Creation and Validation of a Shorthand Magnetic Resonance Imaging Bone Age Assessment Tool of the Knee as an Alternative Skeletal Maturity Assessment.

BACKGROUND: In managing pediatric knee conditions, an accurate bone age assessment is often critical for diagnostic, prognostic, and treatment purposes. Historically, the Greulich and Pyle atlas (hand atlas) has been the gold standard bone age assessment tool. In 2013, a shorthand bone age assessment tool based on this atlas (hand shorthand) was devised as a simpler and more efficient alternative. Recently, a knee magnetic resonance imaging (MRI) bone age atlas (MRI atlas) was created to circumvent the need for a left-hand radiograph. PURPOSE: To create a shorthand version of the knee MRI atlas. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A shorthand bone age assessment method was created utilizing the previously published MRI atlas, which utilizes several criteria that are visualized across a series of images. The MRI shorthand draws on characteristic criteria for each age that are best observed on a single MRI scan. For validation, we performed a retrospective assessment of skeletally immature patients. One reader performed the bone age assessment using the MRI atlas and the MRI shorthand on 200 patients. Then, 4 readers performed the bone age assessment with the hand atlas, hand shorthand, MRI atlas, and MRI shorthand on a subset of 22 patients in a blinded fashion. All 22 patients had a knee MRI scan and a left-hand radiograph within 4 weeks of each other. Interobserver and intraobserver reliability, as well as variability among observers, were evaluated. RESULTS: A total of 200 patients with a mean age of 13.5 years (range, 9.08-17.98 years) were included in this study. Also, 22 patients with a mean age of 13.3 years (range, 9.0-15.6 years) had a knee MRI scan and a left-hand radiograph within 4 weeks. The intraobserver and interobserver reliability of all 4 assessment tools were acceptable (intraclass correlation coefficient [ICC] ≥ 0.8; P < .001). When comparing the MRI shorthand with the MRI atlas, there was excellent agreement (ICC = 0.989), whereas the hand shorthand compared with the hand atlas had good agreement (ICC = 0.765). The MRI shorthand also had perfect agreement in 50% of readings among all 4 readers, and 95% of readings had agreement within 1 year, whereas the hand shorthand had perfect agreement in 32% of readings and 77% agreement within 1 year. CONCLUSION: The MRI shorthand is a simple and efficient means of assessing the skeletal maturity of adolescent patients with a knee MRI scan. This bone age assessment technique had interobserver and intraobserver reliability equivalent to or better than the standard method of utilizing a left-hand radiograph.

Electric Scooter Orthopaedic Injury Demographics at an Urban Level I Trauma Center.

OBJECTIVES: This study highlights demographics and orthopaedic injuries of electric scooter-related trauma that presented to our institution over a 27-month period. DESIGN: Retrospective review. SETTING: Urban Level 1 trauma center. PATIENTS: Patients presenting to the emergency department, trauma bay, or outpatient clinic after electric scooter injury were identified from November 2017 through January 2020 using ICD-10 diagnosis codes. MAIN OUTCOMES: Patient charts were reviewed for demographics, injury characteristics, imaging, treatment, perioperative data, and Injury Severity Scores. RESULTS: Four hundred eighty-five patients presented during the study period. Of these, 44% had orthopaedic injuries, including 30% with pelvis or extremity fractures. There were 21 (10%) polytraumatized patients in the orthopaedic cohort. The age ranged from 16 to 79 years (average 36 years), with 58% men, and 18% were visitors from out of town. Of 49 patients requiring orthopaedic surgery, 8 underwent surgery on an urgent basis. The average Injury Severity Score for orthopaedic patients was 8.4 with a median of 5.0 for nonoperative injuries versus a significantly higher median of 16.0 for operative injuries. Twenty-nine percent of patients were intoxicated and only 2% wore a helmet. CONCLUSIONS: Electric scooter injuries are increasing, and many patients sustain high-energy injuries. As electric scooter use continues to increase, the prevalence of orthopaedic injuries is also likely to rise. Further studies are needed to fully understand the impact scooter-related injuries have on individual patients and the health care system. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Obesity is Associated with an Increased Prevalence of Glenohumeral Osteoarthritis and Arthroplasty: A Cohort Study.

The relationship between obesity and glenohumeral osteoarthritis is relatively understudied. The purpose of this study was to better define this relationship by age- and gender-matching 596,874 patients across six body mass index (BMI) cohorts and determining the prevalence of glenohumeral osteoarthritis and the standardized rate of glenohumeral arthroplasty in each cohort. Individuals with a BMI over 24 were found to be at increased odds for developing glenohumeral osteoarthritis, compared to the normal BMI cohort, and individuals with a BMI over 30 were additionally found to be at increased odds for undergoing glenohumeral arthroplasty.

Use and Cost of Reverse Shoulder Arthroplasty Versus Hemiarthroplasty for Acute Proximal Humerus Fractures.

Although reverse total shoulder arthroplasty (RTSA) may outperform hemiarthroplasty (HSA) for acute proximal humerus fractures (PHF), both the RTSA implant and the procedure are more expensive. The goal of this study was to compare the use and longitudinal cost of care for RTSA vs HSA for the treatment of PHF. Patients were selected from a private payer database with a surgical date between 2010 and 2015. The International Classification of Diseases, 9th Revision, Clinical Modification(ICD-9-CM), codes were used to identify patients who underwent RTSA and HSA for PHF. The 1-year cost follow-up was guaranteed. During the study period, a total of 1038 patients underwent RTSA and 1046 patients underwent HSA for the treatment of PHF. A total of 601 patients who underwent RTSA and 431 patients who underwent HSA with at least 1 year of follow-up were matched by age and sex. The average Charlson Comorbidity Index for the RTSA and HSA groups was 4, indicating similar health status. From 2010 to 2015, the use of RTSA increased linearly (R2=0.986), whereas the use of HSA decreased linearly (R2=0.796). The average index admission cost was higher for RTSA than for HSA ($15,263 vs $14,356, respectively; mean difference [MD], $907; 95% confidence interval [CI], $58-$1760; P=.04). At 1 year postoperatively, however, no statistically significant difference was noted in cost (P=.535). The 1-year physical and occupational therapy cost per patient was higher after HSA than after RTSA (MD, $723; CI, $718-$728; P<.001), but no difference was noted in discharge disposition or 1-year revision or readmission rates. The results of this study suggest that despite the higher initial cost of RTSA, the total cost of care in the year after RTSA and HSA is similar. Therefore, RTSA should be considered in the appropriate clinical setting. [Orthopedics. 2020;43(2):119-125.].

Assessing the Effectiveness of Evidence-Based Medicine in Practice: A Case Study of First-Time Anterior Shoulder Dislocations.

BACKGROUND: The dissemination of evidence-based information into medical practice is essential to provide patients with optimal care and realize society's substantial investments in medical research. Effective information delivery and treatment utilization may lead to improvements in patient outcome, reductions in cost, and an overall lower burden on the health-care system. This study examines the dissemination of medical evidence following a first-time anterior shoulder dislocation (FTASD) and assesses the impact of potential dissemination strategies. METHODS: The state of evidence dissemination into clinical practice for FTASD was evaluated with use of the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. The treatment pathway for patients with FTASDs was mapped and evaluated using data that were collected through an orthopaedic shoulder-specialist survey and with review of a claims database. RESULTS: A total of 1,755 patients with an FTASD were identified through a national claims database; 50% of patients followed up with a care provider within 30 days after an emergency department (ED) or urgent care visit. Based on shoulder-specialist survey data, physician estimates of the risk of redislocation within a 2-year window aligned with medical evidence 59% of the time. Only 29% of patients obtained information for FTASD that aligns with high-level medical evidence. CONCLUSIONS: There are gaps and deficiencies in the dissemination and application of evidence in the treatment of FTASDs. Specifically, patients have limited exposure to health-care encounters where appropriate information related to low rates of follow-up following ED or urgent care visits may be communicated. Evaluating the current state of practice and identifying areas of improvement for the dissemination of evidence regarding FTASDs can be achieved through application of the RE-AIM framework. Greater consideration and resourcing of dissemination and implementation strategies may improve the dissemination and the impact of existing medical evidence.

The American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator Has a Role in Predicting Discharge to Post-Acute Care in Total Joint Arthroplasty.

BACKGROUND: Patient demand and increasing cost awareness have led to the creation of surgical risk calculators that attempt to predict the likelihood of adverse events and to facilitate risk mitigation. The American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator is an online tool available for a wide variety of surgical procedures, and has not yet been fully evaluated in total joint arthroplasty. METHODS: A single-center, retrospective review was performed on 909 patients receiving a unilateral primary total knee (496) or hip (413) arthroplasty between January 2012 and December 2014. Patient characteristics were entered into the risk calculator, and predicted outcomes were compared with observed results. Discrimination was evaluated using the receiver-operator area under the curve (AUC) for 90-day readmission, return to operating room (OR), discharge to skilled nursing facility (SNF)/rehab, deep venous thrombosis (DVT), and periprosthetic joint infection (PJI). RESULTS: The risk calculator demonstrated adequate performance in predicting discharge to SNF/rehab (AUC 0.72). Discrimination was relatively limited for DVT (AUC 0.70, P = .2), 90-day readmission (AUC 0.63), PJI (AUC 0.67), and return to OR (AUC 0.59). Risk score differences between those who did and did not experience discharge to SNF/rehab, 90-day readmission, and PJI reached significance (P < .01). Predicted length of stay performed adequately, only overestimating by 0.2 days on average (rho = 0.25, P < .001). CONCLUSION: The American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator has fair utility in predicting discharge to SNF/rehab, but limited usefulness for 90-day readmission, return to OR, DVT, and PJI. Although length of stay predictions are similar to actual outcomes, statistical correlation remains relatively weak.

Characterizing Patient Preferences Surrounding Total Knee Arthroplasty.

BACKGROUND: Episode-based bundled payments for total knee arthroplasty emphasize cost-effective patient-centered care. Understanding patients' perceptions of components of the total knee arthroplasty care episode is critical to achieving this care. This study investigated patient preferences for components of the total knee arthroplasty care episode. METHODS: Best-worst scaling was used to analyze patient preferences for components of the total knee arthroplasty care episode. Participants were selected from patients presenting to 2 orthopaedic clinics with chronic knee pain. They were presented with descriptions of 17 attributes before completing a best-worst scaling exercise. Attribute importance was determined using hierarchical Bayesian estimation. Latent class analysis was used to evaluate varying preference profiles. RESULTS: One hundred and seventy-four patients completed the survey, and 117 patients (67%) were female. The mean age was 62.71 years. Participants placed the highest value on surgeon factors, including level of experience, satisfaction rating, and complication rates. Latent class analysis provided a 4-segment model of the population. CONCLUSIONS: This study demonstrated differences in patient preferences for the components of a total knee arthroplasty care episode and characterized distinct preference profiles among patient subsets. Stakeholders can use this information to focus efforts and policy on high-value components and to potentially create customized bundles guided by preference profiles. CLINICAL RELEVANCE: This study is clinically relevant because the patient preferences identified here may help providers to design customized bundles for total knee arthroplasty care.

Trends in Opioid Utilization Before and After Total Knee Arthroplasty.

BACKGROUND: Opioids are a mainstay in perioperative pain management among patients undergoing total knee arthroplasty (TKA). However, patterns in opioid use before and after TKA have not been well-studied. The objectives of this study are to characterize prescribing trends preoperatively and postoperatively and identify risk factors for chronic postoperative opioid use. METHODS: A review of the prescription-tracking database of a large private payer from 2007 to 2013 was performed using International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes. Chronic opioid use was defined as opioid prescriptions over 6 contiguous months postoperatively. RESULTS: We identified 66,950 patients who underwent TKA with minimum 2-year follow-up and medication codes. Of those taking opioids preoperatively (n = 36,668), 34.8% became chronic users postoperatively compared to only 5.0% of the opioid-naïve cohort (n = 30,282). Major risk factors for chronic postoperative opioid use included preoperative opioid use (relative risk [RR] 3.75, 95% confidence interval [CI] 3.59-3.93), female gender (RR 1.23, 95% CI 1.20-1.25), and younger age (≤44 vs ≥60: RR 1.41, 95% CI 1.32-1.49; 45-59 vs ≥60: RR 1.42, 95% CI 1.40-1.46). From 2007 to 2013, there was a significant linear increase in opioid use preoperatively (odds ratio [OR] 1.04, 95% CI 1.03-1.05, P < .001) and postoperatively (OR 1.20, 95% CI 1.18-1.21, P < .001), but chronic postoperative opioid use increased only marginally (OR 1.01, 95% CI 1.00-1.02, P = .021). CONCLUSION: The greatest risk factors for chronic postoperative opioid use were preoperative use, younger age, female gender, greater length of stay, and worse health status. Although the use of opioids continues to grow significantly preoperatively and postoperatively, chronic opioid use post-TKA has remained clinically unchanged.

Short and Long-Term Postoperative Complications Following Total Joint Arthroplasty in Patients With Human Immunodeficiency Virus, Hepatitis B, or Hepatitis C.

INTRODUCTION: Due to advancement in treatment against human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV), the prevalence of this patient population electing to undergo total joint arthroplasty (TJA) is increasing. Current literature is scarce and conflicting especially when evaluating long-term surgical complications. The purpose of this study is to assess the postoperative medical and surgical complications following TJA in these patient populations. METHODS: Using a nationwide database between 2005 and 2012, 4 cohorts were created: patients with HIV, HCV, HBV, and HIV and HBV or HCV who underwent TJA. Cohorts were matched to a control group by age, gender, and Charlson Comorbidity Index. Thirty-day and 90-day medical complications and 90-day and 2-year surgical complications were evaluated using odds ratios with 95% confidence intervals. RESULTS: Following TJA, patients with HCV or HBV had increased risk of pneumonia, sepsis, joint infection, and revision surgery at 90 days and 2 years. Patients with HIV did not have increased risk of infection at 90 days and 2 years but did have increased risk of revision at 90 days (odds ratio 3.21, 95% confidence interval 1.31-7.84) following total hip arthroplasty. CONCLUSIONS: Patients with HIV, HBV, or HCV have an overall increased risk of postoperative medical and surgical complications following TJA. Patients with HBV or HCV are at risk of more complications than patients with HIV especially for infection within 90 days after TJA. Patients with HIV are at risk of mechanical complications but do not appear to be at significant risk for infection following total hip arthroplasty.

An Abbreviated Impulsiveness Scale (ABIS) Constructed through Confirmatory Factor Analysis of the BIS-11.

Impulsiveness is a personality trait that reflects an urge to act spontaneously, without thinking or planning ahead for the consequences of your actions. High impulsiveness is characteristic of a variety of problematic behaviors including attention deficit disorder, hyperactivity, excessive gambling, risk-taking, drug use, and alcoholism. Researchers studying attention and self-control often assess impulsiveness using personality questionnaires, notably the common Barratt Impulsiveness Scale version 11 (BIS-11; last revised in 1995). Advances in techniques for producing personality questionnaires over the last 20 years prompted us to revise and improve the BIS-11. We sought to make the revised scale shorter - so that it would be quicker to administer - and better matched to current behaviors. We analyzed responses from 1549 adults who took the BIS-11 questionnaire. Using a statistical technique called factor analysis, we eliminated 17 questions that did a poor job of measuring the three major types of impulsiveness identified by the scale: inattention, spontaneous action, and lack of planning. We constructed our ABbreviated Impulsiveness Scale (ABIS) using the remaining 13 questions. We showed that the ABIS performed well when administered to additional groups of 657 and 285 adults. Finally, we showed expected relationships between the ABIS and other personality measurements related to impulsiveness, and showed that the ABIS can help predict alcohol consumption. We present the ABIS as a useful and efficient tool for researchers interested in measuring impulsive personality.