Reverse Shoulder Arthroplasty for Proximal Humerus Fractures and Reverse Shoulder Arthroplasty for Elective Indications Should Have Separate Current Procedural Terminology (CPT) Codes.

BACKGROUND: Reverse shoulder arthroplasty (RSA) for fracture currently shares a single current procedural terminology (CPT) code with RSA for arthropathy despite potential differences in patient factors, procedural demands, postoperative care and needs, and overall hospital systems' resource utilization. We hypothesize that patients indicated for RSA for fracture will have greater medical complexity, require longer operative duration, have higher complication rates, demonstrate inferior functional outcomes, and require greater healthcare cost expenditures compared to a cohort undergoing RSA for rotator cuff arthropathy. METHODS: 383 RSAs were retrospectively reviewed from January 2011 to December 2020. Demographics, comorbidities, operative time, financial charge and cost data, length of stay (LOS), discharge disposition, and all-cause revisions were assessed. Visual analog scale (VAS) pain score and active range of motion (AROM) were evaluated at 2, 6, and 12 months postoperatively. RESULTS: 197 total RSA were included with 28 for fracture and 169 for arthropathy indications after exclusions. RSA operative time was longer for fractures with an average of 143.2±33.7 minutes compared to 108.2±33.9 minutes for arthropathy (p=0.001). Average cost per patient for RSA for proximal humerus fracture was $2,489 greater than cost for RSA for elective indications; however, no statistically significant difference was noted between average costs (p=0.126). LOS was longer for RSA for fracture compared to arthropathy with a mean of 4.0 ± 3.6 days versus 1.8 ± 2.3 days (p=0.004). The fracture group was 3.6 times more likely to be discharged to a skilled nursing facility or inpatient rehab (32% versus 9%, p=0.002). Early and late all-cause revisions were similar between groups. Differences in postoperative AROM for fracture versus arthropathy were significant for active forward flexion (aFF) at 2 months (95.5±36.7°, 117.0±32.3°) and 6 months (110.9±35.2°, 129.2±28.3°) (p=0.020) as well as active adducted external rotation (aER) at 6 months (20.0±20.9°, 33.1±12.3°) (p=0.007) and at 12 months (23.3±18.1°, 34.5±13.8°) (p=0.012). No difference in VAS pain scores were noted between fracture and arthropathy groups at any time point. DISCUSSION: RSA for fractures versus arthropathy have substantial differences in patient characteristics, surgical complexity, and hospital resource utilization. This is of importance given the currently available CPT code does not differentiate indications for RSA, especially if intending to accurately document surgical care delivered.

Selective Patella Resurfacing in Contemporary Cruciate Retaining and Substituting Total Knee Arthroplasty: A Matched Cohort Analysis.

BACKGROUND: Leaving the patella unresurfaced in total knee arthroplasty (TKA) is increasing due to modern patella-friendly implants, awareness that complications are not uncommon with resurfacing, and knowledge that historical studies were scientifically confounded. This study examined the effect of selective patellar resurfacing on patient-reported outcome measures (PROMs) using modern implants and techniques in cohorts rigorously matched for demographics and osteoarthritis severity. METHODS: A total of 166 TKAs performed without patellar resurfacing were case-control matched to 166 TKAs with patella resurfacing. Case-control matching was based on demographics, American Society of Anesthesiology Physical Status, comorbidities, and osteoarthritis severity. No significant differences were observed between cohorts for demographics (P ≥ .347), comorbidities (P ≥ .443), or radiographic osteoarthritis severity (P ≥ .078). Radiographic alignment and prospectively collected PROMs were evaluated preoperatively and at latest clinical follow-up. RESULTS: Preoperatively, patellar tilt was less for the unresurfaced patella group (3 versus 4°, P = .003); however, postoperative patellar tilt was not different (3 versus 3°, P = .225). At a mean of 2.1 years follow-up (range, 1 to 7), University of California Los Angeles Activity Level was significantly higher for the unresurfaced patella group (6.3 versus 5.5, P = .002), but the mean group difference did not reach a minimal clinically important difference. There were no other significant differences in PROMs or reoperation rates between cohorts (P ≥ .135). CONCLUSION: In contemporary cruciate retaining and substituting TKA designs, not resurfacing the patella in select patients may achieve comparable PROMs and re-operation rates; and potentially greater activity level compared to patella resurfacing at early follow-up. LEVEL OF EVIDENCE: III.

Coronal and Sagittal Component Position in Contemporary Total Knee Arthroplasty: Targeting Native Alignment Optimizes Clinical Outcomes.

BACKGROUND: Advanced technologies, like robotics, provide enhanced precision for implanting total knee arthroplasty components; however, optimal component position and limb alignment remain unknown. This study sought to identify sagittal and coronal alignment targets that correlate with minimal clinically important differences (MCIDs) in patient-reported outcome measures (PROMs). METHODS: A total of 1,311 consecutive total knee arthroplasties were retrospectively reviewed. Posterior tibial slope (PTS), femoral flexion (FF), and tibio-femoral alignment (TFA) were measured radiographically. Patients were grouped based on whether they achieved multiple MCIDs for PROM scores. Classification and regression tree machine learning models were utilized to identify optimal alignment zones. The mean follow-up was 2.4 years (range, 1 to 11). RESULTS: The change in PTS and postoperative TFA were most predictive for achieving MCIDs in 90% of the models. Approximating native PTS within 4° correlated with MCID achievement and superior PROMs. Preoperative varus and neutral aligned knees were more likely to meet MCIDs and superior PROM scores when not overcorrected into valgus postoperatively (≥7°). Preoperative valgus-aligned knees correlated with MCID achievement when postoperative TFA was not overcorrected into substantial varus (<0°). Albeit less impactful, FF ≤ 7° correlated with MCID achievement and superior PROMs regardless of preoperative alignment. Sagittal and coronal alignment measurements had moderate to strong interactions in 13 of 20 models. CONCLUSION: Optimized PROM MCIDs correlated with approximating native PTS while maintaining similar preoperative TFA and incorporating moderate FF. Study findings demonstrate interactions between sagittal and coronal alignment which may optimize PROMs, highlighting the importance of three-dimensional implant alignment targets. LEVEL OF EVIDENCE: III.

Telehealth in Orthopedic Sports Medicine: A Survey Study on Patient Satisfaction and Experience.

Background: Telehealth has seen breakthroughs in many fields of medicine, but utilization remains limited in orthopedic sports medicine. The purpose of this investigation was to compare patient satisfaction, duration of care, and overall patient experiences with telehealth and in-person clinical visits for sports-related injuries. Methods: A cross-sectional survey study was conducted at an orthopedic sports medicine clinic during the peak of the COVID-19 pandemic between March and November 2020. Anonymous electronic surveys were used to record patient responses and statistical comparisons were drawn through two-sample t-tests. Results: A total of 175 patients (82 telehealth vs. 93 in-person) consented to participate in this investigation, and all were included in the final analysis. The overall composite satisfaction score, when compared between the two groups, did not differ (p = 0.63). Duration of care was significantly longer in the 93 patients who had in-person clinical visits as compared with the 82 patients who had telehealth visits (61/93: >31 min vs. 75/82: <30 min; p < 0.001). Finally, of the 82 patients who had telehealth, 3 respondents said they were "very unlikely" and "unlikely" to request another virtual clinical visit and/or recommend this mode of health care delivery to friends or family. Of the 93 patients had in-person clinical visits, only 15 respondents stated they were uninterested in telehealth under any circumstance. Conclusion: Most patients presenting to an orthopedic sports medicine clinic are open to telehealth, recognize its utility, and believe it to be just as comparable with in-person clinical visits. Level of Evidence: IV.

Efficacy of a single, image-guided corticosteroid injection for glenohumeral arthritis.

BACKGROUND: Limited data are available on the efficacy of cortisone injections for glenohumeral osteoarthritis (GHOA). The amount and longevity of pain relief provided by a single cortisone injection are unclear. Additionally, it remains uncertain how the severity of radiographic GHOA and patient-reported function and pain levels impact the efficacy of an injection. Therefore, we sought to describe the relief provided by a single, image-guided glenohumeral injection in patients with GHOA. We hypothesized that patients with more severe radiographic GHOA and poorer baseline shoulder function would require earlier secondary intervention. METHODS: Patients with symptomatic GHOA who elected to receive a corticosteroid injection for pain relief were prospectively enrolled. A phone interview was conducted to record the baseline Oxford Shoulder Score (OSS) and visual analog scale (VAS) score prior to the injection, as well as the OSS and VAS score at months 1, 2, 3, 4, 6, 9, and 12 after the injection. The endpoint of the study occurred when patients required a second injection, progressed to surgery, or reached month 12. Patients were grouped by their respective baseline OSS (mild vs. moderate or severe) and Samilson-Prieto radiographic classification (mild, moderate, or severe) for analysis. RESULTS: We analyzed 30 shoulders (29 patients). Of the patients, 52% were men. The average age was 66.1 years. No significant difference in overall survival (defined as no additional intervention) was seen between groups based on either the OSS or Samilson-Prieto grade. Additionally, the OSS and VAS score at each follow-up were compared with baseline values. For the entire cohort, a clinically significant difference was seen between baseline and months 1-4 for the OSS and between baseline and months 1-4, 6, 9, and 12 for the VAS score. DISCUSSION: This study aimed to determine the efficacy of corticosteroid injections for GHOA. There were no differences in the need for secondary intervention in this population based on the severity of either the OSS or the Samilson-Prieto radiographic classification. However, patients with more severe shoulder dysfunction based on the OSS did experience statistically significantly greater symptomatic relief than patients with milder dysfunction. Additionally, following a single injection, patients in this cohort experienced statistically and clinically relevant improvements in shoulder function and pain up to 4 months after injection.

Machine Learning Algorithms Identify Optimal Sagittal Component Position in Total Knee Arthroplasty.

BACKGROUND: Advanced technologies, like robotics, provide enhanced precision for implanting total knee arthroplasty (TKA) components; however, the optimal targets for implant position specifically in the sagittal plane do not exist. This study identified sagittal implant position which may predict improved outcomes using machine learning algorithms. METHODS: A retrospective review of 1091 consecutive TKAs was performed. All TKAs were posterior cruciate ligament retaining or sacrificing with an anterior-lip (49.4%) or conforming bearing (50.6%) and performed with modern perioperative protocols. Preoperative and postoperative tibial slope and postoperative femoral component flexion were measured with standardized radiographic protocols. Analysis groups were categorized by satisfaction scores and the Knee Society Score question 'does this knee feel normal to you?' Machine learning algorithms were used to identify optimal sagittal alignment zones that predict superior satisfaction and knees "always feeling normal" scores. RESULTS: Mean age and median body mass index were 66 years and 34 kg/m2, respectively, with 67% being female. The machine learning model predicted an increased likelihood of being "satisfied or very satisfied" and a knee "always feeling normal" with a change in tibial slope closer to native (-2 to +2°) and femoral component flexion 0 to +7°. Worse outcomes were predicted with any femoral component extension, femoral component flexion beyond +10°, and adding or removing >5° of native tibial slope. CONCLUSION: Superior patient-reported outcomes were predicted with approximating native tibial slope and incorporating some femoral component flexion. Deviation from native tibial slope and excessive femoral flexion or any femoral component extension were predictive of worse outcomes. LEVEL OF EVIDENCE: Therapeutic level III.

Predictors of Patient Satisfaction Following Primary Total Knee Arthroplasty: Results from a Traditional Statistical Model and a Machine Learning Algorithm.

BACKGROUND: It is well-documented in the orthopedic literature that 1 in 5 patients are dissatisfied following total knee arthroplasty (TKA). However, multiple statistical models have failed to explain the causes of dissatisfaction. Furthermore, payers are interested in using patient-reported satisfaction scores to adjust surgeon reimbursement rates without a full understanding of the influencing parameters. The purpose of this study was to more comprehensively identify predictors of satisfaction and compare results using both a statistical model and a machine learning (ML) algorithm. METHODS: A retrospective review of consecutive TKAs performed by 2 surgeons was conducted. Identical perioperative protocols were utilized by both surgeons. Patients were grouped as satisfied or unsatisfied based on self-reported satisfaction scores. Fifteen variables were correlated with satisfaction using binary logistic regression and stochastic gradient boosted ML models. RESULTS: In total, 1325 consecutive TKAs were performed. After exclusions, 897 TKAs were available with minimum 1-year follow-up. Overall, 85.3% of patients were satisfied. Older age generation and performing surgeon were predictors of satisfaction in both models. The ML model also retained cruciate-retaining/condylar-stabilizing implant; lack of inflammatory conditions, preoperative narcotic use, depression, and lumbar spine pain; female gender; and a preserved posterior cruciate ligament as predictors of satisfaction which allowed for a significantly higher area under the receiver operator characteristic curve compared to the binary logistic regression model (0.81 vs 0.60). CONCLUSION: Findings indicate that patient satisfaction may be multifactorial with some factors beyond the scope of a surgeon's control. Further study is warranted to investigate predictors of patient satisfaction particularly with awareness of differences in results between traditional statistical models and ML algorithms. LEVEL OF EVIDENCE: Therapeutic Level III.

Towards Modified Entropy Mutual Information Feature Selection to Forecast Medium-Term Load Using a Deep Learning Model in Smart Homes.

Over the last decades, load forecasting is used by power companies to balance energy demand and supply. Among the several load forecasting methods, medium-term load forecasting is necessary for grid's maintenance planning, settings of electricity prices, and harmonizing energy sharing arrangement. The forecasting of the month ahead electrical loads provides the information required for the interchange of energy among power companies. For accurate load forecasting, this paper proposes a model for medium-term load forecasting that uses hourly electrical load and temperature data to predict month ahead hourly electrical loads. For data preprocessing, modified entropy mutual information-based feature selection is used. It eliminates the redundancy and irrelevancy of features from the data. We employ the conditional restricted Boltzmann machine (CRBM) for the load forecasting. A meta-heuristic optimization algorithm Jaya is used to improve the CRBM's accuracy rate and convergence. In addition, the consumers' dynamic consumption behaviors are also investigated using a discrete-time Markov chain and an adaptive k-means is used to group their behaviors into clusters. We evaluated the proposed model using GEFCom2012 US utility dataset. Simulation results confirm that the proposed model achieves better accuracy, fast convergence, and low execution time as compared to other existing models in the literature.

Noise figure of electromagnetic systems with parity and time-reversal symmetry.

The primary bottlenecks in designing and implementing PT-symmetric systems at microwave frequency ranges are noise and instability which can weakly break PT-symmetry resulting in system performance degradation. Practical implementation of such systems and devices require significant level of control and stability and it is crucial to analyze the noise performance of such systems in terms of noise figure and signal-to-noise ratio. We describe and develop a simulation model to calculate noise figure of PT-symmetric system and evaluate the performance degradation. We also discuss application design and circuit configurations that could reduce the noise figure resulting in better performance.

Endemic infection of the common mynah Acridotheres tristis with Trichomonas gallinae the agent of avian trichomonosis.

Avian trichomonosis is an architypal disease of wild columbids and those birds that predate them. Increasingly though, it has been reported in passerines; a recent and ongoing epidemic in the chaffinches and greenfinches of Europe and outbreaks amongst house finches, American goldfinches and purple finches in North America. The parasite, Trichomonas gallinae, causes lesions in the upper respiratory tract which can cause mortality associated with dehydration and emaciation. This paper reports for the first time, the widespread, endemic and often asymptomatic infection of common mynah (Acridotheres tristis) around the Faisalabad District, Pakistan. Parasite typing was used to investigate the potential for transmission among the frequently sympatric species. Type C parasites were found in mynah, and while this is analagous to the pandemic finch strain which is Type A, it is the first known example of passerine infections of this parasite genotype. Subtype analysis showed the strain to be C4 a subtype which has a widespread distribution in columbids.

Investigation of process parameters for modeling of ceramic composite SiSiC IN dry EDM (DEDM) cutting.

The manufacturing industry is currently grappling with issues related to energy dissipation and product quality, both of which significantly impact productivity. In addressing this pertinent concern, this study endeavours to identify the key indicators that contribute a crucial role in machining process. The Dry EDM (DEDM) emerges as a novel technology, wherein environmentally friendly gases serve as an alternative dielectric medium instead of liquid EDM approaches. In conventional EDM process, hydrocarbon oils release toxic emissions while the gases used in Dry EDM process don't produce harmful emissions and hence make the DEDM process sustainable. An investigation has been carried out to observe the influence of different gases like O2, N2 and Air on Siliconized Silicon-Carbide plate (SiSiC) of ø50mm*2 mm under Dry Electrical Discharge Machining. Effect of different tools is also observed using varying shapes of electrodes like plane Cu electrode of ø6 mm diameter with 60 mm length and tubular shape with outer diameter ø6mm and inner diameter ø5.1 mm with a length of 60 mm. The three gases are one by one supplied through a nozzle in the presence of plane Cu electrode to make the holes in SiSiC plate. The same process is executed with tubular Cu electrode. Modified Taguchi Orthogonal Array is applied to analyze the effect of control factors such as gap voltage, discharge current and pulse on-time through a series of experiments. Effect of different shape of tools and different gases is observed for the material removal rate (MRR) and surface roughness (SR) of specimen. In this paper, a latest DEDM process of swirl assisted flushing is proposed which provides a new technique to solve the problems of low MRR and poor surface integrity. Swirl assisted flushing works on Decay Law and also microscopic investigation justifies its validity. It is concluded by this research that current and Pulse on time are more contributing factors about 53.3 % and 27 % respectively. Furthermore, it is noted that DEDM increases MRR 19.5 % and lowers Ra approximately 2/3 than traditional machining. The MRR of O2 is about 3.1 times more than Air and N2 comes at least position while N2 creates better quality of surface due to formation of an inert nitride layer. Empirical relations are established for SR and MRR using Minitab 18 Software to develop a robust model. Confirmation test is performed to check the validity of developed mathematical model. The Novelty of this research is also extended by introducing a new method SAF. The results are finally evaluated by ANOVA.

Effects of fluid composition in fluid injection experiments in porous media.

Experiments on fluid flow in porous media, using fluids loaded with solids of various grain sizes, have been conducted in a modified Hele-Shaw setup. This setup utilised weakly cemented porous media with specific hydraulic and mechanical properties. Fluid injection in coarse granular media with clean or low-concentration fine particles, results in infiltration only, with pressure close to the material tensile strength, while injection in finer granular material causes damage alongside infiltration, with the fluid pressure still close to the material tensile strength. When larger particle sizes or higher particle concentrations are used in the mixture, the fluid travels further within the porous medium, primarily influenced by the grain size of the granular medium. In the latter case, the Darcy flow equation with an effective permeability term can be employed to determine the pressure differential. For the largest particle sizes included in the fluid, the equation is still applicable, but the effective permeability requires adjustment for particle size within the fluid rather than the granular medium. This is crucial when the injection point is locally clogged. The experiments show that fracturing conditions are controlled by different mechanisms. Dimensional and statistical analysis was used to classify the injection pressures to regimes predicted by fracturing theory or by Darcy law with modified effective permeabilities. The findings show that both the material properties and fluid composition are important designing parameters.

Exploring Impact and Variability of Research Productivity Among Academic Orthopaedic Leaders.

Introduction: Assessing scholarly contributions in academic orthopaedic surgery remains challenging, despite the importance of publication productivity in evaluating academic leaders. The Hirsch (h)-index and its derivative, the m-index, offer objective measures to compare and evaluate publication productivity. The primary aims of this study were to compare h- and m-indices of department chairs and residency program directors of orthopaedic training programs in the United States and assess the association between h-index and program rank. Methods: A publicly available Doximity report was used to identify and rank orthopaedic surgery residency programs in the United States. Internet-based searches of institution-specific websites were performed to confirm current department chairs and residency program directors as of January 2024. H-index data were collected from a publicly available database known as Scopus. The m-index was calculated as the quotient of h-index and years in practice. Gender and years in practice were obtained through available biographies on institution-specific websites. Results: Department chairs had significantly higher h- and m-indices at both the career and 5-year time intervals compared with program directors. Upon subgroup analysis, department chairs and program directors at top-10 ranked programs had significantly higher h- and m-indices compared with the entire population of department chairs and program directors. Linear regression analyses demonstrated a direct linear association between department chair/program director h- and m-indices and program rank. Conclusions: Publication productivity was higher for department chairs than residency program directors. Orthopaedic leaders at top-10 institutions had higher publication productivity compared with those at institutions outside of the top 10, per Doximity rankings. Finally, there is substantial variation in publication productivity of orthopaedic surgeons in leadership roles at academic institutions in the United States. Clinical Relevance: This study highlights the publication productivity of orthopaedic surgery department chairs and residency program directors and describes the linear association between publication productivity of academic orthopaedic leaders and program rank. This information can be utilized by those interested in learning more about the publication productivity among academic orthopaedic surgeons across different institutions and can assist those who are involved in the hiring and promotion process at these academic institutions.

Accuracy of intraoperative approximation of pelvic tilt using preoperative standing radiographs.

Background: Anterior approach surgeons who utilize intraoperative fluoroscopy often try to match a preoperative radiograph as a reference for intraoperative cup position. Every degree of inaccuracy in tilt leads to a roughly 0.7° change in anteversion. This study aimed to determine how closely pelvic tilt (PT) is approximated intraoperatively when compared to preoperative anteroposterior (AP) radiographs. Methods: This was a retrospective review of 193 primary THA's done by 2 surgeons at an academic tertiary referral center between September 2021-January 2023. There were 24 patients excluded for distorted anatomy, post-traumatic arthritis, insufficient x-rays, or a sacroiliac joint that could not be visualized on film. Data collected included age and BMI. PT was calculated using the formula, Tilt = -(ln((B/A) x (1/0.483)))/0.051. Value A is the distance from the base of the SI joint to the superior margin of the obturator foramen; value B is the height of the obturator foramen. Results: Mean preoperative PT was 0.2° versus intraoperative PT was 3.4° (p < 0.001). Mean absolute difference was 6.5°. 48% of patients (n = 81) had an absolute difference less than 5°, 31% (n = 52) between 5° and 10°, 14% (n = 24) between 10° and 15°, and 7% (n = 12) greater than 15°. There was no correlation between BMI or age and PT discrepancy. Conclusion: Of the patients, 21% had a discrepancy of 10° or greater between their preoperative radiographs and intraoperative fluoroscopic images. Surgeons should be aware of potential errors in cup positioning and be particularly diligent in high-risk cases.

The ipsilateral olecranon tip is a suitable anatomic autograft for unrepairable coronoid fractures: A comparative three-dimensional mapping analysis.

Background: Perform computed tomography (CT) three-dimensional (3D) mapping analysis of the ipsilateral olecranon tip to determine its suitability as an autograft for unrepairable coronoid fractures. Methods: CT was evaluated using Mimics 13.0 and 3-matic software (Materialise, Inc., Leuven, Belgium). Coronoid fracture fragment was measured from the medial sublime tubercle to the halfway point of the proximal radioulnar joint. Ipsilateral olecranon tip graft was measured at the equivalent height of the coronoid fragment and the angle of graft "cut" necessary to match the coronoid fragment was measured. The overall width of each graft site was measured in thirds and the congruity of surface geometry was measured by overlapping both fragments. The ipsilateral olecranon tip lateral facet which rotates to become the coronoid medial facet was also measured. Results: The olecranon tip and coronoid fragments were similar in average maximum height and width. The average angle of graft cut needed to match the coronoid fragment was 86°. The average difference between the medial facet of the coronoid and lateral facet of the olecranon was <2 mm. Discussion: The ipsilateral olecranon tip can be harvested through the same surgical incision and function as a local autograft during reconstruction of unrepairable coronoid fractures.

Cost Analysis of Conversion Total Knee Arthroplasty: A Multi-Institutional Database Study.

BACKGROUND: Total knee arthroplasty (TKA) after prior knee surgery, also known as conversion TKA (convTKA), has been associated with higher complications, resource utilization, time, and effort. The increased surgical complexity of convTKA may not be reflected by the relative value units (RVUs) assigned under the current U.S. coding guidelines. The purpose of this study was to compare the RVUs of primary TKA and convTKA and to calculate the RVU per minute to account for work effort. METHODS: The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database was analyzed for the years 2005 to 2020. Current Procedural Terminology (CPT) code 27447 alone was used to identify patients who underwent primary TKA, and 27447 plus 20680 were used to identify convTKA. After 1:1 propensity score matching, 1,600 cases were assigned to each cohort. The 2023 Medicare Physician Fee Schedule RVU-to-dollar conversion factor from the U.S. Centers for Medicare & Medicaid Services (CMS) was used to calculate RVU dollar valuations per operative time. Complication rates were compared using a multivariate logistic regression model controlling for baseline characteristics. RESULTS: The mean operative time for TKA was 97.8 minutes, with a corresponding RVU per minute of 0.25, while the mean operative time for convTKA was 124.3 minutes, with an RVU per minute of 0.19 (p < 0.0001). Using the conversion factor of $33.06 per RVU, this equated to $8.11 per minute for TKA versus $6.39 per minute for convTKA. ConvTKA was associated with higher overall complication (10.9% versus 6.5%, p < 0.0001), blood transfusion (6.6% versus 3.7%, p < 0.01), reoperation (2.3% versus 0.94%, p < 0.0001), and readmission (3.7% versus 1.8%, p < 0.001) rates. CONCLUSIONS: The current billing guidelines lead to lower compensation for convTKA despite its increased complexity. The longer operative time, higher complication rate, and increased resource utilization may incentivize providers to avoid performing this operation. CPT code revaluation is warranted to reflect the time and effort associated with this procedure. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Reliability of the Modified Radiographic Union Score for Tibia Fractures (mRUST) for Femoral Shaft Fractures.

OBJECTIVES: To evaluate the interobserver and intraobserver reliability of the modified Radiographic Union Score for Tibia Fractures (mRUST) and the effect of rater experience in evaluation of femoral fractures. DESIGN: Retrospective cohort study. SETTING: Single Level 1 trauma center. PATIENTS/PARTICIPANTS: Patients 18-55 years of age with a femur shaft fracture. INTERVENTION: Intramedullary nail fixation. MAIN OUTCOME MEASUREMENT: Interobserver and intraobserver reliability using the intraclass correlation coefficient. RESULTS: The overall interobserver reliability was 0.96. Among fellowship-trained evaluators, the interobserver reliability was 0.94, and it was 0.92 among trainees. The overall intraobserver reliability was 0.98. The intraobserver reliability was 0.97 among fellowship-trained evaluators and 0.96 for trainees. CONCLUSIONS: These results show high interobserver and intraobserver reliability of mRUST in the evaluation of radiographic healing for femur shaft fractures treated with intramedullary nail. This high reliability was further demonstrated throughout different postoperative healing time frames. In addition, mRUST appears to be reliable when used both by trainees and experienced surgeons for the evaluation of femur shaft fractures. LEVEL OF EVIDENCE: Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Assaults in schools: Findings using a national data base.

BACKGROUND: Assaults can occur at schools/educational facilities involving students, teachers and other school employees. It was the purpose of this study to correlate injury patterns with patient demographics in school assault victims. Understanding injury patterns with their associated demographics will not only be useful for health care providers but can also assist in proposing prevention strategies for both students and school employees. METHODS: Emergency department data from the National Electronic Injury Surveillance System All Injury Program data for the years 2005 through 2015 were used in this study. Statistical analyses were performed with SUDAAN software to account for the weighted, stratified nature of the data. RESULTS: There were an estimated 852,822 ED visits for school assaults. The median age was 13.8 years with 81.3% between 5 and 19 years old; 64.4% were male. After age 4, the number of females proportionately increased with increasing age. The most common diagnosis was a contusion/abrasion (38.6%). The injuries occurred in the head/neck (63.9%), upper extremity (19.0%), upper trunk (6.6%), lower trunk (5.5%), and lower extremity (4.9%). Firearm violence accounted for 0.1% of the assaults. Human bites occurred in 3.7%. Sexual assault was rare and proportionally the highest in those ≤4 years of age. Internal organ injuries were more common in females (13.1% vs 3.55) and for those admitted to the hospital (29.9% vs 19.9%). The incidence of ED visits for school assault decreased 50% from 2005 to 2015. CONCLUSIONS: This study analyzed ED visits due to assaults occurring in schools. Firearm violence accounted for only 0.1% of the injuries, in contrast to media coverage regarding school assaults. The most common injury location was the head/neck (63.9%) and the most common diagnosis was a contusion/abrasion. This data can also serve as a baseline for further studies and the impact of potential reduction strategies.

Delayed surgical repair of the deltoid following acromioplasty: a case report.

Currently, the literature contains few studies that describe any potential complications following arthroscopic acromioplasty. Because part of the anterior deltoid originates from the anterior acromion, there is a risk for violation and subsequent iatrogenic rupture or avulsion during this procedure. This type of injury can be a devastating problem for patients that may lead to poor function and debilitating pain. We present a patient with deltoid insufficiency following arthroscopic acromioplasty who elected to proceed with operative management with a planned arthroscopic evaluation of the shoulder followed by an open deltoid repair. At the final follow-up visit 2.5 years postoperatively, the patient reported improved pain from baseline and no residual disability and was able to perform most activities of daily living without difficulty. This case serves as an example of a surgical repair for a deltoid avulsion following arthroscopic acromioplasty. As there is still a lack of standard guidelines, our suture repair technique can be considered one method of treatment for this type of injury.