National Trends in Orthopaedic Pain Management from 2016 to 2020.

INTRODUCTION: Effective pain management is vital in orthopaedic care, impacting postoperative recovery and patient well-being. This study aimed to discern national and regional pain prescription trends among orthopaedic surgeons through Medicare claims data, using geospatial analysis to ascertain opioid and nonopioid usage patterns across the United States. METHODS: Physician-level Medicare prescription databases from 2016 to 2020 were filtered to orthopaedic surgeons, and medications were categorized into opioids, muscle relaxants, anticonvulsants, and NSAIDs. Patient demographics were extracted from a Medicare provider demographic data set, while county-level socioeconomic metrics were obtained primarily from the American Community Survey. Geospatial analysis was conducted using Geoda software, using Moran I statistic for cluster analysis of pain medication metrics. Statistical trends were analyzed using linear regression, Mann-Whitney U test, and multivariate logistic regression, focusing on prescribing rates and hotspot/coldspot identification. RESULTS: Analysis encompassed 16,505 orthopaedic surgeons, documenting more than 396 million days of pain medication prescriptions: 57.42% NSAIDs, 28.57% opioids, 9.84% anticonvulsants, and 4.17% muscle relaxants. Annually, opioid prescriptions declined by 4.43% ( P < 0.01), while NSAIDs rose by 3.29% ( P < 0.01). Opioid prescriptions dropped by 210.73 days yearly per surgeon ( P < 0.005), whereas NSAIDs increased by 148.86 days ( P < 0.005). Opioid prescriptions were most prevalent in the West Coast and Northern Midwest regions, and NSAID prescriptions were most prevalent in the Northeast and South regions. Regression pinpointed spine as the highest and hand as the lowest predictor for pain prescriptions. DISCUSSION: On average, orthopaedic surgeons markedly decreased both the percentage of patients receiving opioids and the duration of prescription. Simultaneously, the fraction of patients receiving NSAIDs dramatically increased, without change in the average duration of prescription. Opioid hotspots were located in the West Coast, Utah, Colorado, Arizona, Idaho, the Northern Midwest, Vermont, New Hampshire, and Maine. Future directions could include similar examinations using non-Medicare databases.

Recommendations for Orthopedic Surgeons during the COVID-19 Pandemic.

BACKGROUND: Toward the end of 2019, the coronavirus disease-2019 (COVID-19) pandemic began to create turmoil for global health organizations. The illness, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), spreads by droplets and fomites and can rapidly lead to life-threatening lung disease, especially for the old and those with health co-morbidities. Treating orthopedic patients, who presented with COVID-19 while avoiding nosocomial transmission, became of paramount importance. OBJECTIVES: To present relevant methods for pandemic control and hospital accommodation with emphasis on orthopedic surgery. METHODS: We searched search PubMed and Google Scholar electronic databases using the following keywords: COVID-19, SARS-CoV-2, screening tools, personal protective equipment, and surgery triage. RESULTS: We included 25 records in our analysis. The recommendations from these records were divided into the following categories: COVID-19 disease, managing orthopedic surgery in the COVID-19 era, general institution precautions, triage of orthopedic surgeries, preoperative assessment, surgical room setting, personal protection equipment, anesthesia, orthopedic surgery technical precautions, and department stay and rehabilitation. CONCLUSIONS: Special accommodations tailored for each medical facility, based on disease burden and available resources can improve patient and staff safety and reduce elective surgery cancellations. This article will assist orthopedic surgeons during the COVID-19 medical crisis, and possibly for future pandemics.

Comparative study between admission, orthopaedic surgery, and economic trends during Covid-19 and non-Covid-19 pandemic in an Italian tertiary hospital: a retrospective review.

BACKGROUND: The COVID-19 pandemic represents one of the most massive health emergencies in the last century and has caused millions of deaths worldwide and a massive economic and social burden. The aim of this study was to evaluate how the COVID-19 pandemic-during the Italian lockdown period between 8 March and 4 May 2020-influenced orthopaedic access for traumatic events to the Emergency Department (ER). METHODS: A retrospective review of the admission to the emergency room and the discharge of the trauma patients' records was performed during the period between 8 March and 4 May 2020 (block in Italy), compared to the same period of the previous year (2019). Patients accesses, admissions, days of hospitalisation, frequency, fracture site, number and type of surgery, the time between admission and surgery, days of hospitalisation, and treatment cost according to the diagnosis-related group were collected. Chi-Square and ANOVA test were used to compare the groups. RESULTS: No significant statistical difference was found for the number of emergency room visits and orthopaedic hospitalisations (p < 0.53) between the year 2019 (9.5%) and 2020 (10.81%). The total number of surgeries in 2019 was 119, while in 2020, this was just 48 (p < 0.48). A significant decrease in the mean cost of orthopaedic hospitalisations was detected in 2020 compared (261.431 euros, equal to - 52.07%) relative to the same period in 2019 (p = 0.005). Although all the surgical performances have suffered a major decline, the most frequent surgery in 2020 was intramedullary femoral nailing. CONCLUSION: We detected a decrease in traumatic occasions during the lockdown period, with a decrease in fractures in each district and a consequent decrease in the diagnosis-related group (DRG).

Orthopedic and neurosurgical care of X-linked hypophosphatemia.

X-linked hypophosphatemia (XLH) is due to mutations in the PHEX gene leading to unregulated production of FGF23 and uncontrollable hypophosphatemia. XLH is characterized in children by rickets, short stature, waddling gait, and leg bowing of variable morphology and severity. Phosphate supplements and oral vitamin D analogs partially or, in some cases, fully restore the limb straightness. XLH patients may also be affected by premature, complete, or partial ossification of sutures between cranial bone, which could eventually result in cranial dysmorphia, decreased intracranial volume, and secondary abnormally high intracranial pressure with a cerebral compression. Our goal is to address the criteria and the management of the skeletal complications associated with XLH, mainly orthopedic and neurosurgical care, and reflect on decision-making and follow-up complexities.

The effect of care transition pathway implementation on patients undergoing joint replacement during the COVID-19 pandemic: a quasi-experimental study from a tertiary care hospital orthopedic department in Beijing, China.

BACKGROUND: The coronavirus disease (COVID-19) pandemic has had a massive impact on individuals globally. The Chinese government has formulated effective response measures, and medical personnel have been actively responding to challenges associated with the epidemic prevention and control strategies. This study aimed to evaluate the effect of the implementation of a care transition pathway on patients that underwent joint replacement during the COVID-19 pandemic. METHODS: A quasi-experimental study was designed to evaluate the effect of implementing a care transition pathway for patients who underwent joint replacement during the COVID-19 pandemic in the orthopedic department of a tertiary care hospital in Beijing, China. Using a convenient sampling method, a total of 96 patients were selected. Of these, 51 patients who had undergone joint replacement in 2019 and received treatment via the routine nursing path were included in the control group. The remaining 45 patients who underwent joint replacement during the COVID-19 epidemic in 2020 and received therapy via the care transition pathway due to the implementation of epidemic prevention and control measures were included in the observation group. The quality of care transition was assessed by the Care Transition Measure (CTM), and patients were followed up 1 week after discharge. RESULTS: The observation group was determined to have better general self-care preparation, written planning materials, doctor-patient communication, health monitoring, and quality of care transition than the control group. CONCLUSIONS: A care transition pathway was developed to provide patients with care while transitioning through periods of treatment. It improved the patient perceptions of nursing quality. The COVID-19 pandemic is a huge challenge for health professionals, but we have the ability to improve features of workflows to provide the best possible patient care.

Postoperative delirium mediates 180-day mortality in orthopaedic trauma patients.

BACKGROUND: Frailty has been associated with increased incidence of postoperative delirium and mortality. We hypothesised that postoperative delirium mediates a clinically significant (≥1%) percentage of the effect of frailty on mortality in older orthopaedic trauma patients. METHODS: This was a single-centre, retrospective observational study including 558 adults 65 yr and older, who presented with an extremity fracture requiring hospitalisation without initial ICU admission. We used causal statistical inference methods to estimate the relationships between frailty, postoperative delirium, and mortality. RESULTS: In the cohort, 180-day mortality rate was 6.5% (36/558). Frail and prefrail patients comprised 23% and 39%, respectively, of the study cohort. Frailty was associated with increased 180 day mortality from 1.4% to 12.2% (11% difference; 95% confidence interval [CI], 8.4-13.6), which translated statistically into an 88.7% (79.9-94.3%) direct effect and an 11.3% (5.7-20.1%) postoperative delirium mediated effect. Prefrailty was also associated with increased 180 day mortality from 1.4% to 4.4% (2.9% difference; 2.4-3.4), which was translated into a 92.5% (83.8-99.9%) direct effect and a 7.5% (0.1-16.2%) postoperative delirium mediated effect. CONCLUSIONS: Frailty is associated with increased postoperative mortality, and delirium might mediate a clinically significant, but small percentage of this effect. Studies should assess whether, in patients with frailty, attempts to mitigate delirium might decrease postoperative mortality.

Intraoperative consultation of vascular surgeons is increasing at a major American trauma center.

OBJECTIVE: Vascular surgeons are often called to aid other surgical specialties for complex exposure, hemorrhage control, or revascularization. The evolving role of the vascular surgeon in the management of intraoperative emergencies involving trauma patients remains undefined. The primary aims of this study included determining the prevalence of intraoperative vascular consultation in trauma, describing how these interactions have changed over time, and characterizing the outcomes achieved by vascular surgeons in these settings. We hypothesized that growing endovascular capabilities of vascular surgeons have resulted in an increased involvement of vascular surgery faculty in the management of the trauma patient over time. METHODS: A retrospective review of all operative cases at a single level I trauma center where a vascular surgeon was involved, but not listed as the primary surgeon, between 2002 and 2017 was performed. Cases were abstracted using Horizon Surgical Manager, a documentation system used in our operating room to track staff present, the type of case, and use. All elective cases were excluded. RESULTS: Of the 256 patients initially identified, 22 were excluded owing to the elective or joint nature of the procedure, leaving 234 emergent operative vascular consultations. Over the 15-year study period, a 529% increase in the number of vascular surgery consultations was seen, with 65% (n = 152) being intraoperative consultations requiring an immediate response. Trauma surgery (n = 103 [44%]) and orthopedic surgery (n = 94 [40%]) were the most common consulting specialties, with both demonstrating a trend of increasing consultations over time (general surgery, 1400%; orthopedic surgery, 220%). Indications for consultation were extremity malperfusion, hemorrhage, and concern for arterial injury. The average operative time for the vascular component of the procedures was 2.4 hours. Of patients presenting with ischemia, revascularization was successful in 94% (n = 116). Hemorrhage was controlled in 99% (n = 122). In-hospital mortality was relatively low at 7% (n = 17). Overall, despite the increase in intraoperative vascular consultations over time, a concomitant increase in the proportion of procedures done using endovascular techniques was not seen. CONCLUSIONS: Vascular surgeons are essential team members at a level I trauma center. Vascular consultation in this setting is often unplanned and often requires immediate intervention. The number of intraoperative vascular consultations is increasing and cannot be attributed solely to an increase in endovascular hemorrhage control, and instead may reflect the declining experience of trauma surgeons with vascular trauma. When consulted, vascular surgeons are effective in quickly gaining control of the situation to provide exposure, hemorrhage control, or revascularization.

COVID-19 among patients with orthopedic surgery: our experience from the Middle East.

BACKGROUND: We report our experiences with COVID-19 in one of the largest referral orthopedic centers in the Middle East and aimed to describe the epidemiology and clinical characteristics of these patients. METHODS: During February 20 and April 20, 2020, patients who underwent orthopedic surgery and healthcare staff who were in contact with these patients were screened for COVID-19. To identify patients who were in the incubation period of COVID-19 during their hospital stay, all patients were tested again for COVID-19 4 weeks after discharge. RESULTS: Overall, 1244 patients underwent orthopedic surgery (1123 emergency and 121 elective) during the study period. Overall, 17 patients were diagnosed with COVID-19 during hospital admission and seven after discharge. Among the total 24 patients with COVID-19, 15 were (62.5%) males with a mean (SD) age of 47.0±1.6 years old. Emergency surgeries were performed in 20 (83.3%) patients, and elective surgery was done in the remaining 4 patients which included one case of posterior spinal fusion, spondylolisthesis, acromioclavicular joint dislocation, and one case of leg necrosis. A considerable number of infections occurred in patients with intertrochanteric fractures (n=7, 29.2%), followed by pelvic fractures (n=2, 8.3%), humerus fractures (n=2, 8.3%), and tibial plateau fractures (n=2, 8.3%). Fever (n=11, 45.8%) and cough (n=10, 37.5%) were the most common symptoms among patients. Laboratory examinations showed leukopenia in 2 patients (8.3%) and lymphopenia in 4 (16.7%) patients. One patient with a history of cancer died 2 weeks after discharge due to myocardial infarction. Among hospital staff, 26 individuals contracted COVID-19 during the study period, which included 13 (50%) males. Physicians were the most commonly infected group (n = 11), followed by operation room technicians (n = 5), nurses (n = 4), and paramedics (n = 4). CONCLUSIONS: Patients who undergo surgical treatment for orthopedic problems, particularly lower limb fractures with limited ambulation, are at a higher risk of acquiring COVID-19 infections, although they may not be at higher risks for death compared to the general population. Orthopedic surgeons in particular and other hospital staff who are in close contact with these patients must be adequately trained and given appropriate personal protective equipment during the COVID-19 outbreak.

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.

How Long Will It Take to Reach Gender Parity in Orthopaedic Surgery in the United States? An Analysis of the National Provider Identifier Registry.

BACKGROUND: Although previous studies have evaluated how the proportion of women in orthopaedic surgery has changed over time, these analyses have been limited by small sample sizes, have primarily used data on residents, and have not included information on growth across subspecialties and geographic regions. QUESTION/PURPOSE: We used the National Provider Identifier registry to ask: How have the (1) overall, (2) regional, and (3) subspecialty percentages of women among all currently practicing orthopaedic providers changed over time in the United States? METHODS: The National Provider Identifier Registry of the Centers for Medicare and Medicaid Services (CMS) was queried for all active providers with taxonomy codes pertaining to orthopaedic subspecialties as of April 2020. Women orthopaedic surgeons were identified among all physicians with subspecialty taxonomy codes. As all providers are required to provide a gender when applying for an NPI, all providers with queried taxonomy codes additionally had gender classification. Our final cohort consisted of 31,296 practicing orthopaedic surgeons, of whom 8% (2363 of 31,296) were women. A total of 11,714 (37%) surgeons possessed taxonomy codes corresponding with a specific orthopaedic subspecialty. A univariate linear regression analysis was used to analyze trends in the annual proportions of women who are active orthopaedic surgeons based on NPI enumeration dates. Specifically, annual proportions were defined using cross-sections of the NPI registry on December 31 of each year. Linear regression was similarly used to evaluate changes in the annual proportion of women orthopaedic surgeons across United States Census regions and divisions, as well as orthopaedic subspecialties. The national growth rate was then projected forward to determine the year at which the representation of women orthopaedic surgeons would achieve parity with the proportion of all women physicians (36.3% or 340,018 of 936,254, as determined by the 2019 American Medical Association Physician Masterfile) and the proportion of all women in the United States (50.8% or 166,650,550 of 328,239,523 as determined by 2019 American Community Survey from the United States Census Bureau). Gender parity projections along with corresponding 95% confidence intervals were calculated using the Holt-Winters forecasting algorithm. The proportions of women physicians and women in the United States were assumed to remain fixed at 2019 values of 36.3% and 50.8%, respectively. RESULTS: There was a national increase in the proportion of women orthopaedic surgeons between 2010 and 2019 (r2 = 0.98; p < 0.001) at a compound annual growth rate of 2%. Specifically, the national proportion of orthopaedic surgeons who were women increased from 6% (1670 of 26,186) to 8% (2350 of 30,647). Assuming constant growth at this rate following 2019, the time to achieve gender parity with the overall medical profession (that is, to achieve 36.3% women in orthopaedic surgery) is projected to be 217 years, or by the year 2236. Likewise, the time to achieve gender parity with the overall US population (which is 50.8% women) is projected to be 326 years, or by the year 2354. During our study period, there were increases in the proportion of women orthopaedic surgeons across US Census regions. The lowest growth was in the West (17%) and the South (19%). Similar growth was demonstrated across census divisions. In each orthopaedic subspecialty, we found increases in the proportion of women surgeons throughout the study period. Adult reconstruction (0%) and spine surgery (1%) had the lowest growth. CONCLUSION: We calculate that at the current rate of change, it will take more than 200 years for orthopaedic surgery to achieve gender parity with the overall medical profession. Although some regions and subspecialties have grown at comparably higher rates, collectively, there has been minimal growth across all domains. CLINICAL RELEVANCE: Given this meager growth, we believe that substantive changes must be made across all levels of orthopaedic education and leadership to steepen the current curve. These include mandating that all medical school curricula include dedicated exposure to orthopaedic surgery to increase the number of women coming through the orthopaedic pipeline. Additionally, we believe the Accreditation Council for Graduate Medical Education and individual programs should require specific benchmarks for the proportion of orthopaedic faculty and fellowship program directors, as well as for the proportion of incoming trainees, who are women. Furthermore, we believe there should be a national effort led by American Academy of Orthopaedic Surgeons and orthopaedic subspecialty societies to foster the academic development of women in orthopaedic surgery while recruiting more women into leadership positions. Future analyses should evaluate the efficacy of diversity efforts among other surgical specialties that have achieved or made greater strides toward gender parity, as well as how these programs can be implemented into orthopaedic surgery.

Factors Predicting Chronic Opioid Use after Orthopedic Surgical Procedures.

BACKGROUND: Opioid abuse has been an increasing problem since the 1990s. With over 47,000 opioid related deaths recorded in 2017 alone, concerns have been raised regarding the dangers of introducing opioids perioperatively to patients undergoing major surgeries. OBJECTIVES: The present study proposes to examine the frequency, amount, and trends in post-operative opioid consumption in patients undergoing orthopedic surgical procedures. STUDY DESIGN: This was a randomized, retrospective questionnaire-based study. SETTING: Patients who underwent any type of orthopedic surgery at the University of Pennsylvania Presbyterian Hospital from 1/1/2018 to 3/12/2019 were randomly selected and called during the summer of 2019. METHODS: In this retrospective questionnaire-based study, 828 patients were called by telephone in the summer of 2019. These patients were asked a variety of questions involving opioid consumption behavior post-surgery. The study ended after receiving responses from 200 patients. RESULTS: Nineteen (9.5%) patients reported positively for experiencing euphoria while taking opioids post-surgery. Of the 200 patients contacted, 6 patients (3%) reported switching to marijuana instead of opioids. Thirty-eight (19%) patients preferred to take no opioids at all post-surgery, and one patient was found to have given their prescription to a family member or friend. Twenty-one patients (10.5%) were found to have been taking opioids for non-severe pain. Blacks and whites were the most common racial demographics, making up 84 and 109 of the totals, respectively. The odds ratios for all of the predictors showed that the relative risk for opioid misuse was higher for black patients than white patients (OR = 3.034). There was no relationship between the intra- and post-operative opioid administration and long-term opioid misuse. LIMITATIONS: Patients are self-selected and had the option to opt out of the study when contacted. Some patients may not have been available to answer the phone when our study was being conducted. This study was only conducted for orthopedic patients and for patients who received surgery at the University of Pennsylvania Presbyterian Hospital, thus affecting the demographics for our research. CONCLUSIONS: Prescription opioid misuse is more common among the black population. The total opioid consumption is frequently lower than the quantity prescribed. Patients frequently use opioids even though they feel that pain is insufficient to deserve such an intervention. Euphoria is experienced by a significant number of patients taking prescription opioids Often patients do not take any opioids, although they had prescriptions.

Association Between Antifibrinolytic Therapy and Perioperative Outcomes in Patients With Coronary Artery Stents Undergoing Noncardiac Surgery.

BACKGROUND: Patients with existing coronary artery stents are at an increased risk for major adverse cardiac events (MACEs) when undergoing noncardiac surgery (NCS). Although the use of antifibrinolytic (AF) therapy in NCS has significantly increased in the past decade, the relationship between perioperative AF use and its association with MACEs among patients with existing coronary artery stents has yet to be assessed. In this study, we aim to evaluate the association of MACEs in patients with existing coronary artery stents who receive perioperative AF therapy during orthopedic surgery. METHODS: A single-center retrospective cohort study was conducted in adult patients with existing coronary artery stents who underwent orthopedic surgery from 2008 to 2018. Two cohorts were established: patients with existing coronary artery stents who did not receive perioperative AF and patients with coronary artery stents who received perioperative AF. Associations between AF use and the primary outcome of MACEs within 30 days postoperatively and the secondary outcomes of thrombotic complications, excessive surgical bleeding, and intensive care unit (ICU) admissions were analyzed using logistic regression models. Inverse probability of treatment weighting was used to control for confounding. Secondary analyses examining the association between coronary stent type/timing and the outcomes of interest were performed using unadjusted logistic regression models. RESULTS: A total of 473 patients met study criteria, including 294 who did not receive AF and 179 patients who received AF. MACEs occurred in 15 (5.1%) patients who did not receive AF and 1 (0.6%) who received AF (P = .007). In weighted analyses, no significant difference was found in patients who received AF with regard to MACEs (odds ratio [OR] = 0.13, 95% confidence interval [CI], 0.01-1.74, P = .12), thrombotic complications (OR = 1.19, 95% CI, 0.53-2.68, P = .68), or excessive surgical bleeding (OR = 0.13, 95% CI, 0.01-2.23, P = .16) compared to patients who did not receive AF. CONCLUSIONS: The results of this study are inconclusive whether an association exists between perioperative AF use in patients with coronary artery stents and the outcome of MACEs compared to patients who did not receive perioperative AF therapy. The authors acknowledge that the imprecise CI hinders the ability to definitively determine whether an association exists in the study population. Further large prospective studies, powered to detect differences in MACEs, are needed to assess the safety of perioperative AF in patients with existing coronary artery stents and to clarify the mechanism of perioperative MACEs in this high-risk population.

Recent Trends in Medicare Utilization and Reimbursement for Orthopaedic Procedures Performed at Ambulatory Surgery Centers.

BACKGROUND: As part of a market-driven response to the increasing costs of hospital-based surgical care, an increasing volume of orthopaedic procedures are being performed in ambulatory surgery centers (ASCs). The purpose of the present study was to identify recent trends in orthopaedic ASC procedure volume, utilization, and reimbursements in the Medicare system between 2012 and 2017. METHODS: This cross-sectional, national study tracked annual Medicare claims and payments and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization rates, and reimbursement rates, and to identify demographic predictors of ASC utilization. RESULTS: A total of 1,914,905 orthopaedic procedures were performed at ASCs in the Medicare population between 2012 and 2017, with an 8.8% increase in annual procedure volume and a 10.5% increase in average reimbursements per case. ASC orthopaedic procedure utilization, including utilization across all subspecialties, is strongly associated with metropolitan areas compared with rural areas. In addition, orthopaedic procedure utilization, including for sports and hand procedures, was found to be significantly higher in wealthier counties (measured by average household income) and in counties located in the South. CONCLUSIONS: This study demonstrated increasing orthopaedic ASC procedure volume in recent years, driven by increases in hand procedure volume. Medicare reimbursements per case have steadily risen and outpaced the rate of inflation over the study period. However, as orthopaedic practice overhead continues to increase, other Medicare expenditures such as hospital payments and operational and implant costs also must be evaluated. These findings may provide a source of information that can be used by orthopaedic surgeons, policy makers, investors, and other stakeholders to make informed decisions regarding the costs and benefits of the use of ASCs for orthopaedic procedures.

The orthopaedic experience of COVID-19: A literature review.

This literature review aims to provide an account of the changes to orthopaedics in the era of COVID-19. Herein, the authors explored the use of telemedicine in orthopaedics as well as changes in surgical protocols, screening methods, work priorities and orthopaedic education. There was increased utilisation of telemedicine in orthopaedic training and outpatient cases as a means to provide continuity in education and care. The need to implement social distancing measures, coupled with the reduced availability of staff, has dictated that the practice of orthopaedics shifts to focus on acute care whilst redistributing resources to front-line specialities. This was facilitated by the cancellation of electives and the reduction of outpatient clinics. Thus, it is demonstrated that major changes have been implemented in many aspects of orthopaedic practice in order to address the challenges of the COVID-19 pandemic.