Faculty Bibliography

INTRODUCTION/BACKGROUND:To aid implementing an ethics curriculum in an orthopaedic residency program, the American Academy of Orthopaedic Surgeons (AAOS) created 14 ethics scenarios. Because delivery of this curriculum could be burdensome, an online module-based curriculum might be optimal. METHODS:Two cohorts of orthopaedic residents participated: cohort I completed 14 online ethics modules converted from the 14 AAOS ethics scenarios. For each module, we gave a multiple-choice assessment immediately before the module, immediately afterward, and 3 months afterward. Cohort II completed only the 14-module assessments at similar time intervals without any educational content. RESULTS:Cohort I demonstrated improvement in 3-month postmodule assessment scores in 11 of the 14 modules, 3 of which had statistical differences in baseline scores for cohort I and cohort II. We observed no statistical difference in scores within cohort II on repeat testing. DISCUSSION/CONCLUSIONS:This study demonstrates that 11 of the 14 AAOS ethics scenarios, converted to online modules, teach ethical concepts to orthopaedic residents. Orthopaedic residency programs may find it valuable to engage their residents in the ethics scenarios created by the AAOS to complement their ethics curriculum.

BACKGROUND:At our institution, all postoperative total hip arthroplasty (THA) candidates have received home health services (HHS), consisting of visiting nurses, physical and occupational therapists. However, with a more technologically inclined patient population, electronic patient rehabilitation applications (EPRAs) can be used to deliver perioperative care at the comfort of the patient's home. The aim of this study is to investigate the clinical utility and economic burden associated with digital rehabilitation applications in primary THA recipients. METHODS:We conducted a single-center, retrospective review of patients operated between November 2016 and November 2017. Before surgery, and at the discretion of the surgeon, patients were assigned to EPRA with HHS or EPRA alone. Patient baseline demographics, EPRA engagement, and validated patient-reported outcomes (PROs) were (Veterans Rand 12-Item Health Survey [VR-12] and Hip Disability and Osteoarthritis Outcome Score Junior) at baseline and 12 weeks. These PRO scores were correlated with cohort assignments to assess noninferiority of EPRA alone. RESULTS:In total, 268 patients received either EPRA-HHS (n = 169) or EPRA (n = 99) alone. Patients receiving EPRA only were on average younger (60.8 vs 65.8; P < .0001), but otherwise similar to patients in the EPRA-HHS cohort. EPRA-only patients demonstrated no differences in VR-12 (P > .05) and Hip Disability and Osteoarthritis Outcome Score Junior (P > .05) when compared with EPRA-HHS. CONCLUSION/CONCLUSIONS:The integration of electronic rehabilitation tools is gaining acceptance within the orthopedic community. Our study demonstrated that EPRA alone was clinically noninferior while substantially less costly than EPRA-HHS.

Background /UNASSIGNED:Evaluation of resident physicians' communications skills is a challenging task and is increasingly accomplished with standardized examinations. There exists a need to identify the effective, efficient methods for assessment of communications skills. Objective /UNASSIGNED:We compared objective structured clinical examination (OSCE) and direct observation as approaches for assessing resident communications skills. Methods /UNASSIGNED:We conducted a retrospective cohort analysis of orthopaedic surgery resident physicians at a single tertiary care academic institution, using the Institute for Healthcare Communication "4 Es" model for effective communication. Data were collected between 2011 and 2015. A total of 28 residents, each with OSCE and complete direct observation assessment checklists, were included in the analysis. Residents were included if they had 1 OSCE assessment and 2 or more complete direct observation assessments. Results /UNASSIGNED: = .16), after adjusting for chance agreement. Conclusions /UNASSIGNED:Our results suggest that OSCE and direct observation tools provide different insights into resident communications skills (simulation of rare and challenging situations versus real-life daily encounters), and may provide useful perspectives on resident communications skills in different contexts.

BACKGROUND:There is evidence to suggest that liposomal bupivacaine (LB) is an effective component of a multimodal pain regimen for total joint arthroplasty (TJA). Obesity has been associated with chronic pain following TJA. This study assessed whether early postoperative pain is affected by body mass index (BMI), and whether the standard LB dose has similar effects on obese vs nonobese patients. METHODS:A retrospective analysis of 2629 primary TJA over a 12-month period was conducted, with LB used in half of this group. Patients were further classified as nonobese (BMI < 30) or obese (BMI ≥ 30). Pain scores and narcotic use were recorded. Independent-sample t-tests were used for continuous variables and chi-squared analyses for categorical variables. A multivariate regression analysis was performed. RESULTS:Significantly less narcotic was required on postoperative days (POD) 0 and 1 in patients receiving LB compared to those who did not in both obese and nonobese patient groups. On POD 2, obese and nonobese patients had an increase in narcotic requirement, which was significant in obese patients. A regression analysis found that on POD 0 and POD 1, lack of LB use, obesity, and younger age were independently associated with increased narcotic use. CONCLUSION/CONCLUSIONS:While narcotic requirement of obese and nonobese patients decreased on POD 0 and POD 1 with initiation of LB at our institution, all patients demonstrated increased narcotic requirement on POD 2 which was statistically and clinically significant in obese patients. Further studies are needed to determine the optimal pain regimen in the growing obese population undergoing TJA.

OBJECTIVE: We developed a series of orthopedic unannounced standardized patient (USP) encounters for the purpose of objective assessment of residents during clinic encounters. DESIGN: Consecutive case-series. SETTING: NYU-Langone Multi-center Academic University Hospital System. PARTICIPANTS: NYU-Langone/Hospital for Joint Diseases Orthopedic Surgery residents; 48 consecutive residents assessed. METHODS: Four orthopedic cases were developed. USPs presented themselves as patients in outpatient clinics. Residents were evaluated on communication skills (information gathering, relationship development, and education and counseling). USPs globally rated whether they would recommend the resident. RESULTS: Forty-eight USP encounters were completed over a 2-year period. Communication skills items were rated at 51% (+/-30) "well done." Education and counseling skills were rated as the lowest communication domain at 33% (+/-33). Residents were globally recommended based on communication skills in 63% of the encounters recommended in 70% of encounters based on both professionalism and medical competence. CONCLUSIONS: The USP program has been useful in assessing residents' clinical skills, interpersonal and communications skills, and professionalism. Use of USP in orthopedic surgery training programs can be an objective means for trainee assessment.

The purpose of this study is to evaluate incidence, preoperative laboratory markers, and outcomes of patients who positively cultured pathogens (PCP) at time of surgery for long bone fracture nonunion. Two-hundred and eighty-eight patients were enrolled in a trauma study on long bone nonunion. Two-hundred and sixteen of those 288 patients were cultured at the time of fracture nonunion surgery. Laboratory data were collected prior to intervention and infectious laboratory markers ordered on patients suspected for infection. Patients were followed for one year. Wound complications, antibiotic use, healing, function, and re-admission for further surgery were assessed. Cultures returned positive on 59 patients (representing 20.5% of the 288 patient cohort or 27.3% of the 216 patients cultured in the operative suite). More PCP's (47.5%; 28 of 59) developed wound complications, with greater mean antibiotic duration and more frequent returns to the OR averaging 1.3 procedures per patient. Twelve-month follow-up was obtained on 249 of the 288 (86.5%) and PCPs reported globally worse function. Patients who PCP at the time of operative management for long bone nonunion was a prognostic indicator of poorer long-term functional outcomes.

OBJECTIVES: To assess the presence of fracture site gross motion on physical examination to predict humeral shaft fracture progression to nonunion in patients managed nonoperatively. DESIGN: Retrospective cohort study. SETTING: Single trauma level 1 institutional center. PATIENTS: Eighty-four consecutive patients undergoing nonoperative treatment of a diaphyseal humeral shaft fracture were identified. The average age of the population was 48.3 years, and 50% of the cohort was men. INTERVENTION: Clinical examination for fracture stability was routinely performed on patients by the treating physicians and documented it in the medical record. Patients were followed until union or surgery for persistent fracture mobility. MAIN OUTCOME MEASUREMENTS: Stability was graded if there was motion at the site (1: motion of any kind and 0: moved as a unit). RESULTS: Seventy-three patients (87%) healed their fracture within our study cohort by 6 months postfracture. Of the remaining 11 patients, after discussion with their treating physicians about the option of surgical intervention, 8 chose to undergo open reduction internal fixation at an average of 8 months, 1 proceeded nonsurgical interventions, and 2 were lost of follow-up. If the humeral shaft fracture site was mobile at 6 weeks follow-up visit, it identified future fracture nonunion with 82% sensitivity and 99% specificity (only 1 patient with motion at 6 weeks proceeded to fracture union). CONCLUSION: With a high negative predictive value, clinical examination of fracture motion at 6 weeks should be assessed in every patient to determine which patients should obtain closer follow-up for the risk of nonunion progression. Knowledge of gross fracture motion can be used in the shared decision-making model in counseling about early surgical options. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

STUDY DESIGN: Observational database review. OBJECTIVE: To determine the effect of patient severity of illness (SOI) on the cost of spine surgery among New York state hospitals. SUMMARY OF BACKGROUND DATA: National health care spending has risen at an unsustainable rate with musculoskeletal care, and spine surgery in particular, accounting for a significant portion of this expenditure. In an effort towards cost-containment, health care payers are exploring novel payment models some of which reward cost savings but penalize excessive spending. To mitigate risk to health care institutions, accurate cost forecasting is essential. No studies have evaluated the effect of SOI on costs within spine surgery. MATERIALS AND METHODS: The New York State Hospital Inpatient Cost Transparency Database was reviewed to determine the costs of 69,831 hospital discharges between 2009 and 2011 comprising the 3 most commonly performed spine surgeries in the state. These costs were then analyzed in the context of the specific all patient refined diagnosis-related group (DRG) SOI modifier to determine this index's effect on overall costs. RESULTS: Overall, hospital-reported cost increases with the patient's SOI class and patients with worse baseline health incur greater hospital costs (P<0.001). Moreover, these costs are increasingly variable for each worsening SOI class (P<0.001). This trend of increasing costs is persistent for all 3 DRGs across all 3 years studied (2009-2011), within each of the 7 New York state regions, and occurs irrespective of the hospital's teaching status or size. CONCLUSIONS: Using the 3M all patient refined-DRG SOI index as a measure of patient's health status, a significant increase in cost for spine surgery for patients with higher SOI index was found. This study confirms the greater cost and variability of spine surgery for sicker patients and illustrates the inherent unpredictability in cost forecasting and budgeting for these same patients.

PURPOSE: Surgical costs are under scrutiny and surgeons are being held increasingly responsible for cost containment. In some instances, implants are the largest component of total procedure cost, yet previous studies reveal that surgeons' knowledge of implant prices is poor. Our study aims to (1) understand drivers behind implant selection and (2) assess whether educating surgeons about implant costs affects implant selection. METHODS: We surveyed 226 orthopedic surgeons across 6 continents. The survey presented 8 clinical cases of upper extremity fractures with history, radiographs, and implant options. Surgeons were randomized to receive either a version with each implant's average selling price ("price-aware" group), or a version without prices ("price-naive" group). Surgeons selected a surgical implant and ranked factors affecting implant choice. Descriptive statistics and univariate, multivariable, and subgroup analyses were performed. RESULTS: For cases offering implants within the same class (eg, volar locking plates), price-awareness reduced implant cost by 9% to 11%. When offered different models of distal radius volar locking plates, 25% of price-naive surgeons selected the most expensive plate compared with only 7% of price-aware surgeons. For cases offering different classes of implants (eg, plate vs external fixator), there was no difference in implant choice between price-aware and price-naive surgeons. Familiarity with the implant was the most common reason for choosing an implant in both groups (35% vs 46%). Price-aware surgeons were more likely to rank cost as a factor (29% vs 21%). CONCLUSIONS: Price awareness significantly influences surgeons' choice of a specific model within the same implant class. Merely including prices with a list of implants leads surgeons to select less expensive implants. This implies that an untapped opportunity exists to reduce surgical expenditures simply by enhancing surgeons' cost awareness. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/Decision Analyses I.

INTRODUCTION: Diabetes has been associated with negative outcomes following orthopaedic surgery. While previous studies have reported on diabetes-associated complications in shoulder arthroplasty, those cohorts were heterogeneous in terms of patient population, nature of elective surgery, and arthroplasty type. Given that the number of elective total shoulder arthroplasties (TSAs) performed has grown substantially in volume and is predicted to rise even further, it is important to recognize the role that diabetes may play in developing in-hospital complications within a more homogenous sample of patients undergoing elective TSA. METHODS: The Nationwide Inpatient Sample (NIS) was searched for the year 2012 to identify all patients undergoing elective TSA. Patients with diabetes were identified, and differences regarding demographics and in-hospital outcomes were compared to non-diabetics using multivariate logistic regression. RESULTS: A total of 44,050 patients underwent elective total shoulder arthroplasty (TSA) in 2012. Diabetic patients tended to be older, of minority racial status, and had a greater medical comorbidity burden. When controlling for preoperative factors and comorbidities, diabetes was an independent risk factor for non-home bound discharge (OR 1.285; 95% CI 1.093-1.509, p = 0.002), length of stay in 75th percentile (OR 1.390; 95% CI 1.233-1.567, p < 0.001), total charges in the 75th percentile (OR 1.136; 95% CI 1.006-1.283, p = 0.040), and postoperative acute renal failure (OR 1.460; 1.002-2.128, p = 0.048). CONCLUSION: Diabetes was associated with marginal increases in non-home bound discharge, length of stay, and total charges, following elective TSA. Subgroup analysis revealed that diabetic patients undergoing reverse total shoulder arthroplasty (rTSA) have higher comorbidity burden and worse outcomes than diabetic patients undergoing anatomic total shoulder arthroplasty (aTSA).