Association Between Social Media Activity and Ratings on Physician Review Websites Among Orthopaedic Surgeons With an Active Online Media Presence.

Background: Social media has the potential to play a substantial role in the decision-making of patients when choosing a physician for care. Purpose: The purpose of this study was to determine whether an association exists between physician social media activity and patient satisfaction ratings on physician review websites (PRWs) as well as number of reviews. It was hypothesized that there would be a significant association between physician social media utilization and patient satisfaction ratings. Study Design: Cross-sectional study. Methods: The American Orthopaedic Society for Sports Medicine database was queried for the complete membership list. The online media profile and level of activity of the members were evaluated, and an online media presence score was calculated. The surgeons with the approximately top 10% of online media presence scores were compiled to assess the relationship between social media usage (Twitter, Instagram, YouTube, and Facebook) and patient satisfaction ratings on the Google Reviews, Healthgrades, and Vitals PRWs. Bivariate analysis was performed to compare demographic variables and level of online presence. Results: A total of 325 surgeons were included in the analysis. The most common platform used was Facebook (88.3%). There was no significant relationship between active social media use and overall ratings on any of the PRWs. Active Twitter use was associated with a greater number of ratings on all review websites, a greater number of comments on Google Reviews and Healthgrades, and shorter patient-reported clinic wait times on Healthgrades. Active Instagram use was associated with a greater number of comments on Vitals. No relationships were observed for YouTube or Facebook. Conclusion: For the included sports medicine surgeons who were most active on social media, no significant relationships were found between social media use and overall ratings on PRWs. Of all the platforms assessed, active use of Twitter was the only significant predictor of more reviews on PRWs. Thus, when deciding which form of social media engagement to prioritize in building one's practice, Twitter may serve as a relatively low-demand, high-reward option.

Lateral Patellofemoral Ligament Reconstruction With Semitendinosus Allograft in the Setting of Previous Lateral Release.

The lateral patellofemoral ligament acts to resist medial displacement of the patella. When medial subluxation occurs, it usually has an iatrogenic cause such as prior lateral release, an over-tightened medial patellofemoral ligament reconstruction, or detachment of the vastus lateralis from the patella. The justification for lateral retinacular release has historically been to address extensor mechanism issues such as imbalance of the mechanism due to increased retinacular tension. We present a Technical Note on the treatment of chronic medial patellar instability due to a previous lateral retinacular release using a soft-tissue reconstruction approach with a semitendinosus allograft.

General Versus Neuraxial Anesthesia in Revision Surgery for Periprosthetic Joint Infection.

BACKGROUND: The purpose of this study was to compare neuraxial and general anesthesia in revision surgery for periprosthetic joint infection (PJI). METHODS: Patients undergoing revision arthroplasty for PJI were identified in the 2005-2019 American College of Surgeons National Surgical Quality Improvement Program databases. Thirty-day outcomes were compared between general and neuraxial anesthesia. Propensity-score matching and multivariate analysis were used to control patient and procedural variables. RESULTS: Neuraxial anesthesia was used in 1511 (16.8%) cases and general anesthesia in 7468 (83.2%) cases. Neuraxial anesthesia had a lower risk of any adverse event (odds ratio [OR] 0.70, P < .001), serious adverse events (OR 0.77, P < .001), and minor adverse events (OR 0.66, P < .001). Among 875 reoperations and 1351 readmissions, two had a diagnosis of intraspinal abscess, both occurring after general anesthesia. CONCLUSIONS: Neuraxial anesthesia was associated with a lower risk of adverse events when compared to general anesthesia in revision surgery for PJI.

"Can you see my screen?" Addressing Racial and Ethnic Disparities in Telehealth.

PURPOSE OF REVIEW: Telehealth is an innovative approach with great potential to bridge the healthcare delivery gap, especially for underserved communities. While minority populations represent a target audience that could benefit significantly from this modern solution, little of the existing literature speaks to its acceptability, accessibility, and overall effectiveness in underserved populations. Here, we review the various challenges and achievements of contemporary telehealth and explore its impact on care delivery as an alternative or adjunct to traditional healthcare delivery systems. RECENT FINDINGS: Given the COVID-19 pandemic, there has been a rapid acceleration in telemedicine adoption. Recent studies of telemedicine utilization during the pandemic reveal stark disparities in telemedicine modality use based on race, socioeconomic status, geography, and age. SUMMARY: While telehealth has great potential to overcome healthcare obstacles, the digital divide stands as a challenge to equitable telehealth and telemedicine adoption. Achieving health equity in telehealth will require the mobilization of resources, financial incentives, and political will among hospital systems, insurance companies, and government officials.

Predictors and Sequelae of Postoperative Delirium in a Geriatric Patient Population With Hip Fracture.

INTRODUCTION: Postoperative delirium is common for patients with hip fracture. Predictors of postoperative delirium and its association with preexisting dementia and adverse postoperative outcomes in a geriatric hip fracture population were assessed. METHODS: Patients with hip fracture aged 60 years and older were identified in the 2016 and 2017 National Surgical Quality Improvement Program Procedure Targeted Databases. Independent risk factors of postoperative delirium were identified. Associations with mortality, readmission, and revision surgery were evaluated using moderation and mediation analysis. RESULTS: Of 18,754 patients with hip fracture, 30.2% had preoperative dementia, 18.8% had postoperative delirium, and 8.3% had both preoperative dementia and postoperative delirium. Independent predictors of postoperative delirium were as follows: older age, male sex, higher American Society of Anesthesiologists score, dependent functional status, nongeneral anesthesia, preoperative diabetes, bleeding disorder, and preoperative dementia. Preoperative dementia and postoperative delirium each had an independent correlation with 30-day mortality (odds ratios = 2.06 and 1.92, respectively, with P < 0.001 for both). However, when both were present, those with preoperative dementia and postoperative delirium had an even higher odds of mortality based on moderation analysis (odds ratio = 2.25, P < 0.001). Readmissions and reoperations were significantly correlated with postoperative delirium, but not with preoperative dementia. The combination of preoperative dementia and postoperative delirium, however, did have compounding effects. Furthermore, a significant proportion of the total effect of preoperative dementia on mortality and readmission was accounted for by the development of postoperative delirium based on mediation analysis (medeff: 7%, P < 0.001 and medeff: 35%, P < 0.001). DISCUSSION: Postoperative delirium is a potentially preventable postoperative adverse outcome that was seen in 18.8% of 18,754 patients with hip fracture. Those with preoperative dementia seem to be a particularly at-risk subpopulation. Quality improvement initiatives to minimize postoperative delirium in this hip fracture population should be considered and optimized.

Incidence, predictors, and timing of post-operative stroke following elective total hip arthroplasty and total knee arthroplasty.

BACKGROUND: Postoperative stroke is a rare but potentially devastating complication following total hip arthroplasty (THA) and total knee arthroplasty (TKA). The purpose of the current study was to determine the incidence, independent risk factors, and timing of stroke following THA and TKA utilizing the National Surgical Quality Improvement (NSQIP) database. METHODS: Patients who underwent elective primary THA and TKA were identified in the 2005-2016 NSQIP database. Thirty-day postoperative strokes were identified, timing was characterized, and an incidence curve was created. Multivariate analyses determined the independent predictors of these strokes. RESULTS: Of 333,117 patients identified, 286 (0.09%) experienced a stroke. Given that THA vs TKA was not a univariate predictor of stroke, the two procedures were considered together. The majority (65%) of strokes occurred before discharge. Of the strokes observed, 25% occurred by postoperative day one, 50% by postoperative day two, and 75% by postoperative day nine. Independent risk factors for postoperative stroke were: age (60-69 years old odds ratio [OR] = 4.2; 70-79 years old OR = 8.1; ≤80 years old OR = 16.1), higher American Society of Anesthesiologists (ASA) score (ASA≥3 OR = 1.7), and smoking [OR = 1.6). CONCLUSION: The incidence of stroke after THA/TKA was low at 0.09%, with the majority occurring prior to discharge and half occurring by postoperative day two. Patients who were older, sicker, or who were smokers were at greater risk of postoperative stroke. These findings can be used to council patients and to optimize patient care. LEVEL OF EVIDENCE: Level III, Retrospective comparative study.

Perioperative Outcomes of Hemiarthroplasty Versus Total Hip Arthroplasty for Geriatric Hip Fracture: The Importance of Studying Matched Populations.

BACKGROUND: Geriatric femoral neck fracture is a common injury for which hemiarthroplasty (HA) or total hip arthroplasty (THA) may be considered in select patients. As prior database studies comparing these have not used propensity matching, which is a robust statistical method of controlling for potentially confounding variables, unmatched and matched methodologies are contrasted in the present study. METHODS: Patients aged ≥70 years who underwent HA or THA for hip fractures were identified from the 2012-2015 National Surgical Quality Improvement database. Propensity score 1:1 matching was performed. Differences in rates of 30-day postoperative adverse outcomes were compared using multivariate logistic regression for unmatched and matched cohorts. RESULTS: In total, 15,558 patients (14,403 HA and 1155 THA) were evaluated. Although multivariate outcomes for the unmatched populations were different for blood transfusion, mortality, minor adverse events, major adverse events, and reoperation, multivariate outcomes for matched populations only differed for blood transfusion (odds ratio 0.6 for HA vs THA, P < .001). Of note, although readmissions were similar for the two groups, patients undergoing THA had a 5.4% greater rate of perioperative readmission due to dislocation. CONCLUSION: Geriatric patients undergoing HA and THA for hip fracture were compared with and without propensity matching. Once matching was performed, the only differences in outcomes between the two groups were a lower transfusion rate among the HA group and a greater readmission rate due to dislocation among the THA group. This suggests that either procedure can be safely considered if found to be advantageous from a longer-term outcome perspective. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Abnormally High, as Well as Low, Preoperative Platelet Counts Correlate With Adverse Outcomes and Readmissions After Elective Total Knee Arthroplasty.

BACKGROUND: Laboratory studies are routinely performed as a part of the preoperative workup for a total knee arthroplasty (TKA). The ramifications of abnormal preoperative platelet counts remain uncharacterized in large, multicenter patient populations. METHODS: Patients who underwent elective primary TKA were identified in the 2011-2015 National Surgical Quality Improvement Program database. Risk of 30-day postoperative complications was calculated as a function of preoperative platelet counts. Patients were characterized as having a normal platelet count, abnormally low platelet count, and abnormally high platelet count based on relative risk calculations. Univariate and multivariate analyses were performed to associate abnormal platelet counts with patient demographics, operative variables, 30-day postoperative complications, and readmissions. RESULTS: In total, 140,073 patients who underwent elective TKA were identified. Using the relative risk threshold of 1.5 for any adverse event, abnormally low and abnormally high platelet count thresholds were set at ≤116,000/mL and ≥492,000/mL, respectively. Multivariate analyses revealed low platelet counts to be associated with higher rates of any, major, and minor adverse events and longer length of stay. Analogously, high platelet counts were associated with higher rates of any and minor adverse events and longer length of stay. CONCLUSION: The present study employed a large patient sample size and showed that elective TKA patients with abnormally high, as well as low, platelet counts are at increased risk of postoperative adverse outcomes. Focused attention needs to be paid to TKA patients with preoperative abnormal platelet counts for optimization and postoperative care. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Cardiac Complications Related to Spine Surgery: Timing, Risk Factors, and Clinical Effect.

INTRODUCTION: Large cohort studies evaluating cardiac complications in patients undergoing spine surgery are lacking. The purpose of this study was to determine the incidence, timing, risk factors, and effect of cardiac complications in spine surgery by using a national database, the American College of Surgeons National Surgical Quality Improvement Program. METHODS: Patients who underwent spine surgery in the 2005 to 2012 National Surgical Quality Improvement Program database were identified. The primary outcome was an occurrence of cardiac arrest or myocardial infarction during the operation or the 30-day postoperative period. Risk factors for development of cardiac complications were identified using multivariate regression. The postoperative length of stay, 30-day readmission, and mortality were compared between patients who did and did not experience a cardiac complication. RESULTS: A total of 30,339 patients who underwent spine surgery were identified. The incidence of cardiac complications was 0.34% (95% confidence interval [CI], 0.27% to 0.40%). Of the cases in which a cardiac complication developed, 30% were diagnosed after discharge. Risk factors for the development of cardiac complications were greater age (most notably ≥80 years, relative risk [RR] = 5.53; 95% CI = 2.28 to 13.43; P < 0.001), insulin-dependent diabetes (RR = 2.58; 95% CI = 1.51 to 4.41; P = 0.002), preoperative anemia (RR = 2.46; 95% CI = 1.62 to 3.76; P < 0.001), and history of cardiac disorders and treatments (RR = 1.88; 95% CI = 1.16 to 3.07; P = 0.011). Development of a cardiac complication before discharge was associated with a greater length of stay (7.9 versus 2.6 days; P < 0.001), and a cardiac complication after discharge was associated with increased 30-day readmission (RR = 12.32; 95% CI = 8.17 to 18.59; P < 0.001). Development of a cardiac complication any time during the operation or 30-day postoperative period was associated with increased mortality (RR = 113.83; 95% CI = 58.72 to 220.68; P < 0.001). DISCUSSION: Perioperative cardiac complications were diagnosed in approximately 1 in 300 patients undergoing spine surgery. High-risk patients should be medically optimized and closely monitored through the perioperative period. LEVEL OF EVIDENCE: Level III.

Dialysis Patients Undergoing Total Knee Arthroplasty Have Significantly Increased Odds of Perioperative Adverse Events Independent of Demographic and Comorbidity Factors.

BACKGROUND: The prevalence of dialysis-dependent patients is growing, and an increasing number of these patients are being considered for total knee arthroplasty (TKA). Studies assessing the preoperative risk associated with TKA in this population are limited to institutional cohorts with small sample sizes or national inpatient databases that lack follow-up data. METHODS: The 2006-2015 National Surgical Quality Improvement Program databases were queried for adult patients undergoing elective TKA. Differences in 30-day any/severe/minor adverse event, need for reoperation, readmission, and mortality were compared for dialysis-dependent and nondialysis TKA patients using risk-adjusted logistic regression. To account for the smaller number of dialysis patients and variations in study populations, coarsened exact matching was used. The proportion of adverse events that occurred before vs after discharge was also assessed. RESULTS: In total, 250 dialysis-dependent patients and 163,560 nondialysis patients met inclusion criteria. After controlling for patient demographics (age, sex, body mass index, functional status) and overall health (American Society of Anesthesiologists class), matched analysis revealed dialysis-dependent patients to be significantly more likely to experience any adverse event (odds ratio = 2.01; 95% confidence interval [CI], 1.34-3.02; P = .001), severe adverse event (odds ratio = 2.49; 95% CI, 1.61-3.84; P < .001), reoperation (odds ratio = 2.38; 95% CI, 1.19-4.75; P = .014), readmission (odds ratio = 2.32; 95% CI, 1.47-3.66; P = .001), and mortality (odds ratio = 6.71; 95% CI, 2.99-22.50; P = .002). The majority of adverse outcomes occurred postdischarge. CONCLUSION: Independent of patient demographics and overall health (American Society of Anesthesiologists), patients undergoing dialysis before TKA are significantly more likely to experience 30-day adverse outcomes than matched nondialysis cohorts. Preoperative evaluation of bone health status and management of medical treatment are warranted in this fragile population. Cautious surgical planning, patient counseling, and heightened surveillance are necessitated throughout their perioperative period and postoperative recovery plans may need to be different from nondialysis counterparts. Furthermore, hospitals and physicians must take these increased risks into account when working on bundle payment reimbursement strategies and resource allocation. LEVEL OF EVIDENCE: 3.

Molecular Targeted Therapy Approach to Musculoskeletal Tumors.

The future of cancer treatment is promising. Although marred by years of plateau in outcomes, new avenues have been identified that are poised to change how we treat cancer. Molecular targeted therapy or targeted therapy is one of these methods. Molecular targeted therapy involves identifying specific pathways or markers that allow cancer cells to flourish. Once identified, specific molecules can be used to block proliferative pathways, thereby negatively impacting tumor growth. Targeting specific pathways that prolong the survival of the cancer cell can lead to a decreased cancer burden, and improved patient outcomes. This article reviews the tenets of molecular targeted therapy, common pathways, target acquisition for drug development, and the pathways that have been elucidated in musculoskeletal tumors.

Quantifying growing versus non-growing ovarian follicles in the mouse.

BACKGROUND: A standard histomorphometric approach has been used for nearly 40 years that identifies atretic (e.g., dying) follicles by counting the number of pyknotic granulosa cells (GC) in the largest follicle cross-section. This method holds that if one pyknotic granulosa nucleus is seen in the largest cross section of a primary follicle, or three pyknotic cells are found in a larger follicle, it should be categorized as atretic. Many studies have used these criteria to estimate the fraction of atretic follicles that result from genetic manipulation or environmental insult. During an analysis of follicle development in a mouse model of Fragile X premutation, we asked whether these 'historical' criteria could correctly identify follicles that were not growing (and could thus confirmed to be dying). METHODS: Reasoning that the fraction of mitotic GC reveals whether the GC population was increasing at the time of sample fixation, we compared the number of pyknotic nuclei to the number of mitotic figures in follicles within a set of age-matched ovaries. RESULTS: We found that, by itself, pyknotic nuclei quantification resulted in high numbers of false positives (improperly categorized as atretic) and false negatives (improperly categorized intact). For preantral follicles, scoring mitotic and pyknotic GC nuclei allowed rapid, accurate identification of non-growing follicles with 98% accuracy. This method most often required the evaluation of one follicle section, and at most two serial follicle sections to correctly categorize follicle status. For antral follicles, we show that a rapid evaluation of follicle shape reveals which are intact and likely to survive to ovulation. CONCLUSIONS: Combined, these improved, non-arbitrary methods will greatly improve our ability to estimate the fractions of growing/intact and non-growing/atretic follicles in mouse ovaries.

Granulosa cell and oocyte mitochondrial abnormalities in a mouse model of fragile X primary ovarian insufficiency.

STUDY HYPOTHESIS: We hypothesized that the mitochondria of granulosa cells (GC) and/or oocytes might be abnormal in a mouse model of fragile X premutation (FXPM). STUDY FINDING: Mice heterozygous and homozygous for the FXPM have increased death (atresia) of large ovarian follicles, fewer corpora lutea with a gene dosage effect manifesting in decreased litter size(s). Furthermore, granulosa cells (GC) and oocytes of FXPM mice have decreased mitochondrial content, structurally abnormal mitochondria, and reduced expression of critical mitochondrial genes. Because this mouse allele produces the mutant Fragile X mental retardation 1 (Fmr1) transcript and reduced levels of wild-type (WT) Fmr1 protein (FMRP), but does not produce a Repeat Associated Non-ATG Translation (RAN)-translation product, our data lend support to the idea that Fmr1 mRNA with large numbers of CGG-repeats is intrinsically deleterious in the ovary. WHAT IS KNOWN ALREADY: Mitochondrial dysfunction has been detected in somatic cells of human and mouse FX PM carriers and mitochondria are essential for oogenesis and ovarian follicle development, FX-associated primary ovarian insufficiency (FXPOI) is seen in women with FXPM alleles. These alleles have 55-200 CGG repeats in the 5' UTR of an X-linked gene known as FMR1. The molecular basis of the pathology seen in this disorder is unclear but is thought to involve either some deleterious consequence of overexpression of RNA with long CGG-repeat tracts or of the generation of a repeat-associated non-AUG translation (RAN translation) product that is toxic. STUDY DESIGN, SAMPLES/MATERIALS, METHODS: Analysis of ovarian function in a knock-in FXPM mouse model carrying 130 CGG repeats was performed as follows on WT, PM/+, and PM/PM genotypes. Histomorphometric assessment of follicle and corpora lutea numbers in ovaries from 8-month-old mice was executed, along with litter size analysis. Mitochondrial DNA copy number was quantified in oocytes and GC using quantitative PCR, and cumulus granulosa mitochondrial content was measured by flow cytometric analysis after staining of cells with Mitotracker dye. Transmission electron micrographs were prepared of GC within small growing follicles and mitochondrial architecture was compared. Quantitative RT-PCR analysis of key genes involved in mitochondrial structure and recycling was performed. MAIN RESULTS AND THE ROLE OF CHANCE: A defect was found in follicle survival at the large antral stage in PM/+ and PM/PM mice. Litter size was significantly decreased in PM/PM mice, and corpora lutea were significantly reduced in mice of both mutant genotypes. Mitochondrial DNA copy number was significantly decreased in GC and metaphase II eggs in mutants. Flow cytometric analysis revealed that PM/+ and PM/PM animals lack the cumulus GC that harbor the greatest mitochondrial content as found in wild-type animals. Electron microscopic evaluation of GC of small growing follicles revealed mitochondrial structural abnormalities, including disorganized and vacuolar cristae. Finally, aberrant mitochondrial gene expression was detected. Mitofusin 2 (Mfn2) and Optic atrophy 1 (Opa1), genes involved in mitochondrial fusion and structure, respectively, were significantly decreased in whole ovaries of both mutant genotypes. Mitochondrial fission factor 1 (Mff1) was significantly decreased in PM/+ and PM/PM GC and eggs compared with wild-type controls. LIMITATIONS, REASONS FOR CAUTION: Data from the mouse model used for these studies should be viewed with some caution when considering parallels to the human FXPOI condition. WIDER IMPLICATIONS OF THE FINDINGS: Our data lend support to the idea that Fmr1 mRNA with large numbers of CGG-repeats is intrinsically deleterious in the ovary. FXPM disease states, including FXPOI, may share mitochondrial dysfunction as a common underlying mechanism. LARGE SCALE DATA: Not applicable. STUDY FUNDING AND COMPETING INTERESTS: Studies were supported by NIH R21 071873 (J.J./G.H), The Albert McKern Fund for Perinatal Research (J.J.), NIH Intramural Funds (K.U.), and a TUBITAK Research Fellowship Award (B.U.). No conflict(s) of interest or competing interest(s) are noted.