orthopaedic surgery. (Journal of Surgical Orthopaedic Advances 30(3):125-130, 2021).

Corticosteroid Injections May Increase Retear and Revision Rates of Rotator Cuff Repair: A Systematic Review.

PURPOSE: To synthesize the clinical outcome data of preoperative and postoperative corticosteroid injections (CIs) and their effect on rotator cuff repairs (RCRs). METHODS: A systematic review was performed to identify studies that reported the results or clinical outcomes of RCRs in patients receiving either preoperative or postoperative CIs. The searches were performed using MEDLINE, Google Scholar, and Embase, and studies were chosen following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. RESULTS: A total of 11 studies were included with data for 176,352 shoulders: 6 studies involving 175,256 shoulders with data regarding preoperative CIs, 4 studies involving 1,096 shoulders with data regarding postoperative CIs, and 1 study with 212 shoulders containing preoperative and postoperative data. Preoperative CIs were found in 3 studies to increase the risk of revision surgery when administered within 6 months (odds ratio [OR], 1.38-1.82) and up to 1 year (OR, 1.12-1.52) prior to RCR, with revision rates in 2 studies being highest when patients received 2 or more injections (OR, 2.12-3.26) in the prior year. Postoperative CIs reduced pain and improved functional outcomes in 5 studies without increasing the retear rates (5.7%-19% for CI and 14%-18.4% for control) in most studies. CONCLUSIONS: CIs provide benefit by relieving pain and improving functional outcome scores. However, repeated preoperative CIs may increase retear rates and the likelihood of revision surgery. A lower frequency of CI and longer preoperative waiting period after CI should be considered to decrease such risks. Postoperative CIs several weeks after RCR do not appear to increase retear rates. LEVEL OF EVIDENCE: Level IV, systematic review of Level I through IV studies.

Patient Perception of Orthopedic Surgeon Reimbursement.

Significant attention has been directed at evaluating reimbursement rates to orthopedic surgeons for various surgical procedures. To evaluate patients' understanding of the surgeon reimbursement process, studies using patient surveys have been conducted to determine patients' perceptions of orthopedic surgeon compensation. To date, there has been no systematic review to consolidate the data of these studies. This study aimed to synthesize the findings of these individual studies across multiple subspecialties of orthopedic surgery to evaluate the potential discrepancy between how much patients believe orthopedic surgeons are reimbursed and the actual reimbursement rate. We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies that report findings of patient perceptions of orthopedic surgeon reimbursement for various procedures. Searches were conducted using MEDLINE through PubMed, Embase, and Scopus. Summary estimates of reimbursement discrepancies across subspecialties and overall were reported as unweighted averages of the individual study results within each group. Twelve studies were identified that met inclusion criteria, constituting 4309 surveys. These survey studies measured patients' perceptions of how much orthopedic surgeons are reimbursed for common procedures, including anterior cruciate ligament reconstruction, arthroscopic meniscectomy, carpal tunnel release, rotator cuff repair, multiple spine procedures and total shoulder, hip, and knee arthroplasty. It was found that patients reported reasonable surgeon's fees to be 11.2 times more than actual Medicare reimbursement. Among individual studies, the largest discrepancies were seen in total hip arthroplasty (26 times), whereas the smallest difference was in anterior cruciate ligament reconstruction (1.6 times). On average, patients estimated Medicare reimbursement rates to be 5.9 times higher than the actual surgeon reimbursement. Patients consistently overestimate how much orthopedic surgeons are reimbursed for common orthopedic procedures. The results of this systematic review suggest that patients may value these procedures more than what Medicare reimburses. Such information may help educate the public, direct policy, and increase transparency between orthopedic surgeons and patients.

Clinical outcomes following conservative and surgical management of floating shoulder injuries: a systematic review.

BACKGROUND: Floating shoulder is an uncommon injury characterized by fractures of the clavicle and ipsilateral scapular neck. No consensus exists on management. The purpose of this study was to analyze the existing literature on treatment and clinical outcomes of floating shoulder injuries to provide a baseline understanding of current treatment strategies of this injury. METHODS: A systematic review was performed to identity published literature on outcomes and management of floating shoulder injuries. Searches were performed using PubMed, Embase, and SCOPUS. RESULTS: Seventeen studies were identified that included data for 371 shoulders. The mean reported age was 39.4 years (range, 16-82) and the mean follow-up was 49.4 months (range, 6-312). The major mechanism of injury was motor vehicle accident (51%) followed by fall from height (16%). Of the 371 shoulders, 215 (58%) were treated surgically, whereas 156 shoulders (42%) were managed nonoperatively. The most commonly reported outcome score was the Constant-Murley score (9 studies), followed by the Herscovici Floating Shoulder Injury score (5 studies). The mean Constant-Murley score was 80% of ideal maximum for both shoulders treated surgically and those treated nonoperatively. CONCLUSION: Satisfactory outcomes can be expected following both surgical fixation and nonoperative management of floating shoulder injuries when appropriately individualized to the patient, as evidenced by clinical outcome scores. Floating shoulder injuries with significant displacement of the scapular neck may benefit from surgical fixation of both the clavicle and scapula fractures. In those with minimal or nondisplaced scapular neck fractures, good outcomes may be achieved when treated nonoperatively or with surgical fixation of the clavicle alone.

Os acromiale: systematic review of surgical outcomes.

BACKGROUND: The literature is unclear as to the optimal surgical management of a symptomatic os acromiale that has failed nonoperative treatment. Surgical options include excision, acromioplasty, and open reduction and internal fixation. The purpose of this study is to summarize the described methods and compare their reported outcomes with the goal to provide direction on how to surgically manage os acromiale. METHODS: We performed a systematic review of the current medical literature. Fifteen studies met all the inclusion criteria. Two hundred eleven total subjects (220 shoulders) underwent surgical treatment for a symptomatic os acromiale. There were 140 men and 71 women with a mean age of 49.6 ± 9.1 years. The mean follow-up duration was 40 ± 11.6 months. Surgical techniques used in the included studies were excision, acromioplasty, and open reduction with internal fixation. Concurrent surgical procedures performed were also included. RESULTS: Meso-os acromiale was the most common type (167 cases, 94.4%). The most common surgical technique was internal fixation (135 cases, 60.8%), with screw fixation being the majority (76 cases, 56.3%). Excision (65 cases, 29.3%) was the second most used technique. The most common concurrent surgical procedure performed was rotator cuff repair (125 cases, 56.3%), followed by distal clavicle excision (31 cases, 14%). CONCLUSIONS: All surgical techniques employed resulted in improvement in postsurgical clinical outcomes without any technique demonstrating superior results. Operative management of a symptomatic os acromiale that has failed initial nonoperative treatment leads to decreased symptoms and improvement in clinical outcomes.

Subscapularis sparing total shoulder arthroplasty through a superolateral approach: a radiographic study.

BACKGROUND: Most anatomic total shoulder arthroplasty (ATSA) techniques release and reattach the subscapularis tendon. The risk of failed healing is a widely recognized complication. The purpose of this study was to radiographically compare a traditional deltopectoral (DP) approach and a superolateral subscapularis sparing (SSS) technique through the rotator interval. METHODS: A single, independent, blinded, reviewer analyzed preoperative and postoperative radiographs of patients undergoing ATSA performed by a single surgeon. The reviewer assessed humeral head height, humeral head medial offset, humeral head diameter, head-neck angle, humeral head centering, and coracohumeral offset, and used the anatomic reconstruction index (ARI) to evaluate overall reconstruction quality. RESULTS: There were 70 SSS and 20 DP patients included. When comparing preoperative with postoperative differences, we found that there was no difference between groups in humeral head height (P = .19), humeral head medial offset (P = .38), and coracohumeral offset (P = .07). The DP group had a mean humeral head diameter oversizing of 1.4 mm, whereas the superolateral group had an undersizing of 2.8 mm (P < .001). The head-neck angle difference of the SSS approach was 2° greater than that found with the DP group (P < .001). The humeral head centering in the DP group was 7% displaced vs. 12% with the SSS group (P = .001) relative to the glenoid size. The ARI was 7.35 for the DP group and 6.93 for the SSS group (P = .50). DISCUSSION AND CONCLUSIONS: Radiographic comparison of these 2 ATSA techniques identified no statistical significant difference in 4 of 7 radiographic measurements and ARI. The SSS ATSA is a reasonable approach that yields similar radiographic measurements as a traditional DP total shoulder arthroplasty approach.

Subacromial Spacer Implantation for the Treatment of Massive Irreparable Rotator Cuff Tears: A Systematic Review.

PURPOSE: To synthesize and report the early clinical and radiographic outcomes associated with subacromial spacer use in patients with massive irreparable rotator cuff tears. METHODS: A systematic search on MEDLINE, Embase, and Cochrane Library databases was performed during February 2018. Included studies were evaluated regarding the level of evidence and quality using the methodological index for nonrandomized studies. Patient demographics, intraoperative findings, clinical and radiographic outcomes, and complications were recorded for each of the included studies. RESULTS: Seven eligible studies including 204 shoulders from 200 patients with subacromial spacer implantation were identified (6 Level IV studies and 1 Level III study). The mean methodological index for nonrandomized studies score for noncomparative studies was 11, whereas that of comparative studies was 15. The mean age of patients was 67.6 years, and the mean reported follow-up time was 19.4 months. All patients had Goutallier stage 3 and 4 fatty infiltration on magnetic resonance imaging. All studies reported consistent improvement in the total Constant score or American Shoulder and Elbow Surgeons score over the duration of follow-up. A total of 6 (3%) complications were reported in the included studies. Two studies detailed radiographic outcomes, with discrepant changes in the acromiohumeral interval. CONCLUSIONS: Patients undergoing subacromial spacer implantation for the treatment of massive irreparable rotator cuff tears have satisfactory outcomes at the 2- to 3-year follow-up with a low rate of complications. LEVEL OF EVIDENCE: Level IV, systematic review of 1 Level III and 6 Level IV studies.

The surgical anatomy of the dorsal scapular nerve: a triple-tendon transfer perspective.

BACKGROUND: Iatrogenic or traumatic injury to the spinal accessory nerve is a rare but debilitating injury. An effective treatment, known as the Eden-Lange modification triple-tendon transfer procedure, involves the transfer of the rhomboid major (RM), rhomboid minor (Rm), and levator scapulae (LS). Careful detachment of their insertions is necessary to avoid injury of the dorsal scapular nerve (DSN). This study evaluated the surgical anatomy and safety of the DSN relative to this procedure. METHODS: The study used 12 cadavers (22 shoulders). The RM, Rm, and LS were detached from their insertions, and the DSN was dissected. Measurements were taken to evaluate the anatomy of each relative to the triple-tendon transfer procedure. Additional measurements were taken to identify "danger zones" for DSN injury, regarding detachment of RM, Rm, and LS from their respective insertions. RESULTS: Measurements of the 22 shoulders included in the study showed wide variation in anatomy. The minimum distance between the scapula and the DSN at the vertebral scapular border was 0.7 cm, suggesting that care and precision are needed to perform this technique. The region where the DSN crosses the superior border of the Rm was shown to be the greatest "danger zone" of this technique, with a mean distance to the scapula of 1.61 ± 0.53 cm CONCLUSIONS: This study provides insight into the surgical anatomy of the DSN relative to a rare but successful procedure used to treat trapezius paralysis. The results of this study can inform the surgeon regarding potential anatomic considerations when performing the triple-tendon transfer.

Radiographic restoration of native anatomy: a comparison between stemmed and stemless shoulder arthroplasty.

BACKGROUND: Shoulder arthroplasty is a reliable procedure for patients with degenerative glenohumeral disease, and reproduction of native shoulder anatomy leads to superior outcomes. The aim of this study was to compare the ability of stemmed and stemless implants to radiographically restore native glenohumeral anatomy. METHODS: Shoulder arthroplasties were performed in 79 patients, with 58 receiving a stemless implant and 21 receiving a stemmed implant. Preoperative and postoperative radiographs were assessed for humeral head height, humeral head centering, humeral head medial offset, humeral head diameter, humeral neck angle, and lateral humeral offset by 2 independent viewers. Measurements were scored and summed to identify the anatomic reconstruction index (ARI). Radiographic measurements were compared using the Student t test, and significance was set at P < .05 for all statistical analyses. Interobserver agreement of radiographic analyses was assessed using the intraclass correlation coefficient, finding excellent reliability (intraclass correlation coefficient, 0.92). RESULTS: Five of six radiographic measurements along with the calculated ARI demonstrated no differences between stemmed and stemless shoulder implants (humeral head diameter, P = .651; humeral head height, P = .813; humeral head medial offset, P = .592; lateral humeral offset, P = .311; humeral head centering, P = .414; and ARI, P = .862). Stemless implants showed improved restoration of the native humeral neck angle (0° for stemless vs. -3° for stemmed, P = .017). CONCLUSION: Radiographic restoration of anatomy is similar for stemmed and stemless shoulder arthroplasty implants.

Does Medicaid expansion improve access to care for the first-time shoulder dislocator?

BACKGROUND: The purpose of this study was to assess the effect of individual state Medicaid expansion status on access to care for shoulder instability. METHODS: Four pairs of Medicaid expanded (Louisiana, Kentucky, Iowa, and Nevada) and unexpanded (Alabama, Virginia, Wisconsin, and Utah) states in similar geographic locations were chosen for the study. Twelve practices from each state were randomly selected from the American Orthopedic Society for Sports Medicine directory, resulting in a sample size of 96 independent sports medicine offices. Each office was called twice to request an appointment for a fictitious 16-year-old first-time shoulder dislocator with either in-state Medicaid insurance or Blue Cross Blue Shield (BCBS) private insurance. RESULTS: A total of 91 physician offices in 8 states were contacted by telephone. An appointment was obtained at 36 (39.6%) offices when calling with Medicaid and at 74 (81.3%) offices when calling with BCBS (P < .001). Thirty-five (38.5%) offices were able to make appointments for both types of insurance, 39 (42.9%) for only BCBS, 1 (1.1%) for only Medicaid, and 16 (17.5%) for neither. For Medicaid patients, an appointment was booked in 13 (27.7%) clinics from Medicaid expanded states and in 23 (52.3%) clinics from unexpanded states (P = .016). CONCLUSION: For a first-time shoulder dislocator, access to care is more difficult with Medicaid insurance compared with private insurance. Within Medicaid insurance, access to care is more difficult in Medicaid expanded states compared with unexpanded states. Medicaid patients in unexpanded states are twice as likely as those in expanded states to obtain an appointment.

Optimization of Orthopedic Surgical Instrument Trays: Lean Principles to Reduce Fixed Operating Room Expenses.

BACKGROUND: Optimization of surgical instrument trays improves efficiency and reduces cost. The purpose of this study is to assess the economic impact of optimizing orthopedic instrument trays at a tertiary medical center. METHODS: Twenty-three independent orthopedic surgical instrument trays at a single academic hospital were reviewed from 2017 to 2018. Using Lean methodology, surgeons agreed upon the fewest number of instruments needed for each of the procedure trays. Instrument usage counts, cleaning times, room turnover times, tray weight, holes in tray wrapping, wet trays, and time invested to optimize each tray were tracked. Cost savings were calculated. Student's t-test was used to determine statistical significance, with P < .05 considered significant. RESULTS: The mean instrument usage before and after Lean optimization was 23.4% and 54.2% (P < .0001). By Lean methods, 433 of 792 instruments (55%) were removed from 11 unique instrument trays (102 total trays), resulting in a reduction of 3520 instruments. Total weight reduction was 574.3 pounds (22%), ranging from 2.1-16.2 pounds per tray. The number of trays with wrapping holes decreased from 13 to 1 (P < .0001). The process of examining and removing instruments took an average of 7 minutes 35 seconds per tray. The calculated total annual savings was $270,976 (20% overall cost reduction). CONCLUSION: In addition to substantial cost savings, tray optimization decreases tray weights and cleaning times without negatively impacting turnover times. Lean methodology improves efficiency in instrument tray usage, and reduces hospital cost while encouraging surgeon and staff participation through continuous process improvement. LEVEL OF EVIDENCE: Economic Quality Improvement, Level III.

Trends and Characteristics of Highly Cited Articles in Proximal Humerus Fracture Research.

As the treatment of proximal humerus fractures remains controversial in the literature, this study aims to identify highly cited articles and examine trends and characteristics. Scopus was used to identify the highest cited articles of proximal humerus fracture research. SPSS 23 was used for descriptive statistics and Pearson correlations for the relationship between citation count and density. Average citation count was 233 ± 164 with an annual citation density of 14 ± 7. Total citation count was associated with total citation density, 5-year citation count, and 5-year citation density. The Journal of Bone and Joint Surgery-American produced the most articles with 15 (30%). Thirty-five articles originated in Europe. The five most represented authors published three articles each. Finally, 13 (26%) papers appear in the American Shoulder and Elbow Surgeons Curriculum Guide. This study compiles a collection of articles investigating proximal humerus fractures for future review and demonstrates citation count to be an acceptable measure of an article's contemporary academic influence. (Journal of Surgical Orthopaedic Advances 28(3):180-188, 2019).

Predictive Accuracy of the ACS-NSQIP Surgical Risk Calculator for Pathologic Humerus Fracture Fixation.

Pathologic fractures are associated with poor outcomes. This article investigated the prevalence of underestimation of risk by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Surgical Risk Calculator (SRC) in patients with pathologic humerus fractures. Two hundred seven (207) patients were identified and analyzed using the ACS-NSQIP SRC. Predicted and actual outcomes were then compared. Average hospitalization was 6 ± 10 days. Ten patients (5%) had a mild adverse event (AE), and 15 (7%) had a serious AE. The ACS-NSQIP SRC underestimated hospitalizations (p < 0.001), but not serious AE (p = 0.601), mild AE (p = 0.948), cardiac complications (p = 0.817), pneumonia (p = 0.713), surgical site infection (p = 0.692), urinary tract infection (p = 0.286), venous thromboembolism (p = 0.554), acute renal failure (p = 0.191), discharge to acute care facility (p = 0.865), readmission (p = 1.0), reoperation (0.956) or mortality (p = 0.872). Negative outcomes were limited in this cohort, and the SRC demonstrated acceptable accuracy. Future investigation of the calculator in other orthopaedic populations is warranted. (Journal of Surgical Orthopaedic Advances 28(4):250-256, 2019).

Sternoclavicular joint palpation pain: the shoulder's Waddell sign?

BACKGROUND: Pain is a complex and subjective reality and can be magnified by nonorganic or nonanatomic sources. Multiple studies have demonstrated a correlation between psychological factors and patients' perceptions of musculoskeletal pain and disability. In addition, nonorganic findings as part of the physical examination are well and long recognized. The purpose of this study was to analyze the relationship between a shoulder examination test, palpation of the sternoclavicular joint (SCJ), and psychosocial conditions including chronic pain, depression, and anxiety. METHODS: From June until October 2016, all new patients of 2 sports/shoulder fellowship-trained surgeons at an academic practice were screened for study enrollment. After their consent was obtained, patients were given a set of 5 surveys (Pain Catastrophizing Scale; Patient-Health Questionnaire 2; Pain Self-Efficacy Questionnaire; shortened Disabilities of the Arm, Shoulder and Hand questionnaire; and Shoulder Pain and Disability Index) to complete. The physician then completed a comprehensive standardized physical examination, with the examining physician being blinded to the patient's survey responses. Palpation of the SCJ was done with the examiner's thumbs and was accompanied by the question "Does this hurt?" If a positive pain response was given, clarification as to the correct side of the pain was made. RESULTS: A total of 132 patients were enrolled and completed the surveys and physical examination. Of the patients, 26 (19.7%) reported SCJ pain with SCJ palpation. Patients with and without confirmed pain on SCJ palpation had significantly different (P < .001) mean scores for all 5 surveys. A review of the medical histories between the 2 groups identified a significantly increased prevalence of chronic pain and mental health disorders, such as anxiety and depression, in SCJ palpation-positive patients. CONCLUSIONS: Patients who confirmed pain on SCJ palpation had significantly higher scores on various psychological surveys than those who denied pain on palpation, indicating that a portion of their pain was stemming from a nonorganic source. Inclusion of SCJ palpation during a routine shoulder or upper extremity physical examination may improve selection of treatment options for patients.

Readability of Orthopaedic Patient-reported Outcome Measures: Is There a Fundamental Failure to Communicate?

BACKGROUND: Patient-reported outcome measures (PROMs) are increasingly used to quantify patients' perceptions of functional ability. The American Medical Association and NIH suggest patient materials be written at or below 6th to 8th grade reading levels, respectively, yet one recent study asserts that few PROMs comply with these recommendations, and suggests that the majority of PROMs are written at too high of a reading level for self-administered patient use. Notably, this study was limited in its use of only one readability algorithm, although there is no commonly accepted, standard readability algorithm for healthcare-related materials. Our study, using multiple readability equations and heeding equal weight to each, hopes to yield a broader, all-encompassing estimate of readability, thereby offering a more accurate assessment of the readability of orthopaedic PROMS. QUESTIONS/PURPOSES: (1) What proportion of orthopaedic-related PROMs and orthopaedic-related portions of the NIH Patient Reported Outcomes Measurement Information System (PROMIS®) are written at or below the 6th and 8th grade levels? (2) Is there a correlation between the number of questions in the PROM and reading level? (3) Using systematic edits based on guidelines from the Centers for Medicare and Medicaid Services, what proportion of PROMs achieved American Medical Association and NIH-recommended reading levels? METHODS: Eighty-six (86) independent, orthopaedic and general wellness PROMs, drawn from commonly referenced orthopaedic websites and prior studies, were chosen for analysis. Additionally, owing to their increasing use in orthopaedics, four relevant short forms, and 11 adult, physical health question banks from the PROMIS®, were included for analysis. All documents were analyzed for reading grade levels using 19 unique readability algorithms. Descriptive statistics were performed using SPSS Version 22.0. RESULTS: The majority of the independent PROMs (64 of 86; 74%) were written at or below the 6th grade level, with 81 of 86 (94%) written at or below the 8th grade level. All item banks (11 of 11) and short forms (four of four) of the PROMIS® were written below the 6th grade reading level. The median reading grade level of the 86 independent PROMs was 5.0 (interquartile range [IQR], 4.6-6.1). The PROMIS® question banks had a median reading grade level of 4.1 (IQR, 3.5-4.8); the Adult Short Forms had a median reading grade level of 4.2 (IQR, 4.2-4.3) There was no correlation appreciated between the median reading grade level and the number of questions contained in a PROM (r = -0.081; p = 0.460). For PROMs above NIH-recommended levels, following edits, all (five of five) achieved NIH reading level goals and three (three of five) achieved American Medical Association goals. Editing of these PROMs improved readability by 4.3 median grade level (before, 8.9 [IQR, 8.4-9.1], after 4.6 [IQR, 4.6-6.4], difference of medians, 4.3; p = 0.008). CONCLUSIONS: Patient literacy has great influence on healthcare outcomes, and readability is an important consideration in all patient-directed written materials. Our study found that more than 70% of PROMs commonly used in orthopaedics, and all orthopaedic-related portions of the PROMIS® are written at or below the most stringent recommendations (≤ 6th grade reading level), and more than 90% of independent PROMs and all PROMIS® materials are written at or below an 8th grade level. Additionally, the use of the Centers for Medicare and Medicaid Services guidelines for editing high reading level PROMs yields satisfactory results. CLINICAL RELEVANCE: Fears of widely incomprehensible PROMs may be unfounded. Future research to identify the most appropriate readability algorithm for use in the healthcare sector, and revalidation of PROMs after readability-improving edits is warranted.