Evaluating the Need for Preoperative MRI Before Primary Hip Arthroscopy in Patients 40 Years and Younger With Femoroacetabular Impingement Syndrome: A Multicenter Comparative Analysis.

Background: Routine hip magnetic resonance imaging (MRI) before arthroscopy for patients with femoroacetabular impingement syndrome (FAIS) offers questionable clinical benefit, delays surgery, and wastes resources. Purpose: To assess the clinical utility of preoperative hip MRI for patients aged ≤40 years who were undergoing primary hip arthroscopy and who had a history, physical examination findings, and radiographs concordant with FAIS. Study Design: Cohort study; Level of evidence, 3. Methods: Included were 1391 patients (mean age, 25.8 years; 63% female; mean body mass index, 25.6) who underwent hip arthroscopy between August 2015 and December 2021 by 1 of 4 fellowship-trained hip surgeons from 4 referral centers. Inclusion criteria were FAIS, primary surgery, and age ≤40 years. Exclusion criteria were MRI contraindication, reattempt of nonoperative management, and concomitant periacetabular osteotomy. Patients were stratified into those who were evaluated with preoperative MRI versus those without MRI. Those without MRI received an MRI before surgery without deviation from the established surgical plan. All preoperative MRI scans were compared with the office evaluation and intraoperative findings to assess agreement. Time from office to arthroscopy and/or MRI was recorded. MRI costs were calculated. Results: Of the study patients, 322 were not evaluated with MRI and 1069 were. MRI did not alter surgical or interoperative plans. Both groups had MRI findings demonstrating anterosuperior labral tears treated intraoperatively (99.8% repair, 0.2% debridement, and 0% reconstruction). Compared with patients who were evaluated with MRI and waited 63.0 ± 34.6 days, patients who were not evaluated with MRI underwent surgery 6.5 ± 18.7 days after preoperative MRI. MRI delayed surgery by 24.0 ± 5.3 days and cost a mean $2262 per patient. Conclusion: Preoperative MRI did not alter indications for primary hip arthroscopy in patients aged ≤40 years with a history, physical examination findings, and radiographs concordant with FAIS. Rather, MRI delayed surgery and wasted resources. Routine hip MRI acquisition for the younger population with primary FAIS with a typical presentation should be challenged.

Institution Origin and Medical School Rank Impact the Citation Frequency and Publication Rate in Orthopaedic Sports Medicine Journals.

Purpose: To examine the trends between various categories of institutions with their respective published orthopaedic sports medicine content and to determine the publication output and citation rate from the 25 highest-ranked medical schools compared with lower-ranked institutions. Methods: Publications between 2015 and 2019 from the American Journal of Sports Medicine, Journal of Bone and Joint Surgery, Journal of Shoulder and Elbow Surgery, Clinical Orthopaedics and Related Research, and Arthroscopy were categorized into university/university affiliated hospitals, non-university affiliated teaching hospitals, public/semi-government research institutes, nonprofit research institutes, private sector institutions, government institutions, and other institutions. Citation rates were collected from PubMed for the first and corresponding author. Similarly, corresponding authors were stratified by U.S. News and World Report 2021 medical school research rankings. Results: Of the 12,152 publications identified, 5,044 publications met the inclusion criteria. Nonprofit research institutions garnered the greatest number of citations on average (6.44 based on first author, SD 8.83, n = 214; 6.62 based on corresponding author, SD 9.65, n = 208; P < .001), while university/university-affiliated hospitals produced the majority of published articles (77.0% based on first author, 76.8% based on corresponding author), but had lower average citation rates (4.48 based on first author, SD 6.67, n = 3,886; 4.44 based on corresponding author, SD 6.55, n = 3,873; P < .001). Furthermore, of 1953 medical school publications, the top 25 accounted for 53.1% of publications; however, there was no statistical difference between their citation rates and those of lower rankings (P = 0.47). Conclusions: Publications are cited at different rates, depending on their institution of origin. In addition, high-ranking medical schools produce a disproportionately greater output of publications than lower-ranking schools, but there is no statistically significant difference in citation rates on an individual publication basis. Clinical Relevance: Knowing how an institution's ranking influences publication and citation rates can help us understand bias in the scientific literature.

Workplace-related musculoskeletal injury trends in the United States from 1992 to 2018.

INTRODUCTION: The purpose of our study is to assess workplace-related musculoskeletal (wrMSK) injury trends by utilizing Bureau of Labor Statistics (BLS) data. We hypothesize that trunk injuries are the most commonly reported, injuries occur most frequently in the manufacturing sector, and that injury type occurrence differs according to body region affected. METHODS: This study assessed wrMSK injury data provided by the BLS from 1992 to 2018. The three main body regions analyzed were lower extremity (LE), upper extremity (UE), and trunk. Injury data was also assessed by industrial sector (Agriculture, Manufacturing, Healthcare, and Construction) and injury type (fractures, multiple injuries, sprains/strains/tears, tendonitis, cuts/lacerations, pain/soreness, and bruises). Negative binomial regression and pairwise comparisons with a Benjamini-Hochberg adjustment were utilized to compare calculated incidence rate ratios for wrMSK injuries. Exponentiated beta estimates were used to calculate the estimated annual percent changes of wrMSK injuries within each industrial sector. RESULTS: Occurrence of wrMSK injuries from 1992 to 2018 was significantly lower for LE when compared to both upper extremity and trunk (p < 0.001). Manufacturing is shown to be the industry with the most wrMSK injuries in each of UE, LE, and trunk. wrMSK injuries were shown to decrease in each industrial sector over the timespan assessed, with the greatest percent change occurring in the manufacturing sector. Lacerations and tendonitis were the most common diagnosis types in UE, while pain/soreness and strains/sprains/tears were most common in trunk and bruises were most common in LE. DISCUSSION: From 1992 to 2018, trunk injuries were the most frequently occurring wrMSK injury, but not to a significantly higher degree than upper extremity injuries. wrMSK injury types that may require orthopedic surgical care affect specific body regions to different degrees, with cuts/lacerations and tendonitis most commonly affecting the upper extremity. Thus, it appears that wrMSK injuries in the upper extremity are of particular importance from an orthopedic care perspective.

Time-Driven Activity-Based Costing Accurately Determines Bundle Cost for Rotator Cuff Repair.

PURPOSE: The purpose of this study was to determine the cost of the episode of care for primary rotator cuff repair (RCR) from day of surgery to 90 days postoperatively using the time-driven activity-based costing (TDABC) method. The secondary purpose of this study was to identify the main drivers of cost for both phases of care. METHODS: This retrospective case series study used the TDABC method to determine the bundled cost of care for an RCR. First, a process map of the RCR episode of care was constructed in order to determine drivers of fixed (i.e., rent, power), direct variable (i.e., healthcare personnel), and indirect costs (i.e., marketing, building maintenance). The study was performed at a Midwestern tertiary care medical system, and patients were included in the study if they underwent an RCR from January 2018 to January 2019 with at least 90 days of postoperative follow-up. In this article, all costs were included, but we did not account for fees to provider and professional groups. RESULTS: The TDABC method calculated a cost of $10,569 for a bundled RCR, with 76% arising from the operative phase and 24% from the postoperative phase. The main driver of cost within the operative phase was the direct fixed costs, which accounted for 35% of the cost in this phase, and the largest contributor to cost within this category was the cost of implants, which accounted for 55%. In the postoperative phase of care, physical therapy visits were the greatest contributor to cost at 59%. CONCLUSION: In a bundled cost of care for RCR, the largest cost driver occurs on the day of surgery for direct fixed costs, in particular, the implant. Physical therapy represents over half of the costs of the episode of care. Better understanding the specific cost of care for RCR will facilitate optimization with appropriately designed payment models and policies that safeguard the interests of the patient, physician, and payer. LEVEL OF EVIDENCE: IV, therapeutic case series.

Assessing Orthopedic Patient Preferences for Mandated Virtual Care During the COVID-19 Pandemic and Elective Virtual Care in Non-Pandemic Circumstances.

The purpose of this study was to compare orthopedic patient preferences for mandated virtual care during the coronavirus disease 2019 (COVID-19) pandemic and elective virtual care during non-pandemic circumstances. An orthopedic virtual care questionnaire was administered to adult orthopedic patients undergoing their first orthopedic virtual visit between March 15, 2020, and May 18, 2020. The questionnaire had 13 items rated on a 1-to-5 Likert scale ("strongly agree" to "strongly disagree"). Responses were compared using Kruskal-Wallis and nonparametric Wilcoxon rank-sum tests. Patients showed higher preferences for mandated virtual care during the pandemic when compared with elective virtual care during non-pandemic circumstances (2.25±1.31 vs 4.10±1.25, P<.0001) and also preferred virtual visits in other specialties compared with orthopedics (2.17±1.35 vs 2.79±1.42, P<.0001). Patients older than 50 years were more likely to view virtual care as the best option during the pandemic (2.06±1.25 vs 2.48±1.35, P<.0165) and equally as effective as in-person visits in non-pandemic circumstances (2.45±1.36 vs 2.83±1.18, P<.0150). Female patients were more likely to pursue future orthopedic virtual visits (2.61±1.37 vs 3.07±1.45, P<.0203) and view their virtual visit as equally effective as an in-person visit (2.47±1.33 vs 2.87±1.18, P<.0181). Orthopedic patient preference for mandated virtual care during the COVID-19 pandemic seems to be higher than for elective virtual care during non-pandemic circumstances, and older and female patients appear to favor virtual care. [Orthopedics. 2021;44(4):e471-e476.].

Orthopaedic provider perceptions of virtual care : which providers prefer virtual care?

AIMS: The purpose of our study was to determine which groups of orthopaedic providers favour virtual care, and analyze overall orthopaedic provider perceptions of virtual care. We hypothesize that providers with less clinical experience will favour virtual care, and that orthopaedic providers overall will show increased preference for virtual care during the COVID-19 pandemic and decreased preference during non-pandemic circumstances. METHODS: An orthopaedic research consortium at an academic medical system developed a survey examining provider perspectives regarding orthopaedic virtual care. Survey items were scored on a 1 to 5 Likert scale (1 = "strongly disagree", 5 = "strongly agree") and compared using nonparametric Mann-Whitney U test. RESULTS: Providers with less experience were more likely to recommend virtual care for follow-up visits (3.61 on the Likert scale (SD 0.95) vs 2.90 (SD 1.23); p = 0.006) and feel that virtual care was essential to patient wellbeing (3.98 (SD 0.95) vs 3.00 (SD 1.16); p < 0.001) during the pandemic. Less experienced providers also viewed virtual visits as providing a similar level of care as in-person visits (2.41 (SD 1.02) vs 1.76 (SD 0.87); p = 0.006) and more time-efficient than in-person visits (3.07 (SD 1.19) vs 2.34 (SD 1.14); p = 0.012) in non-pandemic circumstances. During the pandemic, most providers viewed virtual care as effective in providing essential care (83.6%, n = 51) and wanted to schedule patients for virtual care follow-up (82.2%, n = 50); only 10.9% (n = 8) of providers preferred virtual visits in non-pandemic circumstances. CONCLUSION: Orthopaedic providers with less clinical experience seem to favourably view virtual care both during the pandemic and under non-pandemic circumstances. Providers in general appear to view virtual care positively during the pandemic but are less accommodating towards it in non-pandemic circumstances. Cite this article: Bone Jt Open 2021;2(6):405-410.

Manufacturing Workers Have a Higher Incidence of Carpal Tunnel Syndrome.

OBJECTIVE: It is unclear whether clerical or labor-type work is more associated with risk for developing work-related carpal tunnel syndrome (WrCTS). METHODS: National employment, demographic, and injury data were examined from the Bureau of Labor Statistics databases for the years 2003 to 2018. Injuries for clerical and labor industries were compared using linear regression, two-group t test, and one-way analysis of variance (ANOVA) analysis. RESULTS: WrCTS injuries are decreasing over time (B = -1002.62, P < 0.001). The labor industry demonstrated a significantly higher incidence of WrCTS when compared with the clerical industries (P < 0.001). Within labor industries, the manufacturing industry had the highest incidence of WrCTS over time (P < 0.001). CONCLUSIONS: Our study showed WrCTS injuries have declined over time. Additionally, our findings may suggest that the labor industry has a stronger association with WrCTS than the clerical industry.

The Effect of the Crow Hop on Elbow Stress During an Interval Throwing Program.

BACKGROUND: Postoperative rehabilitation protocols after ulnar collateral ligament (UCL) reconstruction typically involve a structured interval throwing program. In an effort to minimize torque placed on the UCL, athletes are often instructed to throw with a crow hop, even at short throwing distances. However, the effect of the crow hop on medial elbow stress is unknown. PURPOSE/HYPOTHESIS: The purpose was to determine whether elbow stress differs with and without a crow hop across the throwing distances of a typical interval throwing program. We hypothesized that crow hop throws would generate lower torque on the elbow than standing throws at each distance of the interval throwing program. STUDY DESIGN: Controlled laboratory study. METHODS: Healthy high school and collegiate pitchers and position players were recruited from the surrounding area. Each player was outfitted with a wearable athletic sleeve and device that recorded elbow torque (Newton-meters), arm slot (degrees), arm speed (revolutions per minute), and shoulder rotation (degrees). Ball velocity (miles per hour) was measured using a radar gun. Players were instructed to perform 3 crow hop throws and 3 standing throws at distances of 30, 45, 60, 90, 120, 150, and 180 feet. A repeated measures analysis of variance was used to compare ball velocity, elbow torque, arm slot, arm speed, and shoulder rotation between crow hop and standing throws at each throwing distance. RESULTS: Twenty athletes participated in this study (average age, 17.8 years; range, 15-25 years). The average medial elbow torque increased at each distance for both crow hop and standing throws at distances of 30, 45, 60, and 90 feet (P < .05), after which there were no significant increases in elbow torque (P > .05). The average torque was higher for crow hop throws than standing throws at distances of 30 feet (13.9 N·m vs 12.0 N·m; P = .002), 45 feet (21.8 N·m vs 19.3 N·m; P = .005), and 60 feet (28.0 N·m vs 24.5 N·m; P = .02). CONCLUSION: Crow hop throws generated greater medial elbow torque than standing throws at distances up to 60 feet; however, there were no differences in elbow torque at distances greater than 60 feet between the 2 throw types. For both crow hop and standing throws, elbow stress increased at each distance interval up to 90 feet before plateauing at distances greater than 90 feet. The crow hop throwing technique does not reduce medial elbow stress during a simulated interval throwing program, and it may actually increase torque at shorter throwing distances. CLINICAL RELEVANCE: The results of our study indicate that it would be prudent for players to initially perform standing throws at shorter distances and only later be allowed to employ a natural crow hop at greater distances to minimize torque placed on the medial elbow during UCL rehabilitation protocols.

Older, Male Orthopaedic Surgeons From Southern Geographies Prescribe Higher Doses of Post-Operative Narcotics Than do their Counterparts: A Medicare Population Study.

PURPOSE: We wanted to evaluate opioid prescribing patterns among orthopaedic surgeons and to identify demographics that may be associated with more extensive opioid prescribing habits that could be candidates for targeted education policies. METHODS: Medicare Part D prescriber and prescription information for the most recent available year, 2017, was accessed via a publicly available database offered by the Centers for Medicare and Medicaid. Number of total prescriptions, number of opioid prescriptions, and the total days' supply of opioids prescribed were analyzed for each of 19,219 orthopaedic surgeons. Demographics and board certification status were also recorded. RESULTS: Orthopaedic surgeons who wrote the most opioid prescriptions (>400 per year) also wrote the longest prescription durations (14.1 days/prescription, P < .05 for all comparisons). Surgeons with more than 30 years of experience wrote the longest prescriptions (11.8 days/prescription; P < .001). Male surgeons wrote more opioid prescriptions than female surgeons (151 vs 95, respectively; P < .001). However, female surgeons wrote longer prescriptions than male surgeons (7.5 days/prescription vs 6.1 days/prescription, respectively; P = .01). Surgeons from southern states wrote the most opioid prescriptions (1,386,897) and the longest prescriptions, with an average of 13.0 days per prescription, whereas western states wrote the shortest prescriptions at 10.4 days per prescription (P = .004). CONCLUSION: There are demographic correlations between orthopaedic surgeons and opioid prescribing patterns. In particular, male, older southern surgeons prescribe the highest volumes of opioids. This provides an opportunity for targeted education versus overarching, general policies. Potential directions for future investigation can focus on assessing recent trends in opioid prescriptions among orthopaedic providers. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Preoperative Patient-Reported Outcomes Measurement Information System Computerized Adaptive Testing (PROMIS CAT) Scores Predict Achievement of Minimum Clinically Important Difference Following Anterior Cruciate Ligament Reconstruction Using an Anchor-Based Methodology.

PURPOSE: To determine the change in Patient-Reported Outcomes Measurement Information System Computerized Adaptive Testing (PROMIS CAT) scores for physical function, pain interference, and depression that constitute minimum clinically important difference (MCID) using an anchor-based technique and to identify pre-operative clinical thresholds in anchor-based MCID that predict likelihood of achieving MCID following anterior cruciate ligament (ACL) reconstruction. METHODS: Adult patients aged 18 years or older undergoing ACL reconstruction that completed both preoperative and postoperative PROMIS CAT assessments and an anchor-based questionnaire were identified over a 23-month period. Anchor-based MCID was determined for PROMIS CAT forms for physical function (PROMIS PF CAT), pain interference (PROMIS PI CAT), and depression (PROMIS D CAT). RESULTS: A total of 137 patients were included for statistical analysis, with pre-operative PROMIS CAT forms completed 27.9 ± 31.2 days before surgery and 492.5 ± 219.9 days postoperatively on average. Statistically significant improvements were observed for all PROMIS CAT domains. PROMIS PF CAT improved from 39.5 ± 8.2 to 55.0 ± 9.7 (P < .0005), PROMIS PI CAT from 59.8 ± 7.2 to 48.2 ± 8.3 (P < .0005), and PROMIS D CAT from 47.9 ± 8.8 to 41.5 ± 8.6 (P < .0005). Anchor-based MCID for each PROMIS CAT form was calculated to be +4.5, -5.4, and -4.1 for PROMIS PF CAT, PROMIS PI CAT, and PROMIS D CAT, respectively. Mean difference between preoperative and postoperative PROMIS CAT scores exceeded MCID for all domains. The percentage of patients achieving MCID for PROMIS PF CAT, PROMIS PI CAT, and PROMIS D CAT was 85%, 72%, and 55%, respectively. After introduction of 95% specificity cutoffs, the percentage of patients achieving MCID for PROMIS PF CAT, PROMIS PI CAT, and PROMIS D CAT increased to 100% (<35.6 cutoff score), 92% (>65.7 cutoff score), and 83% (>57.5 cutoff score), respectively. CONCLUSIONS: According to anchor-based analysis of PROMIS CAT MCID, ACL reconstruction is effective in improving physical function, pain interference, and depression symptoms. In addition, preoperative PROMIS CAT scores can predict the likelihood of achieving MCID postoperatively. LEVEL OF EVIDENCE: Level IV, prognostic case series.