Faculty Bibliography

Health equity is the fair and just opportunity for every individual to achieve their full potential in all aspects of health and well being. The combination of the COVID-19 pandemic and increased awareness of social injustice shed critical light on health inequities. DEI efforts in health care directly affect patient outcomes and quality of life. By creating and implementing high-quality DEI programs, our orthopedic surgery practices and organizations can help ameliorate healthcare inequities and deliver inclusive, person-centered, and culturally competent patient care. Substantial variability in definition, data collection, methodology, and goals exist between organizations that measure health equity. DEI metrics and targets will be used to measure quality, but reliance on data acquired through patient questionnaires or through their interaction with technology may exclude the most at-risk populations. The purpose of this review is to outline the various organizations involved in evaluating DEI metrics so that orthopaedic teams can better measure and more effectively report the effect of DEI efforts on patient outcomes.

PURPOSE/OBJECTIVE:The purpose of this study is to compare the quality and clinical outcomes of patients who underwent open reduction internal fixation for a proximal humerus fracture in a "timely manner" which was defined to be within 5 days of injury compared to those with "delayed intervention" (>5 Days) to determine the effect this had. METHODS:This IRB-approved study evaluated patients who sustained a proximal humerus fracture treated with plate and screw fixation (ORIF) between January 2004 and October 2022 and had time from injury to surgery documented. Patients were grouped based on the time to surgery (TTS) - Less than 5 Days (L5) vs. More than 5 Days (M5). TTS was also evaluated as a continuous variable. Univariable and multivariable analysis compared patient demographics, injury/surgical characteristics, postoperative complications, and clinical outcomes to determine effect of TTS. Clinical outcomes included shoulder range of motion (ROM) and Disabilities of the Arm, Shoulder, and Hand (DASH) score at least 1 year following the date of injury. Standard statistical tests were used (p<0.05 considered significant). RESULTS:, p=0.03, β= -0.27, 95% CI = -41.71- -2.89) surgery was associated with less passive forward elevation. CONCLUSION/CONCLUSIONS:Timing of surgery did not impact outcomes of patients who underwent open reduction internal fixation for proximal humerus fractures. Surgical intervention after 14 days was associated with diminished passive forward elevation only.

BACKGROUND:A frequently stated goal of an artificial knee arthroplasties is to achieve normal kinematics. However, this is not easily defined based on variations in motions previously measured for a range of activities. For activities such as crouching up and down, a fan pattern has been measured, where the lateral femoral contact displaces progressively posteriorly with flexion, and the medial contact remains almost constant. In walking and other activities, femoral-tibial contacts vary considerably in position, and even lateral pivoting has been measured at the start of the motion cycle. Fluoroscopic studies of total knee arthroplasty (TKA) patients have shown that such kinematics are not usually achieved for most TKA designs. In recent years, there has been an increasing interest in non-cruciate retaining knee arthroplasties, where both cruciate ligaments are resected. A challenge with such designs is to define the design criteria, taking account of the extensive kinematic data of normal knees, as well as clinical factors. METHODS:A TKA design was formulated where the main bearing surfaces produced medial stability and lateral mobility, but where the addition of an offset cylindrical bearing surface in the center induced progressive axial rotation and lateral 'rollback' with flexion. At the same time, anterior-posterior (A-P) and rotational laxity were provided, as in the normal knee. The new design was compared experimentally with four types of contemporary non-cruciate total knee arthroplasties. Three-dimensional printed models were fabricated. A test machine was constructed where shear and torque forces were applied at a range of flexion angles, and contact positions were determined. RESULTS:It was found that the design with the intercondylar cylindrical surface satisfied the design criteria more closely compared with the other designs. CONCLUSION/CONCLUSIONS:For non-cruciate designs to produce more normal motion characteristics, some mechanical configuration acting in concert with the lateral and medial condyles is likely to be necessary.

STUDY DESIGN/METHODS:Retrospective analysis of retrospectively collected data. OBJECTIVE:To determine the effects of preoperative nonsteroidal anti-inflammatory drug (NSAID) use on estimated blood loss (EBL) and postoperative drain output in TLIF procedures. SUMMARY OF BACKGROUND DATA/BACKGROUND:Current standards of care recommend patients prescribed NSAIDs for chronic lower back pain discontinue NSAIDs at least 1 week before spine fusion surgery. The literature surrounding the effects of preoperative NSAID use is unclear, however, with dissonant findings regarding postoperative blood loss and complications. METHODS:A retrospective case review was performed on 429 cases of 1-level or 2-level TLIF, with patient NSAID use recorded within 3 days of surgery, at a single institution. Linear and logistic regressions were used to assess associations between NSAID use, patient and surgical characteristics, EBL, and drain output. RESULTS:NSAID use was significantly positively associated with drain output (P=0.03), with an approximate increase of 21±9.7 mL/day but no significant association with any postoperative complications (P=0.77). Drain output also had significant, independent positive associations with patient age (P=0.007), male sex (P<0.001), and a number of levels fused (P<0.001), and significant negative associations with robot-assisted (P<0.001) and minimally invasive (P=0.04) procedures. No significant association was detected between NSAID use and EBL (P=0.21), though EBL had significant positive associations with operative time (P<0.001) and levels fused (P<0.001), and multiple NSAIDs had a significant positive association with EBL (P<0.001). CONCLUSIONS:NSAID use had a statistically significant, but small, effect on drain output and no detectable effect on postoperative complications within 3 days of TLIF procedures, suggesting most patients can safely continue NSAID use up until their date of surgery. Future studies should further delineate the effects of preoperative NSAID use, such that a more refined risk profile could be developed from patient and surgical characteristics and NSAID use information.

PURPOSE/OBJECTIVE:The purpose of this study was to assess the 10-year arthroplasty-free survivorship of patients over 50 years of age who underwent knee arthroscopy and to assess whether this survivorship is affected by the diagnoses of knee osteoarthritis (OA) or obesity at the time of arthroscopy. METHODS:The New York Statewide Planning and Research Cooperative System (SPARCS) administrative database from 2010 to 2020 was queried to identify all patients over the age of 50 who underwent knee arthroscopy. Kaplan-Meier survival analysis was used to assess arthroplasty-free survivorship. Cox proportional hazards models were performed to assess the effect of the diagnoses of knee OA and obesity at the time of arthroscopy based on ICD-9 and 10 codes. RESULTS:A total of 300,587 patients aged 50 years or older underwent knee arthroscopy. The arthroplasty-free survivorship rate following knee arthroscopy is 83.0% at 5 years. However, at 10 years, the arthroplasty-free survivorship decreased to 66.6%. Patients without knee OA nor obesity had an arthroplasty-free survivorship of 84.1% at 5 years and 68.5% at 10 years. However, patients with a diagnosis of both knee OA and obesity based on ICD-9 and 10 codes had an arthroplasty-free survivorship of 66.2% at 5 years and 15.4% at 10 years. (HR: 2.38; 95% CI: 2.18, 2.60; p < 0.001) CONCLUSION: At five years there is an 83% rate of arthroplasty-free survivorship. This effect deteriorates at the 10-year mark, and many are eventually destined for knee arthroplasty. Presence of diagnosis codes for both knee OA and obesity are risk factors for knee arthroplasty following knee arthroscopy in patients 50 years and older. LEVEL OF EVIDENCE/METHODS:IV, Prognostic, Case Series.

OBJECTIVES/OBJECTIVE:While extracorporeal shockwave therapy (ESWT) may be an efficacious adjunctive treatment option for musculoskeletal injuries, current research is limited by significant heterogeneity within treatment protocols. This study aims to establish international expert consensus recommendations on ESWT terminology, parameters, procedural considerations, contraindications and side effects in the application of ESWT to sports injuries. METHODS:A systematic literature search was performed on the use of ESWT for musculoskeletal and sports medicine injuries to identify potential panellists, followed by the development of a steering committee-led questionnaire. A three-stage, modified Delphi questionnaire was provided to a panel of 41 international clinical and research experts across 13 countries. Panellists had the opportunity to suggest edits to existing statements or recommend additional statements in Round 1. Consensus was defined as≥75% agreement. RESULTS:All 41 panellists completed Rounds 1, 2 and 3. Consensus was reached on 69/118 statements (58.5%), including recommendations on terminology and fundamental concepts, indications for use, procedural aspects for tendinopathy and bone pathologies, treatment correlations with imaging, periprocedural and postprocedural considerations, absolute and relative contraindications and potential side effects. Of the 49 statements that did not reach consensus, 17/49 (34.7%) were related to procedural aspects of bone pathology. CONCLUSION/CONCLUSIONS:This international panel presents recommendations on ESWT terminology, indications and treatment considerations to guide ESWT use and decision-making by sports medicine clinicians. While our panel supported the use of ESWT in the treatment of bone pathologies, certain procedural aspects of ESWT specific to these injuries did not reach consensus and require further investigation.

OBJECTIVES/OBJECTIVE:To determine if there is a correlation between time to surgery (TTS) and outcomes following repair of elbow fractures. METHODS:Design: Retrospective comparative study. SETTING/METHODS:A single, urban hospital system. PATIENT SELECTION CRITERIA/UNASSIGNED:Patients from March 2011 to September 2022 who sustained an isolated fracture about the elbow joint (AO/OTA 13-A, B, and C and 21-A, B, and C), underwent surgical repair, and had at least 6 months of post-operative follow up identified from an Institutional Review Board-approved database. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Time to surgery, in days, was recorded. Radiographic and clinical follow up was obtained at all visits and a Mayo Elbow Performance Index (MEPI) was calculated based on the latest follow up. Complications recorded: elbow contracture, infection, early hardware failure, reoperation, and fracture nonunion. Multivariable regression and Spearman correlation analysis were used to determine any significant outcome differences based on time to surgery. RESULTS:351 patients included with a mean age of 54.8 (range: 18 - 86) years with 217 females (61.8%) and 134 males (38.2%). Eighty-two patients (23.4%) developed at least one complication while 269 patients (76.6%) did not. As a continuous variable, TTS was not correlated with arc of motion at any follow up visit nor with the latest recorded MEPI score (p > 0.05). Mean TTS for patients who did and did not experience a complication was 6 (range: 0-24) and 10 (range: 0-38) days, respectively, and this was not significantly different (p = 0.217). Complication rate and any of the individual complications were not associated with TTS following a multivariable analysis controlling for age, sex, injury mechanism, open fracture, Charlson Comorbidity Index, and AO/OTA classification (p > 0.05 for all). CONCLUSIONS:Timing of surgery following OTA 13 A-C and 21 A-C elbow fractures was not associated with differences in post-operative complications or range of elbow motion. LEVEL OF EVIDENCE/METHODS:Level III.

BACKGROUND/UNASSIGNED:In the past 20 years, the incidence of total shoulder arthroplasty (TSA) has increased greatly, and it is expected to continue growing. Current literature lacks future projections for the utilization of TSA. These projections can help predict demand quantities and anticipate the future burden on the healthcare system. The aim of this study is to determine the predictions of utilization for TSA, primary and revision, through 2060. METHODS/UNASSIGNED:This analysis used the publicly available 2000-2019 data from the Center for Medicare and Medicaid Services Medicare Part-B National Summary. Procedure volumes, including TSA and revision TSA, were determined using Current Procedural Terminology codes and were uplifted to account for the growing number of Medicare eligible patients covered under Medicare Advantage. Log-linear, Poisson, negative binomial regression, and autoregressive integrated moving average models were applied to the procedural volumes to generate projections from 2020-2060. The Poisson model was chosen to display the data based on error analysis and prior literature. RESULTS/UNASSIGNED:The projected annual growth from 2020 to 2060 rates for primary and revision TSA are 11.65% growth (95% confidence interval 11.60%-11.69%) and 13.89% growth (95% confidence interval 13.35%-14.42%), respectively. By 2060, the demand for primary TSA and revision TSA is projected to be 10,029,260 and 1,690,634, respectively. CONCLUSION/UNASSIGNED:The results of this study concluded that both primary and revision TSA procedures are projected to exponentially increase from 2020 to 2060. Additionally, revision procedures are projected to increase at greater rates than their respective primary counterparts.

Endoscopic spine surgery (ESS) is growing in popularity worldwide. An expanding body of literature demonstrates rapid functional recovery with reduced morbidity compared to open techniques. Both full endoscopic spine surgery, or uniportal endoscopy, and unilateral biportal endoscopy (UBE) can be employed in conjunction with various navigation and enabling technologies for assistance with localization of anatomic orientation and assessment of the intraoperative target spinal pathology. This review article describes various navigation technologies in ESS, including 2-dimensional (2D) fluoroscopic imaging, 2D fluoroscopic navigation, 3-dimensional C-arm navigation, augmented reality, and spinal robotics. Employment of enabling navigation and emerging technology with the registration of patient-specific anatomy enables clear delineation of anatomic landmarks and facilitation of a successful procedure. Additionally, avoidance of common pitfalls during use of navigation systems in ESS is discussed in this review.

INTRODUCTION/BACKGROUND:Patient-reported outcome measures (PROMs) are an important component of evaluating patient health and are increasingly utilized in orthopedics. However, their use remains inconsistent among orthopedic subspecialties, with only 21% of orthopedic trauma surgeons reporting regular use of PROMs in their practice. While tools for quantifying patient distress in response to pain have been developed, they are often difficult to apply due to extensive questioning and the need for prospective implementation. The purpose of this study was to propose a novel retrospective technique to measure the Pain Distress Index (PDI) using two common PROMs: the visual analog scale (VAS) and the short musculoskeletal functional assessment (SMFA). METHODS:A total of 797 patients who underwent operative repair of a tibial plateau fracture or revision of long bone nonunion were included. To quantify PDI, a linear trend line was calculated from a scatter plot of SMFA Bothersome Index (BI) vs. VAS pain scores at three months postoperatively. Reported SMFA BI was compared to predicted SMFA BI, and patients were stratified into three cohorts: "limited," "adequate," and "excellent" PDI. RESULTS:In both cohorts, SMFA Function Index scores at 6 and 12 months postoperatively differed significantly among the limited, adequate, and excellent PDI levels (p < 0.0005, p < 0.0005). Worse PDI (indicating greater distress from pain) was associated with poorer SMFA Function Index scores. CONCLUSIONS:The combination of SMFA BI and VAS scores may serve as a useful tool to quantify PDI without requiring an additional questionnaire. "Limited" PDI was associated with poorer functional outcomes at 6 and 12 months postoperatively. This method may help predict which patients are at risk for worse functional outcomes and could serve as a retrospective proxy for resilience in future research.