Nicole Segovia Pham

All Publications

• Evaluating the utility of using ChatGPT 3.5 to generate research ideas for non-operative spine medicine JOURNAL OF MEDICAL ARTIFICIAL INTELLIGENCE Kaufman, M., Pham, N., Levin, J. 2025; 8

  View details for DOI 10.21037/jmai-24-480

  View details for Web of Science ID 001532550700017

• Biomechanical Properties of the Extensor Mechanism Following Retrograde Intramedullary Nailing for Metacarpal Fractures. The Journal of hand surgery Chung, C. C., Lachnish, J., Chan, C. K., Pham, N. S., Yao, J. 2025

  Abstract

  Retrograde percutaneous placement of headless compression screws or threaded intramedullary nails for metacarpal fracture fixation may injure the extensor mechanism. Alternatively, mini-open, tendon-sparing approaches may be used, with instrumentation placed through the sagittal band or a longitudinal split of the tendon. Our study evaluated extensor mechanism biomechanical properties after using different techniques for retrograde threaded intramedullary nail insertion.Sixty-four cadaveric fingers were divided into a control group and three testing groups based on the following implant drilling/insertion techniques: transtendinous, longitudinal tendon split with repair, and trans-sagittal band. After instrumentation was applied, the extensor mechanisms were dissected and loaded for tensile testing to determine the maximum load to failure (LTF), stiffness, and site of failure. Analyses comparing LTF and stiffness were conducted using a mixed-effects linear regression model, adjusting for metacarpal number and cadaver age. Fisher exact tests assessed differences in the failure scenario.There were no significant differences in mean (SD) LTF comparing each test group versus control: control 398.4 N (77.0 N), transtendinous 355.0 N (94.7 N), longitudinal split repair 347.9 N (123.4 N), and trans-sagittal band 384.6 N (110.4 N). Load to failure of extensor tendons from the index and long finger metacarpals was significantly higher compared with the extensor tendon associated with the fifth metacarpal. The mean stiffness was 43.2 N/mm (10.3 N/mm), with no difference between the groups. Tensile failure occurred at the implant insertion site in 44% transtendinous, 25% longitudinal split repair, and 13% trans-sagittal band specimens.Retrograde intramedullary implant placement directly through the extensor tendon, a longitudinal tendon split, or the sagittal band does not significantly decrease extensor mechanism maximum LTF or stiffness. Implant insertion potentiates a tensile failure site, but only under tension far exceeding physiologic loads.Any method of retrograde insertion for intramedullary metacarpal nails likely has minimal clinical impact on extensor mechanism integrity during early functional motion.

  View details for DOI 10.1016/j.jhsa.2025.10.006

  View details for PubMedID 41240020

• Revision Total Hip Arthroplasty in Juvenile Idiopathic Arthritis: Survivorship After a Mean Follow-up of 11 Years. The Journal of arthroplasty Tantikosol, P., Hwang, K., Segovia, N. A., Goodman, S. B. 2025

  Abstract

  Juvenile idiopathic arthritis (JIA) is a chronic inflammatory condition that often affects the hip joints during childhood. Due to the high incidence of failure of initial total hip arthroplasty (THA) performed years earlier for JIA, revision surgeries are frequently necessary and particularly challenging. This study evaluated the outcomes of these complex revision procedures after an average follow-up of 11 years.A retrospective review of 24 patients (34 hips) who had JIA undergoing revision THA between January 1999 and December 2023 was conducted. The mean age of the cohort was 40 years (range, 17 to 61), with an equal number of men and women patients. All surgeries were performed by a single surgeon. Data sources included clinical records and surgical reports. Univariate analyses were performed using Mann-Whitney tests for continuous variables and Chi-square/Fisher's exact tests for categorical variables. Kaplan-Meier survival curves were generated to estimate reoperation-free survival.The Kaplan-Meier survival analysis showed reoperation-free survival rates of 54% at five years and 36% at 10 years. The 95% CI (confidence intervals) for these estimates were 31 to 93% and 17 to 80%, respectively. Univariate analyses revealed a significant association between complications and length of hospital stay (hazard ratio [HR]: 0.15; 95% CI: 0.03 to 0.72; P = 0.018). A total of 41.2% of patients experienced complications such as infection, nerve palsy, and dislocation.Revision THA in patients who had JIA is associated with a high complication rate and reduced reoperation-free survival. Early identification of risk factors, meticulous surgical planning, and comprehensive postoperative care are critical to improving long-term outcomes.

  View details for DOI 10.1016/j.arth.2025.10.009

  View details for PubMedID 41072559

• Clinical Efficacy of Pulsed Electromagnetic Field Therapy on Thumb Carpometacarpal Joint Pain: A Double-Blind, Randomized, Controlled Trial. Hand (New York, N.Y.) Durtschi, M. S., Rajakumar, V., Kenney, D. E., Pham, N. S., Ladd, A. L., Chou, R. C. 2025: 15589447251371088

  Abstract

  Thumb carpometacarpal (CMC) osteoarthritis (OA) is a common source of hand pain with limited nonoperative treatment options. Pulsed electromagnetic field (PEMF) therapy has been recently shown in studies to be effective in providing sustained pain relief in knee osteoarthritis. This study aimed to assess the efficacy of PEMF therapy for treating thumb CMC OA pain.This single-center, double-blind, randomized controlled trial included adults with radiographically and/or clinically diagnosed CMC OA who reported an average Numeric Pain Rating Scale (NPRS) score between 3 and 8. Participants were randomized to either a PEMF device or an identical sham device that was used for 8 hours each night for 4 weeks. The primary outcome measure was the change in average daily NPRS from baseline to 4 weeks. Secondary outcome measures included Patient-Rated Wrist/Hand Evaluation (PRWHE) and Single Assessment Numeric Evaluation at 4 and 6 weeks.Sixty-one participants were recruited, and 51 participants completed the study at 4 weeks. Both the PEMF therapy and sham device groups showed improvements in average NPRS and PRWHE at 4 weeks, but there was not a significant improvement between groups. At 6 weeks, there was a significantly greater change in average NPRS from baseline in the PEMF therapy group compared with the sham device group (P = .02).Pulsed electromagnetic field therapy may improve thumb CMC OA pain with sustained relief beyond the treatment period. Future studies will need to assess if adjusting treatment duration or other factors can enhance its efficacy.

  View details for DOI 10.1177/15589447251371088

  View details for PubMedID 41015912

• Comparative Analysis of Iliotibial Band Graft Length in Pediatric Anterior Cruciate Ligament Reconstruction: MacIntosh Versus All-Epiphyseal Femoral Drilling Technique. The American journal of sports medicine Duru, N. O., Stoner, A. J., Alayleh, A. M., Lind, D. R., Schultz, C., Pham, N. S., Ellis, H. B., Schmitz, M. R., Yen, Y. M., Tompkins, M. A., Ganley, T., Meadows, M. C., Chan, C., Shea, K. G. 2025: 3635465251371321

  Abstract

  Iliotibial band (ITB) grafts yield excellent outcomes for anterior cruciate ligament reconstruction (ACLR) in skeletally immature patients. Because closure of the ITB harvest interval is often not feasible, techniques that allow for shorter ITB grafts may be beneficial.That the all-epiphyseal femur ITB graft would be significantly shorter than the over-the-top ITB graft.Controlled laboratory study.Six fresh-frozen pediatric knees (mean age, 9.7 years; range, 9-11 years) were used. Surgeons simulated the modified MacIntosh and all-epiphyseal ITB ACLRs using No. 2 suture as a proxy for the ITB graft. A suture was attached at the ITB origin on the Gerdy tubercle and then passed over-the-top on the femur, under the transverse meniscal ligament, and to the metaphyseal anchor point. The length of the suture was measured. The suture was then placed through the all-epiphyseal femoral drill hole, under the transverse meniscal ligament to the same tibial metaphyseal anchor point. Femoral condyle width was recorded, and the relationship between graft length and technique was analyzed using analysis of covariance to adjust for femoral condyle widths.Graft length for the all-epiphyseal ITB ACLR was significantly shorter than that for the modified MacIntosh ITB ACLR, with a mean difference of 26.0 ± 6.0 mm (P < .001). Across both groups, each additional millimeter of condyle width was associated with an increase in graft length by 2.3 mm (P < .001). Mean graft lengths for the modified MacIntosh and all-epiphyseal femur were 173.3 ± 16.5 mm and 147.3 ± 16.0 mm, respectively.The all-epiphyseal femoral technique requires a significantly shorter ITB graft length compared with the modified MacIntosh technique. A nomogram was developed to estimate graft length differences adjusted for condyle width. Future pediatric studies should continue to explore the biomechanics of both graft techniques, as they may provide lateral extra-articular stabilization and reduce ACL reinjury rates.Shortened ITB autograft length may reduce symptoms associated with muscle herniation.

  View details for DOI 10.1177/03635465251371321

  View details for PubMedID 40971308

• Pediatric Meniscotibial Ligament Complex Anatomy and Biomechanics. Orthopaedic journal of sports medicine van Deursen, W. H., Johnstone, T. M., Cuellar-Montes, A., Baird, D. R., Chan, C. K., Hollyer, I., Rohde, M. S., Tompkins, M., Ellis, H. B., Ganley, T. J., Yen, Y. M., Schmitz, M. R., Pham, N. S., Sherman, S. L., Levenston, M., Shea, K. G. 2025; 13 (9): 23259671251367060

  Abstract

  Meniscal repair is increasingly performed in pediatric patients, with capsular-based techniques remaining the gold standard despite limitations such as high failure rates and risk of meniscal extrusion. Recent studies highlight the potential role of accessory knee ligaments in improving meniscal stability and repair outcomes. The meniscotibial ligament complex (MTLC) has emerged as a potential area of interest to produce more normal anatomic and biomechanical meniscal function in meniscal repair.To evaluate the native anatomy and biomechanical strength of the MTLC of the medial and lateral meniscus of pediatric knees.Descriptive laboratory study.Fourteen fresh-frozen pediatric human knees (mean age, 7.5 years; range, 5-10 years; 6 male, 8 female) were used in this study. The depth of the recess between the MTLC and the meniscocapsular complex was measured. Subsequently, the medial and lateral menisci were divided into approximate thirds, creating anterior, central, and posterior testing zones for each meniscus. Each meniscus/MTLC complex underwent monotonic load-to-failure testing on an Instron 5944 test frame with a 2-kN load cell with load applied superiorly. Biomechanical properties were analyzed using linear mixed models with donor as a random factor and aspect (medial/lateral) and position (anterior/central/posterior) as fixed factors.The posterior recess depth was significantly larger (mean, 5.4 mm; 95% CI, 4.6-6.3 mm) than anterior (mean, 3.4 mm; 95% CI, 2.6-4.2 mm) (P = .049). Maximal load to failure in the posterior MTLC (mean, 93.5 N; 95% CI, 80.0-107.0 N) was significantly higher than anterior (mean, 69.2 N; 95% CI, 56.7-81.7 N) (P = .01).This study defines a clear space in which the MTLC is distinct from the joint capsule, which is deepest in the posterior third of the medial and lateral meniscus. Our results demonstrate that the posterior region of the MTLC can withstand higher loads than the anterior region in pediatric knees.These findings offer foundational insights into the native anatomy and biomechanics of the MTLC, guiding future studies involving the MTLC in meniscal repair. This knowledge may be particularly relevant to ramp lesions, other posterior meniscal tear patterns, and meniscal transplants.

  View details for DOI 10.1177/23259671251367060

  View details for PubMedID 40949534

  View details for PubMedCentralID PMC12426389

• Preoperative Knee Templating Accuracy Does Not Predict Radiographic or Clinical Outcome in Total Knee Arthroplasty ORTHOPEDICS Mrutyunjaya, S., Bosch, L. C., Bonano, J. C., Pham, N. S., Hwang, K., Goodman, S. B., Amanatullah, D. F. 2025; 48 (5): e215-e219

  Abstract

  The purpose of this study was to evaluate the accuracy of digital templating for primary total knee arthroplasty (TKA) and to evaluate whether accurate templating affects the clinical or radiographic outcome of TKA.We retrospectively reviewed 178 primary TKAs performed by a single surgeon with preoperative templating available and minimum 2-year clinical follow-up. Templated size was compared to the implanted size. Postoperative coronal alignment was measured on standing long-leg radiographs by two independent observers. UCLA Activity Scale and Knee Society scores (KSS) were evaluated after 2 years. Categorical variables are reported as number and percentage. Correlative data were analyzed using Spearman's correlation tests and reported as coefficients (rs) with 95% CI. Significance was set at P<0.05.Preoperative templating accurately estimated the tibia within one size in 95% of cases (169 TKAs), while the femur was templated within one size in 99% of cases (176 TKAs). Templating accuracy did not correlate with postoperative coronal alignment within 3° of the mechanical axis (tibial accuracy: rs=0.10, P=0.120; femoral accuracy: rs= -0.07, P=0.338). Templating accuracy did not correlate with the postoperative UCLA Activity Scale score (tibia P=0.177; femur P=0.354), KSS function (tibia P=0.587; femur P=0.637), KSS expectation (tibia P=0.764; femur P=0.817), or KSS satisfaction (tibia P=0.760; femur P=0.811) at 2 years.Preoperative digital templating for TKA reliably estimates the implanted femoral and tibial component sizes within one size; however, templating did not correlate with radiographic or clinical outcomes at 2 years.

  View details for DOI 10.3928/01477447-20250813-01

  View details for Web of Science ID 001574970400005

  View details for PubMedID 40957004

• Bone marrow concentrate intradiscal injection for chronic discogenic low back pain: A double-blind randomized sham-controlled trial. Interventional pain medicine Levi, D., Tyszko, S., Horn, S., Pham, N., Levin, J. 2025; 4 (3): 100611

  Abstract

  The field of orthobiologics has attempted to address the challenge of discogenic low back pain (LBP). Research in areas such as stem cells, platelet-rich plasma, and specific growth factor injections has seen limited success.The purpose of this trial was to determine the efficacy of a single intradiscal bone marrow concentrate (BMC) injection on pain and function for chronic discogenic LBP.Patients with presumed discogenic LBP participated in a prospective, double-blind, randomized, sham controlled trial of a single intradiscal BMC injection compared to a sham procedure. Pain and function were assessed at baseline, 3, 6, and 12 months by Clinical Outcome Measurement Brief Instrument (COMBI) which includes the Numeric Rating Scale (NRS). Function was also assessed by the Oswestry Disability Index (ODI). The primary outcome was based upon clinical success, defined by at least 50 % pain relief from baseline to 3, 6, and 12 months.Sixty-three patients were included in the trial (45 BMC, 18 sham). There were no significant differences in the primary outcome (>50 % relief in NRS) at 3 months (40 % BMC group [95 %CI: 27-50 %] vs 33 % sham group [95 %CI: 15-56 %]), 6 months (40 % BMC [95 %CI: 27-50 %] vs 39 % sham [95 %CI: 20-61 %]), or 12 months (44 % BMC [95 %CI: 31-59 %] vs 56 % sham [95 %CI: 34-75 %]). There were no significant differences in the proportion of patients achieving at least a 30 % improvement on the ODI at 3 months (51 % BMC group [95 %CI: 37-65 %] vs 33 % sham group [95 %CI: 16-56 %]), 6 months (53 % BMC [95 %CI: 39-67 %] vs 44 % sham [95 %CI: 25-65 %]), or 12 months (56 % BMC [95 %CI: 41-69 %] vs 61 % sham [95 %CI: 39-80 %]).Intradiscal BMC was equivalent to a sham procedure for chronic discogenic LBP. Both groups had a high, but statistically equivalent success rate. Unfortunately, the significant limitations of this trial, including lack of quality cell analysis, limit the ability to draw conclusions on the effectiveness of intradiscal BMC.

  View details for DOI 10.1016/j.inpm.2025.100611

  View details for PubMedID 40704141

  View details for PubMedCentralID PMC12284277

• Prevention in non-oncologic intent sarcoma surgery. Surgical oncology Wise, C. E., Le, C., Pham, N. S., New, C., Kenney, D. E., Avedian, R., Mohler, D., Steffner, R. 2025; 62: 102273

  Abstract

  Non-oncologic resection of soft tissue sarcomas (STS) continue to be a common referral to multidisciplinary sarcoma centers. While previous literature has reported tumor characteristics and outcomes related to non-oncologic resections, little is known regarding the surgical specialties most likely to excise such a mass and the non-oncological manner in which they do so. Such information can facilitate preventative strategies.The goals of this study are: 1) Investigate the surgical specialties that most often perform unplanned excisions and their diagnostic imaging approach, 2) Identify the frequency of non-oncological techniques utilized in initial unplanned excisions, and 3) Define indications for the use of radiation (XRT) in patients with initial non-oncologic resections of STS.Patient data were collected from a large tertiary referral sarcoma center between 2005 and 2022. Eligible patients had a diagnosis of soft tissue sarcoma that was excised at an outside institution in a non-oncologic manner and subsequently underwent tumor bed re-excision using wide resection. Data regarding the index procedures at outside hospitals were obtained from referral documents and tumor bed re-excisions, along with follow-up care. A total of 124 patients were identified.Forty-three percent of referrals for non-oncologic resection of soft tissue sarcomas (STS) involved tumors located deep to the fascia. The majority of these referrals originated from General Surgery (N = 54, 44 %), Orthopedic Surgery (N = 35, 28 %), and Plastic Surgery (N = 11, 9 %). Preoperative imaging was conducted in 59 % of cases. General surgeons were less likely to obtain preoperative imaging (p = 0.009) and perform MRI scans (p = 0.013) than orthopaedic surgeons. The proper orientation of the incision based on location was incorrect for general surgeons in 26 % (N = 20) of cases. General surgeons were less likely to make an appropriate incision (p = 0.052) and to use a tourniquet during the initial procedure (p < 0.001). There were no differences among surgical subspecialties in the use of local anesthetic, drain use, or excision type regarding the initial non-oncologic resection. Residual disease following tumor bed re-excision was linked to masses removed in the clinic (p = 0.030) and initial stage IIIB tumors (p = 0.019). Our institutional use of radiation therapy (XRT) correlated with large initial size, high-grade histology, location deep to fascia, and tumors that were re-excised with staged coverage by plastic surgery.Most referrals for initial non-oncologic resection of STS come from general surgery followed by orthopaedic surgery. Indications for pre-operative MRI imaging, incision orientation, and tourniquet use are education targets for general surgeons in training. Interpretation of MRI scans is an education target for orthopaedic surgeons in training. Clinic procedures are associated with residual disease on tumor re-excision. Radiation before tumor bed re-excision can be considered for larger, high-grade tumors that are deep to the fascia and when plastics coverage is planned.Level IV.

  View details for DOI 10.1016/j.suronc.2025.102273

  View details for PubMedID 40768940

• Risk Factors for Corticosteroid-associated Osteonecrosis in Children: A National Database Study. Journal of the Pediatric Orthopaedic Society of North America Smith, G. B., Pham, N. S., Alayleh, A., Smith, S., Chao, K., Goodman, S. B., Shea, K. G. 2025; 12: 100199

  Abstract

  Corticosteroid-associated osteonecrosis presents a risk for severe pain and joint collapse. While the relationship between corticosteroid treatment and osteonecrosis in pediatric patients is well-documented, less is known about which patients are at greatest risk across medical conditions. The purpose of this study was to identify high-risk pediatric populations for developing osteonecrosis following corticosteroid treatment across autoimmune, inflammatory, and oncologic conditions.The Merative MarketScan Research Databases (2007-2022) were queried to identify pediatric patients with an outpatient oral or intravenous corticosteroid prescription. Demographic, clinical, and prescription differences between osteonecrosis and non-osteonecrosis patients were analyzed using t-tests, Fisher's exact, and chi-square tests. Factors associated with time to osteonecrosis were assessed using a multivariable Cox proportional-hazards regression model.We identified 5,606,781 pediatric patients who received corticosteroids, and 131 developed osteonecrosis. The mean time to osteonecrosis following corticosteroid administration was 7.1 months (SD = 5.2). Osteonecrosis patients were significantly older at the age of corticosteroid administration (12.1 [SD = 4.9] vs. 8.2 [5.6], P < .001) and were prescribed corticosteroids for more total days (136.6 [224.8] vs. 17.1 [89.2], P < .001) compared to patients who did not develop osteonecrosis. Adjusting for all other covariates, risk factors for osteonecrosis include acute lymphoblastic leukemia (HR = 575.82, 95% CI = [346.68, 956.40], P < .001), systemic lupus erythematosus (HR = 106.41, 95% CI = [44.65, 253.63], P < .001), Crohn's disease (HR = 6.67, 95% CI = [1.54, 28.86], P = .011), juvenile idiopathic arthritis (HR = 4.62, 95% CI = [1.06, 20.08], P = .041), solid organ transplant (HR = 4.24, 95% CI = [2.08, 8.65], P < .001), dexamethasone (HR = 2.59, 95% CI = [1.56, 4.28], P < .001), older age (hazard ratio [HR] = 1.11, 95% CI = [1.06, 1.16], P < .001), and greater total days prescribed (HR = 1.01, 95% CI = [1.00, 1.02], P = .041).Our national database study highlights the need for targeted screening of pediatric patients treated with high-dose corticosteroids. This investigation may inform multidisciplinary studies and interventions in children treated with corticosteroids.(1)Corticosteroid-associated osteonecrosis presents a risk for severe pain and joint collapse, yet little is known regarding which pediatric patients are at greatest risk across medical conditions.(2)Adjusting for other covariates, pediatric patients with acute lymphoblastic leukemia, systemic lupus erythematous, Crohn's disease, juvenile idiopathic arthritis, solid organ transplants, patients prescribed dexamethasone, patients prescribed corticosteroids for greater total days, and older patients were at increased risk for osteonecrosis in our national database study.(3)Our findings highlight the need for targeted screening of pediatric patients treated with high-dose corticosteroids.(4)Future prospective multidisciplinary screening and intervention protocols should be studied in children treated with corticosteroids.Level III: Case-control study or retrospective cohort study.

  View details for DOI 10.1016/j.jposna.2025.100199

  View details for PubMedID 40756153

  View details for PubMedCentralID PMC12317409

• Artificial Intelligence-Based Large Language Models Can Facilitate Patient Education. Journal of the Pediatric Orthopaedic Society of North America Bryson, X., Albarran, M., Pham, N., Salunga, A., Johnson, T., Hogue, G. D., Brooks, J. T., Tileston, K. R., Louer, C. R., El-Hawary, R., Imrie, M. N., Policy, J. F., Bouton, D., Hariharan, A. R., Van Nortwick, S., Upasani, V. V., Bauer, J. M., Tice, A., Vorhies, J. S. 2025; 12: 100196

  Abstract

  Background: Artificial intelligence (AI) large language models (LLMs) are becoming increasingly popular, with patients and families more likely to utilize LLM when conducting internet-based research about scoliosis. For this reason, it is vital to understand the abilities and limitations of this technology in disseminating accurate medical information. We used an expert panel to compare LLM-generated and professional society-authored answers to frequently asked questions about pediatric scoliosis.Methods: We used three publicly available LLMs to generate answers to 15 frequently asked questions (FAQs) regarding pediatric scoliosis. The FAQs were derived from the Scoliosis Research Society, the American Academy of Orthopaedic Surgeons, and the Pediatric Spine Foundation. We gave minimal training to the LLM other than specifying the response length and requesting answers at a 5th-grade reading level. A 15-question survey was distributed to an expert panel composed of pediatric spine surgeons. To determine readability, responses were inputted into an open-source calculator. The panel members were presented with an AI and a physician-generated response to a FAQ and asked to select which they preferred. They were then asked to individually grade the accuracy of responses on a Likert scale.Results: The panel members had a mean of 8.9 years of experience post-fellowship (range: 3-23 years). The panel reported nearly equivalent agreement between AI-generated and physician-generated answers. The expert panel favored professional society-written responses for 40% of questions, AI for 40%, ranked responses equally good for 13%, and saw a tie between AI and "equally good" for 7%. For two professional society-generated and three AI-generated responses, the error bars of the expert panel mean score for accuracy and appropriateness fell below neutral, indicating a lack of consensus and mixed opinions with the response.Conclusions: Based on the expert panel review, AI delivered accurate and appropriate answers as frequently as professional society-authored FAQ answers from professional society websites. AI and professional society websites were equally likely to generate answers with which the expert panel disagreed.Key Concepts: (1)Large language models (LLMs) are increasingly used for generating medical information online, necessitating an evaluation of their accuracy and effectiveness compared with traditional sources.(2)An expert panel of physicians compared artificial intelligence (AI)-generated answers with professional society-authored answers to pediatric scoliosis frequently asked questions, finding that both types of answers were equally favored in terms of accuracy and appropriateness.(3)The panel reported a similar rate of disagreement with AI-generated and professional society-generated answers, indicating that both had areas of controversy.(4)Over half of the expert panel members felt they could distinguish between AI-generated and professional society-generated answers but this did not relate to their preferences.(5)While AI can support medical information dissemination, further research and improvements are needed to address its limitations and ensure high-quality, accessible patient education.Levels of Evidence: IV.

  View details for DOI 10.1016/j.jposna.2025.100196

  View details for PubMedID 40791971

• Magnetic Resonance Imaging Characteristics of the Iliocapsularis in Hip Microinstability: A Comparative Analysis. The American journal of sports medicine Raji, Y., Pierre, K. J., Wagle, S., Pham, N. S., Boutin, R. D., Safran, M. R. 2025: 3635465251344600

  Abstract

  Iliocapsularis (IC) muscle hypertrophy in borderline developmental dysplasia of the hip (BDDH) and developmental dysplasia of the hip (DDH) suggests a possible role as a dynamic hip stabilizer. However, its significance in hip microinstability (MI) without acetabular undercoverage remains unclear.To compare IC muscle dimensions and fatty infiltration between patients with MI, BDDH, and mixed-type femoroacetabular impingement (mFAI), and assess the association between IC muscle morphology and hip pathology.Case-control study; Level of evidence, 4.A retrospective analysis was conducted on patients undergoing arthroscopic surgery for hip pathology between January 2014 and December 2022. Patients were categorized based on lateral center-edge angle (LCEA) into BDDH (18° to <25°), MI (25° to 39°), and mFAI (>39°) groups. Preoperative radiographs and magnetic resonance imaging (MRI) scans were reviewed, and IC muscle dimensions, including width, depth, cross-sectional area (CSA), IC fatty infiltration, and combined IC and iliopsoas (IP) (IC+IP) CSA, were measured by 3 independent observers. A priori power analysis was performed. Statistical analyses included parametric and nonparametric comparative tests, interobserver correlation coefficients, and receiver operating characteristic analysis.A total of 95 hips were included in this study. IC depth, width, and CSA and IC+IP CSA were significantly smaller in the MI group (P < .05 for all). Interobserver agreement was good to excellent for IC width (IRC, 0.87), IC CSA (IRC, 0.87), and IC+IP CSA (IRC, 0.96), but poor for IC depth (IRC, 0.26). The alpha angle did not significantly differ among groups (P = .093). The MI group had a higher proportion of female patients (P = .003). No significant differences were noted in radiographic markers, including the ischial spine sign (P = .083), crossover sign (P = .130), and posterior wall sign (P = .41).No detectable IC hypertrophy was observed in the MI group compared with the BDDH and mFAI groups, with patients with MI showing smaller IC width, depth, and CSA. The study offers a reproducible measurement technique with good interobserver agreement. IC muscle mass has limited prognostic value in predicting hip MI.

  View details for DOI 10.1177/03635465251344600

  View details for PubMedID 40503567

• Bedside Aspiration for Workup of the Pediatric Septic Hip: Avoid Trips to the OR and Expedited Time to Diagnosis. Journal of pediatric orthopedics Skaggs, K. F., Okoli, O., Naz, H., Pham, N. S., Vorhies, J. S., Tileston, K. R. 2025

  Abstract

  Septic arthritis of the hip is a pediatric orthopaedic emergency. Joint synovial fluid aspiration is a critical step of diagnosis, which may be delayed due to limited personnel or operating room (OR) availability. To expedite diagnosis, orthopaedic residents perform ultrasound-guided bedside arthrocentesis in the emergency department (ED). This study aims to evaluate the impact of this practice on time to diagnosis and definitive treatment of septic arthritis of the hip and minimizing trips to the operating room.This is a retrospective study of patients presenting to our pediatric orthopaedic tertiary care emergency room requiring a hip aspiration to rule out septic arthritis between 2003 and 2023. We identified all patients who had resulted hip synovial fluid nucleated cell count during the above time period. Chart review was performed to determine how synovial fluid was collected via interventional radiology (IR), in the OR with an orthopaedic surgeon, or via bedside aspiration with the on-call resident. Clinical outcomes were primarily defined as time points in clinical care. Patient demographics, Kocher criteria values, time to aspiration, and final treatment are presented. Kruskal-Wallis and Fisher exact tests were used to compare demographic and clinical differences in RStudio using a two-sided level of significance of 0.05.Hip aspiration was performed in the workup of septic arthritis in 57 patients (median age 5.1 y; 58% female). Aspiration occurred in the ED for 28 patients, interventional radiology (IR) for 11, and in the OR for 18 patients. Bedside aspiration avoided a trip to the OR for 15 patients (54%). Median time to obtaining joint fluid was significantly shorter for patients undergoing bedside or IR-guided aspiration compared with OR aspiration (7.4 vs. 5.3 vs. 15.7 h, respectively; bedside vs. OR P=0.007, IR vs. OR P=0.013). Time from presentation to OR for open surgical debridement, total operative time, and the percentage of patients requiring open surgical debridement did not significantly differ between groups.Bedside aspiration decreases the time to diagnosis of septic arthritis and can prevent ~50% of children from going to the OR. This is beneficial for the patient as it may allow for earlier antibiotic administration, provide pain relief, and avoid possible complications of general anesthesia.Level III-retrospective chart review.

  View details for DOI 10.1097/BPO.0000000000002996

  View details for PubMedID 40391565

• A Pilot Program Implementing an Evidence-Based Walking Plan to Improve Cancer-Related Fatigue in Adult Patients on Oral Cancer Treatments. Journal of the advanced practitioner in oncology Bernt, J. D., Million, R., Pham, N. S. 2025; 16 (3): 95-103

  Abstract

  Fatigue is a prevalent symptom among cancer patients, even after completing treatment. The National Comprehensive Cancer Network Guidelines recommend incorporating physical activity as a strategy to combat cancer-related fatigue.The goal was to develop and implement an evidence-based translational research quality improvement project to improve fatigue in patients starting oral cancer treatment.Outpatient oncology nurses (registered nurses and licensed practical nurses) responsible for educating patients starting treatment for cancer were provided education about the walking program. The information was incorporated into education for patients starting oral chemotherapy. Nursing knowledge, beliefs, and attitudes were evaluated before and after the subject-intensive education. Patient study participants were provided with pedometers and completed the Brief Fatigue Inventory and a survey about their beliefs and attitudes before and after implementing the walking program.Fatigue scores showed a slight decrease post intervention but not a statistically significant difference. Advanced-stage cancer showed a near-significant relationship with increased fatigue levels. Nursing knowledge improved by 13%, and nurses reported increased confidence in six of nine topics. Nursing barriers to education shifted from personal comprehension to a need for resources.Patients diagnosed with advanced-stage cancer should receive timely fatigue prevention and management education. In addition, educating nurses to address this knowledge deficit is imperative. The information gathered from this project presents an opportunity for further research using a walking plan and nursing education to improve current interventions used to reduce cancer-related fatigue.

  View details for DOI 10.6004/jadpro.2025.16.3.2

  View details for PubMedID 40584010

  View details for PubMedCentralID PMC12205717

• Increased Prevalence of Concussion in Collegiate Water Polo Goalkeepers. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine Lee, M. C., Pham, N. S., Song, L., Hwang, C. E. 2025

  Abstract

  OBJECTIVE: To investigate the epidemiology of sport-related concussion in collegiate water polo players and compare the risk of concussion between goalkeepers and field players.DESIGN: Retrospective chart review using injury surveillance data from July 2016 and June 2022. Descriptive statistics, chi2 and Fisher exact tests, and pairwise comparisons using false discovery rate-adjusted P-values were used for statistical analysis.SETTING: Pac-12 conference collegiate water polo teams.PARTICIPANTS: Ninety-six Pac-12 athletes from 4 men's and 5 women's water polo teams, with a total of 124 identified concussions.INDEPENDENT VARIABLE: Player position (goalkeeper vs field player) and location of injury (practice vs competition vs not sport related).MAIN OUTCOME MEASURES: Prevalence of sport-related concussion by player position and location of injury.RESULTS: Goalkeepers experienced a significantly higher proportion of sport-related concussions than field players (26.2% vs 16.0%, P = 0.005). Most concussions in goalkeepers occurred from ball-to-head contact while most field player concussions were because of contact with another player. There was no significant difference in the number of concussions suffered in practice compared with competition.CONCLUSIONS: Collegiate water polo goalkeepers face a higher risk of concussion than field players, particularly from ball-to-head contact. Current safety protocols may be inadequate for goalkeepers. Future research should examine the effectiveness of protective headgear and modified practice equipment in mitigating concussion risk, potentially leading to rule changes.

  View details for DOI 10.1097/JSM.0000000000001365

  View details for PubMedID 40227165

• Retrospective Analysis and Characterization of Avascular Necrosis By Bone Location in Pediatric Leukemia/Lymphoma Patients. Journal of pediatric orthopedics Alayleh, A., Naz, H., Taylor, V., Johnson, T. R., Farook, S., Hofmann, G., Obilo, C., Pham, N. S., Harbacheck, K., Laureano, T., Smith, S. M., Chao, K., Goodman, S. B., Shea, K. G. 2025

  Abstract

  Avascular necrosis (AVN) is a serious complication of high-dose steroid therapy for pediatric patients with leukemia/lymphoma. AVN affects multiple bones and joints, leading to significant pain in different bone regions, early-onset osteoarthritis, and early joint replacement. Early detection and intervention for AVN may prevent pain and progressive joint collapse. The purpose of this study is to evaluate and characterize the specific AVN locations in a cohort of pediatric and adolescent patients with leukemia/lymphoma using the newly developed Bone Location for AVN from STeroids (BLAST) classification system that considers epiphyseal, metaphyseal, and diaphyseal locations in long bones.An imaging database was queried for patients 25 years old and younger with a diagnosis of AVN and leukemia/lymphoma who required steroid treatment. Patient MRIs were reviewed, and AVN sites were classified using the BLAST system. AVN locations were described using descriptive statistics. Multivariable logistic regression analysis was used to assess the odds of AVN bilaterality based on location.A total of 84 patients (49/35 males/females) with acute lymphoblastic leukemia (ALL) (B-cell 74%, T-cell 21%) or acute myeloid leukemia (5%) were included in this cohort. The median age was 14.8 years at leukemia diagnosis and 16.5 years at AVN diagnosis. Most AVN locations include the femur (87%), tibia (68%), and humerus (25%). On the basis of the BLAST classification, the most common sites of AVN overall include the proximal tibial metaphysis (61%), distal femoral metaphysis (60%) and epiphysis (60%), and femoral head epiphysis (50%). The most common sites of AVN in the tibia, humerus, and femur are proximal tibial metaphysis (89%), humeral head epiphysis (86%), and distal femoral metaphysis (68%) and epiphysis (68%), respectively.This analysis demonstrates that AVN in leukemia/lymphoma patients on steroid therapy has a clear predilection for specific locations in long bones. Using the BLAST classification, practitioners are better equipped to characterize the location of AVN, monitor high-risk locations for joint collapse, and track early outcomes of preventative treatment. The development of prospective multicenter AVN study groups and screening protocols for early detection will be critical to improve functional outcomes and joint preservation for leukemia/lymphoma survivors and all other patients taking high-dose steroids.Level II-retrospective cohort study.

  View details for DOI 10.1097/BPO.0000000000002963

  View details for PubMedID 40214168

• Residual Postoperative Valgus After Total Knee Arthroplasty for Preoperative Valgus Deformity Results in Inferior Patient-Reported Outcomes. Arthroplasty today Hunt, A. A., Hollyer, I., Pham, N. S., Maloney, W. J., Huddleston, J. I. 2025; 32: 101660

  Abstract

  The optimal postoperative coronal alignment after total knee arthroplasty (TKA) for preoperative valgus deformity is unknown. This study aims to evaluate the impact of postoperative coronal alignment on clinical outcomes following TKA for valgus deformities.Patients in preoperative valgus undergoing primary TKA between 2010 and 2020 with at least 1 year of follow-up were retrospectively reviewed. Preoperative and postoperative mechanical alignment was assessed on long-leg radiographs via the hip-knee-ankle angle. Postoperative alignment was categorized into valgus (>2° valgus), neutral (within 2° of the mechanical axis), or varus (>2° varus). Patient demographics, preoperative and postoperative outcome scores, and complications were collected.106 patients met inclusion criteria, with a mean preoperative valgus deformity of 11° (standard deviation ± 6.1). Postoperatively, 18 patients were in varus alignment, 58 were neutral, and 30 remained in valgus. At 2-year follow-up, multivariate analyses showed that patients in neutral or varus alignment postoperatively had superior Veterans RAND 12-Item Health Survey Physical and Knee injury and Osteoarthritis Outcome Score Pain scores compared to those in residual valgus. Varus knees showed significantly greater improvement in Knee Society Score Function scores compared to valgus knees. At final follow-up, Knee injury and Osteoarthritis Outcome Score Pain scores were significantly better in varus knees. Patients in varus were 7.79 times more likely to achieve the minimal clinically important difference VR-12 Physical score, while patients in neutral were 3.26 times more likely to achieve the minimal clinically important difference for Knee Society Score Function when compared to valgus knees.Correcting preoperative valgus coronal alignment to neutral or varus yields improved patient-reported outcomes when compared to residual valgus.

  View details for DOI 10.1016/j.artd.2025.101660

  View details for PubMedID 40162324

  View details for PubMedCentralID PMC11954113

• Residual Postoperative Valgus After Total Knee Arthroplasty for Preoperative Valgus Deformity Results in Inferior Patient-Reported Outcomes ARTHROPLASTY TODAY Hunt, A. A., Hollyer, I., Pham, N. S., Maloney, W. J., Huddleston Iii, J. I. 2025; 32

  View details for DOI 10.1016/j.artd.2025.101660

  View details for Web of Science ID 001447323700001

• Incidence and Risk Factors for Steroid-associated Osteonecrosis in Children and Adolescents: A Systematic Review of the Literature. Journal of pediatric orthopedics Johnson, T., Naz, H., Taylor, V., Farook, S., Hofmann, G., Harbacheck, K., Pham, N. S., Smith, S. M., Chao, K., Lee, T., Goodman, S., Shea, K. 2025

  Abstract

  Steroid-associated osteonecrosis in pediatric patients with inflammatory and oncologic disease is an uncommon yet debilitating condition causing significant functional disability. Pediatric orthopaedic surgeons encounter this population during stages in which surgical intervention may be necessary for joint preservation. Various risk factors for steroid-associated osteonecrosis have been suggested, but a comprehensive systematic review of the literature has not been performed. The purpose of this systematic review is to investigate incidence and risk factors for steroid-associated osteonecrosis in pediatric, adolescent, and young adult patients to help guide clinical decision-making.We conducted a systematic review of the literature according to the preferred reporting items for systematic reviews and meta-analyses guidelines. MEDLINE, Embase, PubMed databases, and the Cochrane Central Registry of Controlled Trials were used to search for studies assessing risk factors for osteonecrosis in patients 0 to 21 years of age with systemic corticosteroid exposure. Two reviewers independently screened titles, abstracts, and full texts of retrieved studies for inclusion. Quality assessment of retrospective and prospective nonrandomized case-control and cohort studies was completed using the MINORS criteria. Outcomes and variables of interest included reported incidence and demographic, clinical, radiographic, and genetic risk factors for steroid-associated osteonecrosis. Reported statistics were deemed significant if P <0.05. Due to heterogeneous and limited reporting, data were not combined in a meta-analysis.The literature search revealed 895 articles and 37 articles were included. Of the included studies, 47% were retrospective cohort studies, and 39% were prospective cohort studies. There were 3 randomized controlled trials included. of the included studies, 95% were conducted in patients with leukemia and/or lymphoma. The overall prevalence of steroid-associated osteonecrosis ranged from 1% to 39%. Osteonecrosis was diagnosed with a mean or median of 1 to 2 years after the start of steroid therapy, and the most frequently involved joints were knees, followed by hips. Age older than 10 years, female gender, greater body mass index, and white and non-Hispanic race were the most reported risk factors for steroid-associated osteonecrosis. Core decompression was a frequent operative treatment with variable improvement in outcomes. For pediatric leukemia patients, those stratified as High risk and Intermediate risk were at the greatest risk for steroid-associated osteonecrosis.This systematic review summarizes specific risk factors and demographics of steroid-associated osteonecrosis and helps lay the foundation for future studies to delineate the causal role of risk factors and guides clinical decision-making for current and proposed screening techniques. Steroid-associated osteonecrosis is often asymptomatic with clinical symptoms frequently lagging presentation on advanced imaging. The development of standard clinical pathways that incorporate screening for osteonecrosis may become necessary to improve outcomes through early detection and interventions such as core decompression to reduce pain and prevent progression to early osteoarthritis.

  View details for DOI 10.1097/BPO.0000000000002919

  View details for PubMedID 40078093

• Management of Isolated Partial ACL Tears: A Survey of International ACL Surgeons ORTHOPAEDIC JOURNAL OF SPORTS MEDICINE Frey, C. S., Pierre, K. J., Pham, N. S., Abrams, G. D., Sherman, S. L., Spalding, T., Safran, M. R. 2025; 13 (2): 23259671241311603

  Abstract

  Partial anterior cruciate ligament (ACL) tears, particularly injuries detected with magnetic resonance imaging (MRI) but stable on ligamentous examination, appear to be recognized more frequently; however, there remains no consensus management for this complex pathology.To present the results of a survey of a group of international ACL experts on the management of partial ACL injuries.Survey study; Level of evidence, 5.The ACL Study Group is an international group of orthopaedic surgeons with a special interest in the ACL. There are 169 members overall, with 135 clinically active surgeons. A branching logic survey was developed and circulated to members of the ACL Study Group via electronic mail. Categories included member demographics as well as recommended management strategies of partial ACL injuries, including recommendations on return to play.Of the 135 clinically active surgeon members, 113 responded to the survey (84%). Nonoperative management of partial ACL injuries was selected by 92% of respondents. Of those who managed nonoperatively, 75% indicated they would not restrict weightbearing and 59% would not recommend a knee brace. When those who managed the patient nonoperatively determined criteria for return to sports (RTS), 33% would use differential knee laxity, 87% would assess functional testing, 26% would utilize imaging, and 40% selected time from injury. When using time as a guide for RTS, 13% chose RTS between 7 and 11 weeks postinjury, 56% selected no sport before 3 months, and 22% favored waiting 4 to 6 months before allowing an athlete with a partial ACL injury to RTS. With regard to function as a tool to determine RTS, painless Lachman, strength, swelling, and functional performance tests were all chosen by a majority of respondents.This study presented the results of a survey on partial ACL injury management administered to ACL Study Group active surgical members. The majority favored nonoperative management for partial ACL injuries (stable ligament examination but MRI changes in the ligament). Nonoperative treatment and RTS protocols varied and must be customized to the patient.

  View details for DOI 10.1177/23259671241311603

  View details for Web of Science ID 001417301300001

  View details for PubMedID 39931635

  View details for PubMedCentralID PMC11808748

• Self-reported preoperative anxiety and depression associated with worse patient-reported outcomes for periacetabular osteotomy and hip arthroscopy surgery. Journal of hip preservation surgery Richey, A. E., Segovia, N., Hastings, K., Klemt, C., Pun, S. Y. 2024; 11 (4): 251-256

  Abstract

  Adverse mental health status has been linked to less successful surgical outcomes across several orthopaedic subspecialties. Mental health represents a modifiable risk factor that can be optimized preoperatively to maximize outcomes for hip preservation surgery. This study examines the relationship between preoperative mental health status and preoperative and postoperative outcomes for adolescent and adult patients undergoing hip preservation surgery. A prospectively enrolled registry of patients undergoing periacetabular osteotomy or hip arthroscopy at a single institution between 2013 and 2021 was retrospectively reviewed to collect demographics and outcomes before and after surgery. We identified patients self-reporting anxiety/depression or no anxiety/depression preoperatively based on responses to the EuroQol-5D anxiety/depression dimension and compared their preoperative and postoperative Hip disability and Osteoarthritis Outcome Scores (HOOSs) using multivariable linear models and multivariable mixed effects models. Seventy-three patients were included, 40 patients with no anxiety/depression and 33 patients with anxiety/depression. Patients with anxiety/depression had worse preoperative HOOS pain (b = -12.5, P = .029), function in daily living (b = -12.0, P = .045), function in sports and recreational activities (b = -15.1, P = .030), and quality of life (b = -16.3, P = .005) as compared to patients with no anxiety/depression. Patients with anxiety/depression had worse postoperative HOOS compared to patients with no anxiety/depression, but these associations were not statistically significant after adjusting for preoperative HOOS. There were no significant differences between both groups for percent achieving minimal clinically important difference. Patients who reported anxiety/depression preoperatively had worse preoperative pain and function before hip preservation surgery, with both groups achieving similar levels of clinical effectiveness.

  View details for DOI 10.1093/jhps/hnae029

  View details for PubMedID 39839554

  View details for PubMedCentralID PMC11744469

• Effect of Anatomic Variations in the Anterior Tibial Artery on Risk of Injury During Orthopaedic Knee Surgeries. Orthopaedic journal of sports medicine Frey, C., Bugarinovic, G., Zhou, J., Sherman, S., Abrams, G., Segovia, N., Cheah, J. W. 2024; 12 (12): 23259671241301461

  Abstract

  Injury to the posterior vasculature is a potential complication in orthopaedic knee surgery that may be associated with variations in its anatomy, such as the type II-A2 variant, which places the anterior tibial artery (ATA) in closer proximity to the tibia. However, how close surgical instrumentation comes to injuring the ATA is not well described.To determine how the type II-A2 variant of the popliteal vasculature affects proximity of the ATA to instrumentation for orthopaedic knee procedures.Cross-sectional study; Level of evidence, 3.A total of 222 knee magnetic resonance imaging (MRI) scans from a single academic tertiary referral center were evaluated, and ATA branching patterns were characterized. The distances from the ATA to simulated instrumentation of high tibial osteotomy (HTO), posterolateral corner anatomic reconstruction, posterior cruciate ligament (PCL) reconstruction, lateral meniscus posterior horn repair, and lateral meniscus posterior root repair on axial plane MRI scans were measured by 2 authors independently using imaging software. Intrarater and interrater reliability of the measurements was calculated using the intraclass correlation coefficient.ATAs with the type II-A2 pattern passed anterior to the popliteus on 3.15% (n = 7) of the 222 MRI scans. The distance between the ATA and the simulated instrumentation was significantly closer in type II-A2 compared with normal (type I) knees for the lateral meniscus posterior root repair tunnel (11.1 vs 15.7 mm; P = .014), HTO cuts (0.6 vs 8.2 mm; P < .001), and PCL reconstruction tunnel (4.1 vs 11.7 mm; P < .001). Interrater reliability was good to excellent for all measurements, and intrarater reliability ranged from moderate to excellent.HTO cut, PCL reconstruction tunnel, and lateral meniscus posterior root tunnel instrumentation were significantly closer to the ATA in knees with type II-A2 anatomy compared with normal (type I) anatomy. Careful analysis of vasculature using MRI may be of utility for select surgery about the knee to guide surgical technique.

  View details for DOI 10.1177/23259671241301461

  View details for PubMedID 39711610

  View details for PubMedCentralID PMC11662312

• Liver Function Test Results Correlate With Spleen Size in Patients With Infectious Mononucleosis. Cureus Durtschi, M. S., Pham, N. S., Hwang, C. E. 2024; 16 (9): e70041

  Abstract

  We aimed to evaluate the efficacy of measuring transaminase levels to determine the resolution of splenomegaly in athletes diagnosed with infectious mononucleosis (IM).We collected serial aspartate aminotransferase (AST) and alanine transaminase (ALT) levels and ultrasound-measured spleen sizes in university athletes who had been diagnosed with IM. Our study included seven university-aged athletes from a single institution. Patients received serial liver function tests (LFT) and splenic ultrasound testing until resolution of symptoms and full return to sport. The effects of AST, ALT, and days from symptom onset were analyzed using multivariable mixed-effects linear regression models.Levels of AST and ALT were significantly correlated with spleen size. For each 10-unit increase in AST and ALT values, spleen size increased by 0.1 cm (p = 0.007) and 0.09 cm (p = 0.008), respectively. Decreasing levels of ALT and AST correlated with a decrease in spleen size. Normalization of AST/ALT values correlated with return of spleen size to baseline.Liver function testing may be useful in the return-to-play decision-making process for athletes with IM.

  View details for DOI 10.7759/cureus.70041

  View details for PubMedID 39449903

  View details for PubMedCentralID PMC11499307

• Self-reported preoperative anxiety and depression associated with worse patient-reported outcomes for periacetabular osteotomy and hip arthroscopy surgery JOURNAL OF HIP PRESERVATION SURGERY Richey, A. E., Segovia, N., Hastings, K., Klemt, C., Pun, S. Y. 2024

  View details for DOI 10.1093/jhps/hnae029

  View details for Web of Science ID 001296378800001

• Single-cell transcriptomic atlas reveals increased regeneration in diseased human inner ear balance organs. Nature communications Wang, T., Ling, A. H., Billings, S. E., Hosseini, D. K., Vaisbuch, Y., Kim, G. S., Atkinson, P. J., Sayyid, Z. N., Aaron, K. A., Wagh, D., Pham, N., Scheibinger, M., Zhou, R., Ishiyama, A., Moore, L. S., Maria, P. S., Blevins, N. H., Jackler, R. K., Alyono, J. C., Kveton, J., Navaratnam, D., Heller, S., Lopez, I. A., Grillet, N., Jan, T. A., Cheng, A. G. 2024; 15 (1): 4833

  Abstract

  Mammalian inner ear hair cell loss leads to permanent hearing and balance dysfunction. In contrast to the cochlea, vestibular hair cells of the murine utricle have some regenerative capacity. Whether human utricular hair cells regenerate in vivo remains unknown. Here we procured live, mature utricles from organ donors and vestibular schwannoma patients, and present a validated single-cell transcriptomic atlas at unprecedented resolution. We describe markers of 13 sensory and non-sensory cell types, with partial overlap and correlation between transcriptomes of human and mouse hair cells and supporting cells. We further uncover transcriptomes unique to hair cell precursors, which are unexpectedly 14-fold more abundant in vestibular schwannoma utricles, demonstrating the existence of ongoing regeneration in humans. Lastly, supporting cell-to-hair cell trajectory analysis revealed 5 distinct patterns of dynamic gene expression and associated pathways, including Wnt and IGF-1 signaling. Our dataset constitutes a foundational resource, accessible via a web-based interface, serving to advance knowledge of the normal and diseased human inner ear.

  View details for DOI 10.1038/s41467-024-48491-y

  View details for PubMedID 38844821

• Online video resources pertaining to cerebral palsy: A YouTube-based quality control study. Journal of children's orthopaedics Thomas, N. D., Melchor, J., Carr, R., Ripps, S., Pham, N., Golan, R., Talathi, N., Thompson, R. M., Spence, D., Chambers, H. 2024; 18 (3): 308-314

  Abstract

  To assess the content and quality of YouTube videos related to cerebral palsy to provide insights into the online video resources available for individuals affected by cerebral palsy and suggest strategies for improvement.YouTube videos were analyzed based on interaction parameters, content characteristics/category, and video source. Video reliability and quality were assessed using the Journal of American Medical Association benchmark, Global Quality Scale, and cerebral palsy-specific score. Statistical analyses examined associations between video characteristics and reliability/quality scores.The average video (n = 48) length was 6.8 min, with 29 informational and 19 experiential videos. The mean Journal of American Medical Association score was 2.0, indicating moderate reliability. The Global Quality Scale suggested good quality content (average: 3.5), but only 14% were rated as good via cerebral palsy-specific score. Higher views were associated with higher Journal of American Medical Association score and cerebral palsy-specific score (p = 0.002 and p = 0.006), and nonphysician medical expert videos had lower Journal of American Medical Association scores than academic videos (p = 0.042). Video content was not significantly associated with either score.YouTube provides moderate to good quality information on cerebral palsy. Critical evaluation of video sources and content is essential. Findings can guide strategies to enhance the quality of cerebral palsy-related YouTube content, benefiting individuals with cerebral palsy, health care providers, and caregivers.

  View details for DOI 10.1177/18632521241227803

  View details for PubMedID 38831853

  View details for PubMedCentralID PMC11144379

• A Recess Is Observed Between the Posterior Knee Capsule and the Meniscotibial Ligament Complex in Pediatric Specimens. Arthroscopy, sports medicine, and rehabilitation Dingel, A. B., Tompkins, M., Yen, Y., Karius, A. K., Cinque, M., Vuong, B. B., Taylor, V., Pham, N. S., Ganley, T. J., Wilson, P., Ellis, H. B., Green, D., Fabricant, P. D., Boucher, L., Shea, K. G. 2024; 6 (3): 100852

  Abstract

  Purpose: To define the surgical anatomy of the meniscotibial ligament complex of the pediatric medial and lateral menisci and their relation to the proximal tibial physis and posterior joint capsule.Methods: Fourteen pediatric cadaveric knee specimens (aged 3 months to 11 years) were dissected to clarify the relation of the posterior knee capsule, the meniscus, and the meniscotibial ligament complex. Metallic markers were placed marking the meniscotibial ligament capsular attachment on the proximal tibia. Specimens underwent computed tomography scanning to evaluate pin placement and relation to the physis. A digital measurement tool was used to measure the distances between the proximal tibial physis and the pins (placed at 5 points on both the lateral and medial menisci).Results: In each specimen, clear separation was noted between the posterior joint capsule from the meniscus and meniscotibial ligament complex in the medial and lateral compartments. There was an increase in the distance between the proximal tibial physis and the insertion points of the meniscotibial ligament complex with increasing specimen age. For both the medical and lateral menisci in group 1, the median meniscotibial ligament insertion points were often less than 7 mm (interquartile range, 0.00-7.8 mm) away from the physis. The median meniscotibial ligament insertion points in group 2 tended to be farther from the physis but always less than 20 mm (interquartile range, 2.5-17.5 mm)-and as close as less than 5 mm (lateral posterior root).Conclusions: In this anatomic study of pediatric knees, we observed a distinct recess/cul-de-sac space between the posterior knee capsule and meniscal attachments in all specimens. This defines a distinct plane between the posterior knee capsule and the meniscotibial ligament complex, with a distance between the physis and meniscotibial ligament capsular attachments that increases with age.Clinical Relevance: The anatomic parameters evaluated in our study should be considered as future meniscal repair and transplantation techniques aim to restore the meniscal anatomy, stability, and mobility provided by the meniscotibial ligament complex and capsule structures.

  View details for DOI 10.1016/j.asmr.2023.100852

  View details for PubMedID 39006787

• Association between operative duration and adverse outcomes after hip fracture surgery: A NSQIP matched cohort study. Injury Harris, T., Segovia, N., Koltsov, J., Gardner, M. 2024; 55 (8): 111635

  Abstract

  Prolonged operative duration is an independent risk factor for surgical complications in numerous subspecialties. However, associations between adverse events and operative duration of hip fracture fixation in older adults have not been well-quantified. This study aims to determine if prolonged operative duration of hip fracture surgery is related to adverse outcomes. We hypothesized that patients with high operative durations experience greater rates of 30-day complications.The American College of Surgeons National Surgical Quality Improvement Program database was retrospectively reviewed to identify older adults (55 years and above) who underwent hip fracture fixation between 2015-2019. Prolonged operative duration was defined as >75th percentile, and cases were matched using propensity scores based on demographic, surgical, and comorbidity factors. Univariate differences in adverse events (including readmission, reoperation, mortality, and organ-system complications) were analyzed. Multivariable mixed-effects logistic regression analyses were completed for statistically significant events.A total of 8827 case-control pairs were identified for comparison. Rates of superficial surgical site infection (SSI) (p= 0.022), any SSI (p= 0.032), and any complication (p < 0.001) were elevated in those with prolonged surgical duration in univariate analyses. In multivariable models, prolonged operative time was associated with superficial SSI (OR 1.50, p= 0.019), any SSI (OR 1.35; p= 0.029) and any complication (OR 1.58; p < 0.001). In subgroup analyses, all findings persisted for IMN with operative time associated with superficial SSI (OR 1.98, p= 0.012), any SSI (OR 1.71; p= 0.019), and any complication (OR 1.84; p < 0.001). Operative time was associated only with any complication for hemiarthroplasty/internal fixation and sliding hip screw (OR 1.27 and 1.89, respectively; p < 0.001).Our study demonstrates that duration of surgery is an independent risk factor for superficial SSI, any SSI, and any complication. Notably, our findings suggest that high operative durations may be most concerning for SSIs in IMN fixation, which is currently the most common choice for hip fracture fixation in the US. However, the rate of any complication is significantly elevated when surgical duration is prolonged, regardless of surgery type.

  View details for DOI 10.1016/j.injury.2024.111635

  View details for PubMedID 38852528

• 3D CT modeling demonstrates the anatomic feasibility of S1AI screw trajectory for spinopelvic fixation in neuromuscular scoliosis. Spine deformity Bryson, X. M., Pham, N. S., Hollyer, I., Hu, S., Rinsky, L. A., Vorhies, J. S. 2024

  Abstract

  In patients with neuromuscular scoliosis undergoing posterior spinal fusion, the S2 alar iliac (S2AI) screw trajectory is a safe and effective method of lumbopelvic fixation but can lead to implant prominence. Here we use 3D CT modeling to demonstrate the anatomic feasibility of the S1 alar iliac screw (S1AI) compared to the S2AI trajectory in patients with neuromuscular scoliosis.This retrospective study used CT scans of 14 patients with spinal deformity to create 3D spinal reconstructions and model the insertional anatomy, max length, screw diameter, and potential for implant prominence between 28 S2AI and 28 S1AI screw trajectories.Patients had a mean age of 14.42 (range 8-21), coronal cobb angle of 85° (range 54-141), and pelvic obliquity of 28° (range 4-51). The maximum length and diameter of both screw trajectories were similar. S1AI screws were, on average, 6.3 ± 5 mm less prominent than S2AI screws relative to the iliac crests. S2AI screws were feasible in all patients, while in two patients, posterior elements of the lumbar spine would interfere with S1AI screw insertion.In this cohort of patients with neuromuscular scoliosis, we demonstrate that the S1AI trajectory offers comparable screw length and diameter to an S2AI screw with less implant prominence. An S1AI screw, however, may not be feasible in some patients due to interference from the posterior elements of the lumbar spine.

  View details for DOI 10.1007/s43390-024-00840-z

  View details for PubMedID 38733488

  View details for PubMedCentralID 8505341

• Use of Peripheral Nerve Blocks Is Not Associated With Decreased Postoperative Opioid Prescription After ACL Reconstruction in Adolescents ORTHOPEDICS Kaur, J., Pham, N., Cahan, E., Halvorsen, K., Langner, J. L., Bryson, X. M., Chan, C. M., Vorhies, J. 2024; 47 (2): 83-88

  Abstract

  The rate of anterior cruciate ligament (ACL) injuries and reconstruction in pediatric patients is increasing. Perioperative peripheral nerve blocks (PNBs) are widely used for pain management in this population. We used a multi-state administrative claims database to describe the effect of PNB after ACL reconstruction on postoperative opioid consumption. We identified patients 10 to 18 years old undergoing primary ACL reconstruction between 2014 and 2016 in an administrative claims database. Patients filling an outpatient perioperative prescription for opioids with at least 1 year of follow-up were included. We stratified patients based on PNB. Our primary outcome was opioid prescription patterns (in morphine milligram equivalents [MMEs]) and incidence of opioid represcription. Of the 4459 cases, 2432 (54.5%) of the patients were given a PNB during ACL reconstruction while 2027 (45.5%) were not. Patients with PNB were prescribed more MMEs per day (76.1±41.7 vs 62.7±35.7 MMEs, P<.001), more pills (63.6±53.1 vs 54.4±40.6 pills, P<.001), higher MMEs per pill (10.0±9.5 vs 8.3±5.0 MMEs, P<.001), and more total MMEs (460.6±259.4 vs 355.7±215.1 MMEs, P<.001) than patients without PNB. Adjusting for prescription patterns and demographic variables with logistic regression, PNBs were associated with a 60% increase in the odds of opioid represcription within 30 days and a 32% increase in the odds of opioid represcription within 90 days. We demonstrated an increase in postoperative opioid prescription rates with PNB after ACL reconstruction. [Orthopedics. 2024;47(2):83-88.].

  View details for DOI 10.3928/01477447-20230616-05

  View details for Web of Science ID 001190541800001

  View details for PubMedID 37341565

• Opportunistic hand radiographs to screen for low forearm bone mineral density: a prospective and retrospective cohort study. BMC musculoskeletal disorders O'Mara, A., Kerkhof, F., Kenney, D., Segovia, N., Asbell, P., Ladd, A. L. 2024; 25 (1): 159

  Abstract

  Low bone mineral density affects 53% of women over age 65 in the US, yet many are unaware and remain untreated. Underdiagnosis of forearm osteoporosis and related fragility fractures represent missed warning signs of more deadly, future fractures. This study aimed to determine if hand radiographs could serve as early, simple screening tools for predicting low forearm bone mineral density (BMD).We evaluated posterior-anterior (PA) hand radiographs (x-rays) and Dual-energy X-ray absorptiometry (DXA) scans of 43 participants. The ratio of the intramedullary cavity to total cortical diameter of the second metacarpal (second metacarpal cortical percentage (2MCP)) was used as a potential diagnostic marker. Mixed-effects linear regression was performed to determine correlation of 2MCP with BMD from various anatomic regions. Repeated measures ANOVAs were used to compare BMD across sites. An optimal 2MCP cutoff for predicting forearm osteopenia and osteoporosis was found using Receiver Operating Curves.2MCP is directly correlated with BMD in the forearm. The optimal 2MCP of 48.3% had 80% sensitivity for detecting osteoporosis of the 1/3 distal forearm. An 2MCP cutoff of 50.8% had 84% sensitivity to detect osteoporosis of the most distal forearm. Both 2MCP cutoffs were more sensitive at predicting forearm osteoporosis than femoral neck T-scores.These findings support the expansion of osteoporosis screening to include low-cost hand x-rays, aiming to increase diagnosis and treatment of low forearm BMD and fractures. Proposed next steps include confirming the optimal 2MCP cutoff at scale and integrating automatic 2MCP measurements into PAC systems.

  View details for DOI 10.1186/s12891-023-07127-w

  View details for PubMedID 38378510

  View details for PubMedCentralID 3767038

• Prospective Analysis of Simulated Pneumatic Tourniquet Use and Oedema Following Axillary Lymph Node Dissection. The journal of hand surgery Asian-Pacific volume Wu, E. J., Lai, C. H., Muraoka, K., Segovia, N., Kleimeyer, J. P., Yao, J. 2024; 29 (1): 29-35

  Abstract

  Background: Tourniquet use during upper extremity surgery in patients with a history of axillary lymph node dissection (ALND) remains controversial due to the perceived but unproven risk of lymphoedema. We prospectively evaluated upper extremity swelling in patients with a history of unilateral ALND using a standardised tourniquet model. Methods: A tourniquet was applied to the upper arm bilaterally, with the unaffected side serving as an internal control. Each arm was subsequently held in an elevated position to reduce swelling. Hand volume was measured using an aqueous volumeter. Results: The patients' ALND arms experienced slightly greater increases in volume following tourniquet application compared to their healthy control arms. However, this amount of oedema was temporary and reversible, as both arms experienced spontaneous resolution of swelling with no significant difference in residual hand volume at the conclusion of the study. Conclusions: Tourniquet use may be safe in patients with a history of ALND. Further investigation is needed to verify this in a surgical setting. Level of Evidence: Level II (Therapeutic).

  View details for DOI 10.1142/S242483552450005X

  View details for PubMedID 38299248

• Conversations About Congenital Clubfoot: Investigating How Parents Share Information About a Structural Diagnosis With Their Children. Cureus Baskar, D., Ngnepieba, M., Paul, P., Segovia, N. A., Frick, S. 2023; 15 (11): e48576

  Abstract

  Background and objective Clubfoot is a common congenital musculoskeletal condition that is treated with manipulation and casting in the first few weeks of life, followed by bracing that extends into early childhood. While children typically do not recall treatment with Ponseti casting in infancy, childhood treatment and monitoring may result in a sense of heightened awareness. In light of this, this study explores how parents share information about clubfoot diagnosis and guide their children in understanding the importance of treatment. Methods Parents of clubfoot children aged 5-18 years were eligible to participate. Primary recruitment was done through social media via Facebook clubfoot support groups. Participants who gave consent completed an electronic survey and were invited to take part in a semi-structured interview to share additional experiences. Significant themes elicited from study interviews were analyzed along with survey responses. Results Survey responses were received from 74 parents, and 23 participated in the semi-structured interview. Of note, 91% of parents indicated discussing clubfoot with their children, beginning at a median age of three years. The age at which parents first discussed clubfoot with their child was significantly earlier for those who "strongly agree" that their children understand their condition versus those who "agree". Although 68% of parents indicated that receiving guidance from their orthopedic provider would be helpful for these discussions, only 18% noted receiving direct advice. Recurrent themes across interviews included being open and honest about the children's diagnosis and treatment, aiding the children in taking ownership of their diagnosis, and validating emotional responses throughout treatment.  Conclusions This study provides valuable insights into initiating conversations with children about structural diagnoses like congenital clubfoot. Recurrent themes from conversations with families provide information on helpful strategies to encourage early discussions about clubfoot diagnosis and treatment to aid children in taking ownership of their diagnosis.

  View details for DOI 10.7759/cureus.48576

  View details for PubMedID 38073997

  View details for PubMedCentralID PMC10710312

• Can Caregivers Forecast Their Child's Postoperative Disability After Elective Orthopedic Surgery? Cureus Baskar, D., Mehta, S., Freiman, H., Segovia, N. A., Vuong, B. B., Richey, A., Langner, J. L., Hastings, K. G., Kamal, R. N., Frick, S. 2023; 15 (11): e48575

  Abstract

  Background While there has been a growing emphasis on evaluating the patient's perspective of health outcomes, caregiver expectations of post-orthopedic procedure disability and pain in a pediatric population are yet to be investigated. This study evaluates whether caregivers' preoperative expectations of pain and function differ from their child's early outcomes after surgical orthopedic intervention. Methodology Patients eight to 18 years old undergoing elective orthopedic surgery were enrolled. The caregivers of consented patients completed a survey at the child's preoperative appointment to predict their postoperative pain and disability. The child was given the same survey during their postoperative visit four to six weeks after surgery to assess actual levels of functioning following the procedure. Scores were analyzed to study correlations between patient and caregiver responses (n = 48). Results Caregivers underestimated their child's postoperative psychosocial functioning, as evidenced by the Psychosocial Health Summary Score, and overestimated pain, as demonstrated by the Numeric Pain Rating Scale. The Pediatric Quality of Life Inventory scores showed caregivers had differing expectations of the impact surgery had across various aspects of the physical, emotional, social, and school functioning domains. Higher parental pain catastrophizing was associated with underestimated predictions of their child's psychosocial functioning after surgery. No significant difference was found in the patient's physical functioning, as shown by the Physical Health Summary Score. Conclusions Surgical intervention is a major event that can provoke anxiety for parents and caregivers. Understanding differences in caregiver perspectives and early postoperative patient outcomes provides physicians valuable insights. Explaining to caregivers that patient psychosocial factors and functional outcomes after surgery are commonly better than expected can alleviate anxiety and prevent catastrophizing. This knowledge can help guide caregiver expectations and plans for their child's postoperative pain control and functional recovery.

  View details for DOI 10.7759/cureus.48575

  View details for PubMedID 38073935

  View details for PubMedCentralID PMC10710311

• No Delay in Age of Crawling, Standing or Walking with Pavlik Harness Treatment: A Prospective Cohort Study. The Journal of the American Academy of Orthopaedic Surgeons Stavinoha, T. J., Pun, S. Y., McGlothlin, J. D., Uzosike, M. B., Segovia, N. A., Imrie, M. N. 2023

  Abstract

  BACKGROUND: Pavlik harness treatment is the standard of care for developmental dysplasia of the hip in infants younger than 6 months. The effect of Pavlik harness treatment on the achievement of motor milestones has not previously been reported.METHODS: In this prospective cohort study, 35 patients were prospectively enrolled to participate and received questionnaires with sequential clinical visits monitoring treatment of their developmental dysplasia of the hip. One-sample Student t-tests assessed differences in milestone attainment age, and the Benjamini-Hochberg procedure was conducted to decrease the false discovery rate. Post hoc power analyses of each test were conducted. The age of achievement of eight early motor milestones were recorded and compared with a previously published cohort of healthy infants.RESULTS: Infants treated with a Pavlik harness achieved four early motor milestones markedly later than the reported age of achievement in a historical control group. These milestones included "roll supine" (5.3 vs. 4.5 months; P = 0.039), "roll prone" (5.7 vs. 5.0 months; P = 0.039), "sit" (6.4 vs. 5.2 months; P < 0.001), and "crawl on stomach" (7.7 vs. 6.6 months; P = 0.039). However, there was no difference in time to achievement of later motor milestones of "crawl on knees," "pull to stand," and "independent walking."CONCLUSION: Several early motor milestones were achieved at a statistically significantly later time than historical control subjects not treated in a Pavlik harness. Despite statistical significance, the small delays in early motor milestones were not thought to be clinically significant. No differences were observed in the later motor milestones, including knee crawling, standing, and independent walking. Clinicians and parents may be reassured by these findings.LEVEL OF EVIDENCE: Therapeutic Level II-prospective study.

  View details for DOI 10.5435/JAAOS-D-21-00249

  View details for PubMedID 37862341

• Evaluating the Readability and Quality of Online Patient Education Materials for Pediatric ACL Tears. Journal of pediatric orthopedics Thomas, N. D., Mahler, R., Rohde, M., Segovia, N., Shea, K. G. 2023; 43 (9): 549-554

  Abstract

  As the rate of anterior cruciate ligament (ACL) tears increases in children, the internet has become a major source of information and education. In the United States, the average adult reads at about an eighth grade level. The National Institutes of Health recommends that patient education materials do not exceed a sixth-grade reading level. Therefore, the most accessed resources on the internet should be created with this in mind. The purpose of this study is to assess the readability and quality of online patient resources for pediatric ACL tears.Google was queried using the term "Pediatric ACL Tear" on May 26, 2022. The most popular sites were identified through page one of a Google search. All content was evaluated to assure information was directed toward patients. To determine reading difficulty, the most widely accepted readability tests: Flesch Reading Ease Index, Flesch-Kincaid Grade Level, and Gunning Fog Index were calculated through plain text in Microsoft Word and URL in online readability checker Readable.io.The average grade level for all resources was above the recommended reading level based on both Microsoft Word and Readable.io calculations. Each source exceeded the NIH recommendation by 2.6 grade levels on average (Mean grade level readability was 8.6 ± 1.9). Four of the 6 sites were above the average US reading level, exceeding the eighth grade by an average of 1.5 grade levels. All 6 sites analyzed had a mean DISCERN score of 61.9, meeting the 'good quality' criteria.The most readily available online materials for Pediatric ACL tears were of 'good quality' but above both the NIH-recommended readability level and the average US adult reading level. With the increasing need for treatment of ACL tears in pediatric and adolescent patients and greater internet accessibility in these populations, it is important to consider the readability of these resources in support of increased health literacy and improved outcomes.It is important for physicians treating young patients with ACL tears to be aware of all sources of information and support, including content shared online as these platforms are increasingly utilized, especially by patients and families of lower socioeconomic status.

  View details for DOI 10.1097/BPO.0000000000002490

  View details for PubMedID 37694607

• Concentrated Economic Disadvantage Predicts Resource Utilization after Total Knee Arthroplasty. The Journal of arthroplasty Warren, S. I., Pham, N. S., Foreman, C., Huddleston, J. I. 2023

  Abstract

  BACKGROUND: The Index of Concentration at the Extremes (ICE), a measure of geographic socioeconomic polarization, predicts several health outcomes, but has not been evaluated in the context of total knee arthroplasty (TKA). This study evaluates ICE as a predictor of post-TKA resource utilization.METHODS: Using the Healthcare Cost and Utilization Project's New York State database from 2016 to 17, we retrospectively evaluated 57,426 patients ≥ 50 years undergoing primary TKA. The ICE values for extreme concentrations of income and race were calculated using United States Census Bureau data with the formula ICEi = (Pi - Di)/Ti where Pi, Di, and Ti are the number of households in the most privileged extreme, disadvantaged extreme, and total population in zip code i, respectively. Extremes of privilege and disadvantage were defined as ≥ $150,000 vs. < $25,000 for income and non-Hispanic White vs. non-Hispanic Black for race. Association of ICE values, demographics, and comorbidities with 90-day readmission and 90-day emergency department (ED) visits were examined using multivariable analysis.RESULTS: Overall 90-day readmission and ED visit rates were 12.8 and 9.4%, respectively. On multivariable analysis, the lowest ICEIncome quintile (concentrated poverty) predicted 90-day readmission (odds ratio [OR] 1.17, 95% confidence interval [CI] 1.05-1.30, P = 0.005) and 90-day ED visit (OR 1.22, 95% CI 1.08-1.38, P = 0.001). The ICERace was not predictive of either outcome.CONCLUSION: Patients in communities with the lowest ICEIncome values utilize more inpatient and ED resources after primary TKA. Incorporating ICEIncome into risk-adjusted bundled payment models may help align incentives for equitable care.

  View details for DOI 10.1016/j.arth.2023.08.024

  View details for PubMedID 37595766

• Variations in Duration of Clinical Follow-up After Spinal Fusion for Adolescent Idiopathic Scoliosis: A Survey of POSNA and SRS Membership. Journal of the Pediatric Orthopaedic Society of North America Johnson, T. R., Segovia, N. A., Bryson, X., Imrie, M. N., Vorhies, J. S. 2023; 5 (3): 645

  Abstract

  Background: There are currently no evidence-based guidelines addressing the optimal duration of follow-up after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Despite the safety and efficacy of PSF for AIS, long-term complications exist, including infection, pseudoarthrosis, adjacent segment disease, deformity progression, persistent pain, and junctional deformities. In this study, we describe practice variation existing among surgeons regarding duration and intervals of patient follow-up after surgical treatment of AIS in addition to factors influencing provider recommendations for duration of radiographic and clinical follow-up. This investigation of practice variation is important, as opportunities exist for both limiting unnecessary radiation exposure, while also identifying opportunities for timely intervention to help decrease the morbidity of late complications arising after spinal fusion.Methods: An anonymous online survey was created and subsequently distributed to members of POSNA and SRS to assess practice demographics and surgeon opinions surrounding duration of surveillance following surgery for AIS. Only surgeons who treated at least five operative AIS cases within the past year were included. Descriptive statistics and comparative sub-analyses are presented.Results: Forty-nine participants met inclusion criteria. Respondents were mainly pediatric orthopaedic surgeons (92%) in practice for 21-50 years (49%) who performed approximately 21-50 operative AIS cases per year (49%). Forty-eight percent of providers had an age limit in their practice, and 52% regularly followed operative AIS patients over 18 years of age. Sixty-two percent of surgeons followed operative AIS patients for 2-5 years postoperatively, whereas only 4% followed for more than 10 years. The most cited factors impacting follow-up recommendations were junctional deformities, adjacent segment disease, and symptomatic implants. There were no significant associations between years in practice, operative volume, and recommendations for duration of follow-up after routine operative AIS cases.Conclusions: Significant variability in duration of follow-up after PSF for AIS exists. Although most patients are clinically followed for 2 years after surgery, only a small percentage of providers follow AIS patients for more than 10 years postoperatively. Numerous AIS revisions occur more than 5 years after the index surgery. Further investigations to determine the optimal duration of surveillance following PSF for AIS should be conducted.Level of Evidence: V.•Late complications following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) may occur 5-10 years after the index surgery and currently, there are no guidelines that outline the optimal duration of postoperative follow-up.•Significant variability exists in pediatric orthopaedic provider recommendations for long-term follow-up after PSF for AIS and is not associated with surgeon experience or case volume.•Most providers follow operative AIS patients for 1-2 years postoperatively, and only a small minority follow operative AIS patients for more than 10 years after the index surgery.•Persistent back pain, junctional deformity, and symptomatic implants are the most common factors affecting provider recommendations for duration of follow-up.•These survey findings may be useful for pediatric orthopaedic providers to operatively manage AIS patients in determining the need and frequency for routine radiographic and/or clinical follow-up.

  View details for DOI 10.55275/JPOSNA-2023-645

  View details for PubMedID 40433342

  View details for PubMedCentralID PMC12088193

• Effectiveness of an early operating room start time in managing pediatric trauma. World journal of orthopedics Kym, D., Kaur, J., Pham, N. S., Klein, E., Langner, J. L., Wang, E., Vorhies, J. S. 2023; 14 (7): 516-525

  Abstract

  The timing of operative treatment for pediatric supracondylar humerus fractures (SCHF) and femoral shaft fractures (FSF) remains controversial. Many fractures previously considered to be surgical emergencies, such as SCHF and open fractures, are now commonly being treated the following day. When presented with an urgent fracture overnight needing operative treatment, the on-call surgeon must choose whether to mobilize resources for a late-night case or to add the case to an elective schedule of the following day.To describe the effect of a program allowing an early operating room (OR) start for uncomplicated trauma prior to an elective day of surgery to decrease wait times for surgery for urgent fractures admitted overnight.Starting in October 2017, patients were eligible for the early slot in the OR at the discretion of the surgeon if they were admitted after 21:00 the previous night and before 05:00. We compared demographics and timing of treatment of SCHF and FSF treated one year before and after implementation as well as the survey responses from the surgical team.Of the 44 SCHF meeting inclusion criteria, 16 received treatment before implementation while 28 were treated after. After implementation, the mean wait time for surgery decreased by 4.8 h or 35.4% (13.4 h vs 8.7 h; P = 0.001). There were no significant differences in the operative duration, time in the post anesthesia care unit, and wait time for discharge. Survey results demonstrated decreased popularity of the program among nurses and anesthesiologists relative to surgeons. Whereas 57% of the surgeons believed that the program was effective, only 9% of anesthesiologists and 16% of nurses agreed. The program was ultimately discontinued given the dissatisfaction.Our findings demonstrate significantly reduced wait times for surgery for uncomplicated SCHF presenting overnight while discussing the importance of shared decision-making with the stakeholders. Although the program produced promising results, it also created new conflicts within the OR staff that led to its discontinuation at our institution. Future implementations of such programs should involve stakeholders early in the planning process to better address the needs of the OR staff.

  View details for DOI 10.5312/wjo.v14.i7.516

  View details for PubMedID 37485431

  View details for PubMedCentralID PMC10359751

• Temporary Flexible Rods for Correction of Severe Pediatric Spinal Deformity ORTHOPEDICS Kwong, J. W., Tileston, K. R., Kaur, J., Segovia, N. A., Imrie, M. N., Rinsky, L. A., Vorhies, J. S. 2023; 46 (4): 234-+

  Abstract

  Surgical correction of large, rigid scoliotic and kyphotic curves carries an increased risk of perioperative complications, such as neurological injury and excessive blood loss, compared with correction of less severe curves. Titanium temporary flexible rods (TFRs), designed for pediatric long bone fracture fixation, may be helpful as adjuncts to achieve gradual, stepwise intraoperative correction of severe pediatric spinal deformities. A retrospective review was conducted of spinal fusion cases for pediatric scoliosis or kyphosis at our institution that used TFRs as a correction technique from 2007 to 2019. Patients underwent posterior spinal fusion with predominantly pedicle screw instrumentation. Intraoperatively, a non-contoured titanium elastic nail was temporarily positioned in the screws unilaterally to achieve partial correction while the contralateral side was instrumented. Then, the TFR was removed and replaced with a permanent rod. Thirty-four patients with severe spinal deformities underwent posterior spinal fusion. Seventeen had scoliosis (mean major Cobb angle, 89.3°) and 17 had kyphosis (mean T5-T12 kyphosis, 73.8°). Idiopathic deformity was the most common etiology; neuromuscular, syndromic, and postsurgical causes contributed to the remainder of cases. All patients had Ponte osteotomies. Four patients (11.8%) had neuromonitoring alerts, 1 of which was related to insertion of the TFR; all were reversible. For patients with scoliosis, the mean postoperative Cobb angle measured 40.2° (53.6% correction). For patients with kyphosis, the mean postoperative T5-T12 angle measured 43.3° (30.4° of correction). TFRs appear to be helpful adjuncts for correction of severe pediatric spinal deformities, facilitating gradual intraoperative correction in a single-stage operation. Neuromonitoring alerts are common but reversible. [Orthopedics. 2023;46(4):234-241.].

  View details for DOI 10.3928/01477447-20230207-03

  View details for Web of Science ID 001036949800013

  View details for PubMedID 36779740

• Tarsal Navicular Bone Stress Injuries: A Multicenter Case Series Investigating Clinical Presentation, Diagnostic Approach, Treatment, and Return to Sport in Adolescent Athletes. The American journal of sports medicine Mehta, S., Zheng, E., Heyworth, B. E., Rizzone, K., Halstead, M., Brown, N., Stinson, Z., Nussbaum, E. D., Gray, A., Segovia, N., Kraus, E. 2023: 3635465231170399

  Abstract

  BACKGROUND: Tarsal navicular bone stress injuries (BSIs) are considered "high risk" because of prolonged healing times and higher rates of nonunion in adult populations but, to our knowledge, have not been comprehensively examined in adolescent athletes.PURPOSE: To describe the characteristics of tarsal navicular BSIs in adolescents.STUDY DESIGN: Case series; Level of evidence, 4.METHODS: A retrospective analysis of patients aged 10 to 19 years with a radiographically diagnosed tarsal navicular BSI was performed at 8 academic centers over a 9-year study period. Age, sex, body mass index (BMI), primary sport, physical examination findings, imaging, treatment, surgical technique, return-to-sport time, and complications were analyzed.RESULTS: Among 110 patients (mean age, 14.7 ± 2.7 years; 65% female), common primary sports were cross-country/track and field (29/92 [32%]) and gymnastics/dance (25/92 [27%]). Grade 4 BSIs were identified in 44% (48/110) of patients, with fracture lines present on radiography or magnetic resonance imaging. Nonoperative treatment (mean age, 14.4 ± 2.6 years), consisting of protected weightbearing and either a protective boot (69/88 [78%]) or a cast (19/88 [22%]), was trialed in all patients and was successful in 94 patients (85%). Operative treatment (mean age, 17.1 ± 1.4 years) was ultimately pursued for 16 patients (15%). Patients who required surgery had a higher BMI and a higher percentage of fracture lines present on imaging (nonoperative: 36/94 [38%]; operative: 14/16 [88%]). The median time to return to weightbearing, running, and full sport was significantly longer in duration for the operative group than the nonoperative group (P <.05). Complications associated with surgery included 1 case each of delayed union, nonunion, and painful implants, the latter of which required secondary surgery.CONCLUSION: Adolescent tarsal navicular BSIs were identified most commonly in female patients in leanness sports. Adolescents who required surgery were more likely to be older, have higher BMIs, and have grade 4 BSIs, and they returned to sport within a median of 5 months after single- or double-screw fixation with a low risk of postoperative complications. A better understanding of the presenting signs and symptoms and appropriate diagnostic imaging of navicular BSIs may lead to an earlier diagnosis and improved outcomes.

  View details for DOI 10.1177/03635465231170399

  View details for PubMedID 37265102

• Can Hip Passive Range of Motion Predict Hip Microinstability? A Comparative Study ORTHOPAEDIC JOURNAL OF SPORTS MEDICINE Curtis, D. M., Pullen, W., Hopkins, J. N., Murray, I. R., Money, A., Segovia, N. A., Safran, M. R. 2023; 11 (6): 23259671231169978

  Abstract

  Hip microinstability is an increasingly recognized cause of pain and disability in young adults. It is unknown whether differences in passive hip range of motion (ROM) exist between patients with versus without hip microinstability.Underlying ligamentous and capsular laxity will result in differences in clinically detectable passive ROM between patients with femoroacetabular impingement (FAI), patients with microinstability, and asymptomatic controls.Cross-sectional study; Level of evidence, 3.A retrospective review of all patients undergoing hip arthroscopy between 2012 and 2018 was conducted. Patients with a diagnosis of isolated microinstability based on intraoperative findings were identified and classified as having isolated FAI, instability, or FAI + instability. Patients without a history of hip injury were included as controls. Range of motion was recorded in the supine position for flexion, internal rotation, and external rotation. Univariate and multivariate analysis was performed on each measurement in isolation as well as combinations of motion to include total rotation arc, flexion + rotation arc, and flexion + 2× rotation arc Models were then created and tested to predict instability status.In total, 263 hips were included: 69 with isolated instability, 50 with FAI, 50 with FAI + instability, and 94 control hips. A higher proportion of patients in the instability and FAI + instability groups were female compared with the FAI and control groups (P < .001). On univariate analysis, differences were found in all groups in all planes of motion (P < .001). Multivariable analysis demonstrated differences in all groups in flexion and flexion + rotation arc. In symptomatic patients, the best performing predictive model for hip microinstability was flexion + rotation arc ≥200° (Akaike information criterion, 132.3; P < .001) with a sensitivity of 68.9%, specificity of 80.0%, positive predictive value of 89.1%, and negative predictive value of 51.9%.Patients with hip microinstability had significantly greater ROM than symptomatic and asymptomatic cohorts without hip microinstability. Symptomatic patients with hip flexion + rotation arc ≥200° were highly likely to have positive intraoperative findings for hip microinstability, whereas instability status was difficult to predict in patients with a flexion + rotation arc of <200°.

  View details for DOI 10.1177/23259671231169978

  View details for Web of Science ID 001005240900001

  View details for PubMedID 37347027

  View details for PubMedCentralID PMC10280519

• Spinal fusion is an aerosol generating procedure. World journal of orthopedics Langner, J. L., Pham, N. S., Richey, A., Oquendo, Y., Mehta, S., Vorhies, J. S. 2023; 14 (5): 340-347

  Abstract

  Transmission of severe acute respiratory syndrome coronavirus 2 can occur during aerosol generating procedures. Several steps in spinal fusion may aerosolize blood but little data exists to quantify the risk this may confer upon surgeons. Aerosolized particles containing infectious coronavirus are typically 0.5-8.0 μm.To measure the generation of aerosols during spinal fusion using a handheld optical particle sizer (OPS).We quantified airborne particle counts during five posterior spinal instrumentation and fusions (9/22/2020-10/15/2020) using an OPS near the surgical field. Data were analyzed by 3 particle size groups: 0.3-0.5 μm/m3, 1.0-5.0 μm/m3, and 10.0 μm/m3. We used hierarchical logistic regression to model the odds of a spike in aerosolized particle counts based on the step in progress. A spike was defined as a > 3 standard deviation increase from average baseline levels.Upon univariate analysis, bovie (P < 0.0001), high speed pneumatic burring (P = 0.009), and ultrasonic bone scalpel (P = 0.002) were associated with increased 0.3-0.5 μm/m3 particle counts relative to baseline. Bovie (P < 0.0001) and burring (P < 0.0001) were also associated with increased 1-5 μm/m3 and 10 μm/m3 particle counts. Pedicle drilling was not associated with increased particle counts in any of the size ranges measured. Our logistic regression model demonstrated that bovie (OR = 10.2, P < 0.001), burring (OR = 10.9, P < 0.001), and bone scalpel (OR = 5.9, P < 0.001) had higher odds of a spike in 0.3-0.5 μm/m3 particle counts. Bovie (OR = 2.6, P < 0.001), burring (OR = 5.8, P < 0.001), and bone scalpel (OR = 4.3, P = 0.005) had higher odds of a spike in 1-5 μm/m3 particle counts. Bovie (OR = 0.3, P < 0.001) and drilling (OR = 0.2, P = 0.011) had significantly lower odds of a spike in 10 μm/m3 particle counts relative to baseline.Several steps in spinal fusion are associated with increased airborne particle counts in the aerosol size range. Further research is warranted to determine if such particles have the potential to contain infectious viruses. Previous research has shown that electrocautery smoke may be an inhalation hazard for surgeons but here we show that usage of the bone scalpel and high-speed burr also have the potential to aerosolize blood.

  View details for DOI 10.5312/wjo.v14.i5.340

  View details for PubMedID 37304197

  View details for PubMedCentralID PMC10251270

• Pediatric meniscus morphology varies with age: a cadaveric study. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA Rohde, M. S., Trivedi, S., Randhawa, S., Wright, C. E., Vuong, B. B., Pham, N., Stavinoha, T., Ellis, H. B., Ganley, T. J., Green, D. W., Fabricant, P. D., Tompkins, M., Shea, K. G. 2023

  Abstract

  PURPOSE: In adolescent patients, meniscal tear injury can occur either in isolation (e.g., discoid lateral meniscus tears) or in association with other traumatic injuries including tibial eminence fracture or ACL tear. Damage to meniscal integrity has been shown to increase contact pressure in articular cartilage, increasing risk of early onset osteoarthritis. In symptomatic patients failing conservative management, surgical intervention via meniscus repair or meniscus transplant is indicated. The purpose of this study was to evaluate the radial dimensions of pediatric menisci throughout development. The hypothesis was that the average radial meniscus dimensions will increase as specimen age increases, and mean medial and lateral region measurements will increase at a linear rate.METHODS: Seventy-eight skeletally immature knee cadaver specimens under age 12years were included in this study. The meniscal specimens were photographed in the axial view with ruler in the plane of the tibial plateau and analyzed using computer-aided design (CAD) software (Autodesk Fusion 360). Measurements were taken from inner to outer meniscus rims at five 45 degree intervals using the clockface as a reference (12:00, 1:30, 3:00, 4:30, 6:00), and total area of meniscus and tibial plateau was recorded. Generalized linear models were used to evaluate the associations of radial width measurements with age, tibial coverage, and lateral vs. medial meniscus widths.RESULTS: All radial width measurements increased significantly with specimen age (p≤0.002), and all lateral-medial meniscal widths increased (p<0.001). The anterior zones of the meniscus were found to increase at the slowest rate compared to other regions. Tibial plateau coverage was found to not significantly vary with age.CONCLUSIONS: Meniscus radial width and lateral-medial meniscus width are related to age. The anterior width of the meniscus varied least with age. Improved anatomic understanding may help surgeons more effectively plan for meniscus repair, discoid resection/saucerization/repair, and also support appropriate selection of meniscus allograft for transplantation.

  View details for DOI 10.1007/s00167-023-07447-3

  View details for PubMedID 37178242

• Does spinal deformity affect adolescents' quality of life before we tell them it should? Spine deformity Langner, J. L., Kaur, J., Pham, N. S., Richey, A., Hastings, K., Mehta, S., Bryson, X., Vorhies, J. S. 2023

  Abstract

  PURPOSE: The Scoliosis Research Society 22r Questionnaire(SRS-22r) is the standard for assessing health-related quality of life(HRQoL) in patients with adolescent idiopathic scoliosis. Here we investigate whether patients' perceptions of their HRQoL are influenced by knowledge of scoliosis and counseling by an orthopedic surgeon.METHODS: Patients ages 10-18years referred for their first visit with an orthopaedic surgeon for scoliosis were enrolled from 9/30/19 to 10/22/20. Patients completed the SRS-22r pre- and post-visit. A Wilcoxon signed-rank test was used to analyze the SRS-22r scores.RESULTS: 52 patients participated in the study at a mean age of 14.3years (95% CI 13.8-14.8years) with an average major curve magnitude of 23.2 degrees (95% CI 19.4-27.0 degrees). SRS-22r scores were not correlated to curve magnitude pre- or post-visit. The SRS-22r Satisfaction with care domain exhibited a small increase from pre- to post-visit (pre: 3.3, post: 3.6). All other SRS-22r domains and total scores did not exhibit clinically significant differences.CONCLUSION: Among new adolescent referrals for scoliosis, it is unlikely that counseling by a surgeon influences perceptions of HRQoL as measured by the SRS-22r.LEVEL OF EVIDENCE: III.

  View details for DOI 10.1007/s43390-023-00691-0

  View details for PubMedID 37166749

• The Influence of Race, Income, and Sex on Treatment and Complications of Common Pediatric Fractures ORTHOPEDICS Montgomery, B. K., Joseph, G., Segovia, N., Koltsov, J., Thomas, T. L., Vorhies, J. S., Tileston, K. R. 2023; 46 (3): E156-+

  Abstract

  Despite best intentions, health care disparities exist and can consequently impact patient care. Few studies have examined the impact of disparities in pediatric orthopedic populations. The current study aimed to determine if the treatment type or complication rates of supracondylar, both-bone forearm, or femur fractures are associated with race, ethnicity, sex, or socioeconomic status. The New York Healthcare Cost and Utilization Project's database was used to identify all pediatric patients treated for supracondylar humerus fractures, both-bone forearm fractures, and femoral shaft fractures in 2016. Risk-adjusted relationships with race, ethnicity, sex, hospital location, and median income by zip code were assessed with multivariable logistic regression. Patients who were non-White, resided in the zip codes with the lowest median income (<$42,999 annually), and were treated in metropolitan areas were more likely to receive nonoperative treatments for supracondylar humerus fractures. Female patients with a femoral shaft fracture were less likely to be treated with open reduction and internal fixation vs intramedullary fixation. Finally, complications were not associated with patient race, sex, or socioeconomic statuses. These findings bring attention to health care disparities in the treatment of common pediatric orthopedic fractures. Further studies investigating the underlying etiology behind these disparities are warranted. [Orthopedics. 2023;46(3):e156-e160.].

  View details for DOI 10.3928/01477447-20230104-06

  View details for Web of Science ID 000995876400007

  View details for PubMedID 36623278

• Gadolinium injected concurrently with anesthetic can result in false-negative diagnostic intra-articular hip injections. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA Pullen, W. M., Curtis, D. M., Jamero, C., Segovia, N., Safran, M. R. 2023

  Abstract

  PURPOSE: The purpose of this paper was to evaluate the response to intra-articular hip injections with and without concurrent gadolinium administration. Our secondary outcome was to compare post-operative outcomes between patients with an initial false-negative gadolinium-containing injection and a matched control group.METHODS: Patients receiving a series of two hip diagnostic intra-articular injections (DIAI), the first with gadolinium for concurrent MRA and the second without gadolinium, were retrospectively identified. Pain response to DIAI, injectate volume, local anesthetic volume, inclusion of corticosteroids, and method of injection were compared between injections. False-negative injection was defined as<50% pain relief with concurrent gadolinium, but≥50% pain relief with subsequent anesthetic injection without gadolinium. False-negative injections in patients that ultimately underwent primary hip arthroscopy were identified from this cohort and matched in a 3:1 ratio to a control cohort to compare short-term post-operative single assessment numerical evaluation (SANE) outcomes.RESULTS: Forty-three patients underwent a series of anesthetic injections with and without gadolinium and met inclusion and exclusion criteria. Pain response was significantly different in injections performed with and without gadolinium (18% vs. 81%; p<0.001). There were significant differences in total injectate volume, local anesthetic volume, corticosteroid use, and method of injection between injections, but these variables were not correlated with pain response. Fifteen patients with false-negative responses to injection underwent primary hip arthroscopy and were matched in a 3:1 ratio to a control cohort. There was no difference in short-term post-operative SANE scores between the gadolinium-sensitive and control groups (81.6 vs. 80.0, n.s.).CONCLUSION: Concurrent administration of intra-articular gadolinium with DIAI may result in a false-negative response to anesthetic. Additionally, in patients with initial false-negative DIAI with gadolinium, short-term post-operative outcomes after hip arthroscopy are similar to a matched cohort.LEVEL OF EVIDENCE: Level III.

  View details for DOI 10.1007/s00167-023-07392-1

  View details for PubMedID 37039871

• Endoscopic iliopsoas lengthening for treatment of recalcitrant iliopsoas tendinitis after total hip arthroplasty JOURNAL OF HIP PRESERVATION SURGERY Bonano, J. C., Pierre, K., Jamero, C., Segovia, N. A., Huddleston, J., Safran, M. R. 2023

  View details for DOI 10.1093/jhps/hnac052

  View details for Web of Science ID 000945101700001

• Complications, Implant Survivorships, and Functional Outcomes of Conversion Total Knee Arthroplasty with Prior Hardware. The Journal of arthroplasty Apinyankul, R., Hui, A. Y., Hwang, K., Segovia, N. A., Amanatullah, D. F., Huddleston, J. I., Maloney, W. J., Goodman, S. B. 2023

  Abstract

  End-stage knee osteoarthritis with retained peri-articular hardware is a frequent scenario. Conversion total knee arthroplasty (TKA) leads to excellent outcomes, but poses unique challenges. The evidence supporting retention vs. removal of hardware during TKA is controversial.Patients who underwent TKA with prior hardware between January 2009 and December 2019 were identified. A total of 148 patients underwent TKA with prior hardware. Mean follow-up was 60 months (range, 24 to 223). Univariate and multivariable analyses were used to study correlations among factors and surgical-related complications, prosthesis failures, and functional outcomes.The complication rate was 28 of 148 (18.9%). The use of a quadriceps snips in addition to a medial parapatellar arthrotomy was associated with a higher complication (Odds ratio (OR) 20.7, p < 0.05), implant failures (OR 13.9, p < 0.05), and lower Veteran Rand 12 Mental Score (VR-12 MS) (-14.8, p < 0.05). Hardware removal vs. retention and use of single vs. multiple incisions were not associated with complications or prosthesis failures. Removal of all hardware was associated with significantly higher (+7.3, p < 0.05) VR-12 MS compared to retention of all hardware.TKA with prior hardware was associated with more complications, implant failures, and lower VR-12 MS when a more constrained construct or quadriceps snip was performed. This probably reflects the level of difficulty of the procedure, rather than the surgical approach used. Hardware removal or retention was not associated with complications or implant failures; however, removal rather than retention of all prior hardware is associated with increased general health outcomes.

  View details for DOI 10.1016/j.arth.2023.01.049

  View details for PubMedID 36758842

• Opioid Represcriptions After ACL Reconstruction in Adolescents are Associated With Subsequent Opioid Use Disorder. Journal of pediatric orthopedics Cahan, E. M., Halvorsen, K. C., Pham, N. S., Kaur, J., Bryson, X. M., Chan, C. M., Vorhies, J. S. 2023

  Abstract

  INTRODUCTION: Postoperative opioid prescriptions may confer a risk for subsequent opioid use disorders (OUDs). For many children, postoperative analgesia is often the first opioid exposure. The rates of anterior cruciate ligament (ACL) reconstruction in pediatric populations are rising. Here, we use an administrative claims database to describe opioid prescription patterns after ACL reconstruction and their effect on subsequent risk of OUD.METHODS: Using International Classification of Diseases (ICD)-9, ICD-10, and CPT codes, we identified patients, with ages 10 to 18, undergoing primary ACL reconstruction between 2014 and 2016 with minimum 1 year follow-up in the Optum Clinformatics Data Mart, which is a nationally representative administrative claims database. Demographic variables and prescription patterns (in morphine milligram equivalents [MMEs]) were analyzed using univariate tests and multivariable logistic regression to determine any potential association with the appearance of anew an ICD-9 or ICD-10 code for OUD within 1 year of the initial procedure.RESULTS: A total of 4459 cases were included and 29 (0.7%) of these patients were diagnosed with an OUD within 1 year of surgery. Upon univariate analysis, opioid represcriptions within 6 weeks were significantly more common among patients with OUD; 27.6% vs. 9.7% of patients that did not develop a new diagnosis of OUD (P=0.005). Multivariable logistic regression indicated an independent significant relationship between total MMEs initially prescribed and the odds of a subsequent OUD diagnosis: for each additional 100 MMEs prescribed in total, the odds of OUD increased by 13% (P=0.002). Patients with a represcription within 6 weeks of surgery had an average increase in the odds of OUD by 161% (P=0.027).CONCLUSIONS: In this cohort of patient ages 10 to 18 undergoing primary isolated ACL reconstruction, we found substantial variability in opiate prescribing patterns and higher initial opioid prescription volume, as well as opioid represcription within 6 weeks were predictive of the subsequent development of OUD.LEVEL OF EVIDENCE: Level III.

  View details for DOI 10.1097/BPO.0000000000002340

  View details for PubMedID 36652547

• Distal Metaphyseal Ulnar Shortening Osteotomy Fixation: A Biomechanical Analysis. The Journal of hand surgery Frey, C. S., Zhou, J. Y., Shah, K., Chan, C. K., Joseph, L., Storaci, H., Segovia, N., Yao, J. 2023

  Abstract

  Ulnar shortening osteotomy can be used to treat ulnar impaction syndrome and other causes of ulnar wrist pain. Distal metaphyseal ulnar shortening osteotomy (DMUSO) is one technique that has been proposed to reduce the complications seen with a diaphyseal USO or a wafer resection. However, to our knowledge, the optimal fixation construct for DMUSO has not been studied. We sought to characterize the biomechanical stiffness and rotational stability of different DMUSO constructs.A DMUSO was performed on 40 human cadaveric ulnas using 4 different fixation constructs (10 specimens per group): one 3.0 mm antegrade screw; two 2.2 mm antegrade screws; one 3.0 mm retrograde screw; and two 2.2 mm retrograde screws. Biaxial testing using axial load and cyclical axial torque was performed until failure, defined as 10° of rotation or 2 mm displacement. Specimens were assessed for stiffness at failure. Bone density was assessed using the second metacarpal cortical percentage.Bone density was similar between all 4 testing groups. Of the 4 groups, the 2 antegrade screw group exhibited the highest rotational stiffness of 232 ± 102 Nm/deg. In paired analysis, this was significantly greater than 1 retrograde screw constructs. In multivariable analysis, 2-screw constructs were significantly stiffer than 1 screw and antegrade constructs were significantly stiffer than retrograde. Maximum failure torque did not differ with orientation, but 2 screws failed at significantly higher torques.Using 2 screws for DMUSO fixation constructs may provide higher stiffness and maximum failure torque, and antegrade screw constructs may provide more stiffness than retrograde constructs.Antegrade screw fixation using 2 screws may provide the strongest construct for DMUSO. Antegrade fixation may be preferred because it avoids violating the distal radioulnar joint capsule and articular surface of the ulna.

  View details for DOI 10.1016/j.jhsa.2022.11.007

  View details for PubMedID 36599794

• Potential biomechanical risk factors on developing lead knee osteoarthritis in the golf swing. Scientific reports Kim, S. E., Pham, N. S., Park, J. H., Ladd, A., Lee, J. 2022; 12 (1): 22653

  Abstract

  The load on the lead knee joint during a golf swing is greater than that observed during gait. However, current evidence regarding golf swing biomechanics for risks associated with knee osteoarthritis (OA) is limited. Therefore, this study investigated golf swing styles associated with knee adduction and abduction moments, which are considered to be crucial loading regions of the medial and lateral compartments of knee OA, respectively. Thirteen professional male golfers performed five shots using a 5-iron club, and their swings were recorded using a motion capture system with two force platforms for the feet. A regression analysis was performed to calculate the correlation coefficients between the peak knee adduction and abduction moments of the lead leg and varus/valgus angle, toe-out angle, stance width, weight transfer, and shoulder sway. Swinging with a narrower stance width at address (r =  - 0.62, p = 0.02) with more weight shift (r = 0.66, p = 0.014) and shoulder sway (r = 0.79, p = 0.001) towards the target during the downswing were associated with a higher peak knee adduction of the lead leg, whereas a greater valgus angle at address (r = 0.60, p = 0.03) was associated with a higher peak knee abduction of the lead leg. Based on these findings, we anticipate future research to support postural changes, particularly a wider stance width and restricted shoulder sway for golfers who are classified to be at high risk of developing medial compartment knee OA, as well as a lower valgus (tibial medial tilt) angle at address for those classified to be at high risk of developing lateral compartment knee OA.

  View details for DOI 10.1038/s41598-022-27160-4

  View details for PubMedID 36587045

• Effectiveness of melatonin treatment for sleep disturbance in orthopaedic trauma patients: A prospective, randomized control trial. Injury Tanner, N., Schultz, B., Calderon, C., Fithian, A., Segovia, N., Bishop, J., Gardner, M. 2022; 53 (12): 3945-3949

  Abstract

  Explore sleep disturbance in postoperative orthopedic trauma patients and determine the impact of melatonin supplementation on postoperative sleep, pain, and quality of life.In this prospective, randomized controlled trial at a Level I trauma center, 84 adult orthopedic trauma patients with operative fracture management were randomized 2-weeks postoperatively to either the melatonin or placebo group. Patients randomized to the melatonin group (42 subjects, mean age 41.8 ± 15.5 years) received 5 mg melatonin supplements. Patients in the placebo group (42 subjects, mean age 41.3 ± 14.0 years) received identical glucose tablets. Both groups were instructed to take the tablets 30 minutes before bed for 4 weeks and received sleep hygiene education and access to the Cognitive Behavioral Therapy for Insomnia (CBT-I) Coach app.Our primary outcome was sleep quality as measured by the Pittsburgh Sleep Quality Index (PSQI). Secondary outcomes were pain measured by the Visual Analog Scale (VAS), quality of life measured by the 36-Item Short Form Survey (SF-36), and opioid use.Patients in both groups had significant sleep disturbance (PSQI ≥ 5) at 2-weeks (83%) and 6-weeks (67%) postoperatively. PSQI improved by 3.3 points (p<0.001) at follow-up, but there was no significant difference between groups (melatonin PSQI = 5.6, placebo PSQI = 6.1, P = 0.615). Compared to placebo, melatonin did not affect VAS, SF-36, or opioid use significantly.Sleep disturbance is prevalent in orthopedic trauma patients. Melatonin treatment did not significantly improve subjective sleep quality, pain, quality of life or opioid use.Therapeutic Level I.

  View details for DOI 10.1016/j.injury.2022.10.011

  View details for PubMedID 36424687

• Anatomic relationship of extensor indicis propius and extensor digitorum communis: Implications for tendon transfer. World journal of orthopedics Zhou, J., Frey, C., Segovia, N., Yao, J. 2022; 13 (11): 978-985

  Abstract

  BACKGROUND: The extensor indicis proprius (EIP) tendon is a frequently used donor for a variety of tendon transfers, most commonly for reconstruction of the extensor pollicis longus (EPL). EIP is known to have frequent anatomic variants including split tendons and variations in tendon arrangement.AIM: To characterize the anatomy of the EIP at the level of the extensor retinaculum, where tendon harvest is often performed, and share our preferred technique for EIP to EPL transfer.METHODS: Twenty-nine fresh-frozen cadaveric forearms without history of forearm or hand injury or surgery were dissected. Tendon circumference and relationship of the EIP and extensor digitorum communis to the index (EDCI) at the metacarpophalangeal (MCP) joint and the distal extensor retinaculum were recorded. Distance from the distal extensor retinaculum to the EIP myotendinous junction was measured.RESULTS: EIP was ulnar to the EDCI in 96.5% of specimens (28/29) at the distal edge of the extensor retinaculum. In the remaining specimen, EIP was volar to EDCI. Tendon circumference at the distal extensor retinaculum averaged (9.3 mm ± 1.7 mm) for EDCI and 11.1 mm (± 2.7 mm) for EIP (P = 0.0010). The tendon circumference at the index MCP joint averaged 11.0 mm (± 1.7 mm) for EDCI and 10.6 mm (± 2.1 mm) for EIP (P = 0.33). EIP had a greater circumference in 76% (22/29) of specimens at the distal extensor retinaculum whereas EIP had a greater circumference in only 31% (9/29) of specimens at the MCP joint.CONCLUSION: The EIP tendon is frequently ulnar to and greater in circumference than the EDCI at the distal extensor retinaculum, which can be taken into consideration for tendon transfers involving EIP.

  View details for DOI 10.5312/wjo.v13.i11.978

  View details for PubMedID 36439366

• Prevalence of Positive Rapid Antigen Tests After 7-Day Isolation Following SARS-CoV-2 Infection in College Athletes During Omicron Variant Predominance. JAMA network open Tsao, J., Kussman, A., Segovia, N. A., Abrams, G. D., Boehm, A. B., Hwang, C. E. 2022; 5 (10): e2237149

  Abstract

  Importance: The US Centers for Disease Control and Prevention shortened the recommended isolation period for SARS-CoV-2 infection from 10 days to 5 days in December 2021. It is unknown whether an individual with the infection may still have a positive result to a rapid antigen test and potentially be contagious at the end of this shortened isolation period.Objective: To estimate the proportion of individuals with SARS-CoV-2 infection whose rapid antigen test is still positive starting 7 days postdiagnosis.Design, Setting, and Participants: This case series analyzed student athletes at a National Collegiate Athletic Association Division I university campus who tested positive for SARS-CoV-2 between January 3 and May 6, 2022. Individuals underwent rapid antigen testing starting 7 days postdiagnosis to determine whether they could end their isolation period.Exposures: Rapid antigen testing 7 days after testing positive for SARS-CoV-2.Main Outcomes and Measures: Rapid antigen test results, symptom status, and SARS-CoV-2 variant identification via campus wastewater analysis.Results: A total of 264 student athletes (140 [53%] female; mean [SD] age, 20.1 [1.2] years; range, 18-25 years) representing 268 infections (177 [66%] symptomatic, 91 [34%] asymptomatic) were included in the study. Of the 248 infections in individuals who did a day 7 test, 67 (27%; 95% CI, 21%-33%) tests were still positive. Patients with symptomatic infections were significantly more likely to test positive on day 7 vs those who were asymptomatic (35%; 95% CI, 28%-43% vs 11%; 95% CI, 5%-18%; P<.001). Patients with the BA.2 variant were also significantly more likely to test positive on day 7 compared with those with the BA.1 variant (40%; 95% CI, 29%-51% vs 21%; 95% CI, 15%-27%; P=.007).Conclusions and Relevance: In this case series, rapid antigen tests remained positive in 27% of the individuals after 7 days of isolation, suggesting that the Centers for Disease Control and Prevention-recommended 5-day isolation period may be insufficient in preventing ongoing spread of disease. Further studies are needed to determine whether these findings are present in a more heterogeneous population and in subsequent variants.

  View details for DOI 10.1001/jamanetworkopen.2022.37149

  View details for PubMedID 36255722

• Isolated Versus Full Component Revision In Total Knee Arthroplasty For Aseptic Loosening. The Journal of arthroplasty Apinyankul, R., Hwang, K., Segovia, N. A., Amanatullah, D. F., Huddleston, J. I., Maloney, W. J., Goodman, S. B. 2022

  Abstract

  Revision of both femoral and tibial components of a total knee arthroplasty (TKA) for aseptic loosening has favorable outcomes. Revision of only one loose component with retention of others has shorter operative time and lower cost, however, implant survivorship and clinical outcomes of these different operations are unclear.Between January 2009 and December 2019, a consecutive cohort of revision TKA were reviewed. Univariate and multivariable analyses were used to study correlations among factors and surgical related complications, time to prosthesis failure, and functional outcomes (University of California Los Angeles (UCLA), Knee Society (KS) functional, Knee osteoarthritis and outcome score for joint replacement (KOOS JR), Veterans RAND 12 (VR-12) physical, and VR-12 mental).A total of 238 patients underwent revision TKA for aseptic loosening. The mean follow-up time was 61 months (range 25 to 152). Ten of the 105 patients (9.5%) who underwent full revision (both femoral and tibial components) and 18 of the 133 (13.5%) who underwent isolated revision had subsequent prosthesis failure [Hazard ratio (HR) 0.67, p = 0.343]. The factor analysis of type of revision (full or isolated revision) did not demonstrate a significant difference between groups in terms of complications, implant failures, and times to failure. Metallosis was related to early time to failure [HR 10.11, p < 0.001] and iliotibial band release was associated with more complications (Odds ratio (OR) 9.87, p = 0.027). Preoperative symptoms of instability were associated with the worst improvement in UCLA score. Higher American Society of Anesthesiologists (ASA) and higher Charlson Comorbidity Index (CCI) were related with worse VR-12 physical (-30.5, p = 0.008) and KOOS JR (-4.2, p = 0.050) scores, respectively.Isolated and full component revision TKA for aseptic loosening do not differ with respect to prosthesis failures, complications, and clinical results at 5 years. Poor ASA status, increased comorbidities, instability, and a severe bone defect are related to worse functional improvement.

  View details for DOI 10.1016/j.arth.2022.09.006

  View details for PubMedID 36099937

• Virtual Reality Reduces Fear and Anxiety During Pediatric Orthopaedic Cast Room Procedures: A Randomized Controlled Trial. Journal of pediatric orthopedics Richey, A. E., Hastings, K. G., Karius, A., Segovia, N. A., Caruso, T. J., Frick, S., Rodriguez, S. 2022

  Abstract

  BACKGROUND: Virtual Reality (VR) has been used as a distraction tool in various medical settings to reduce pain and anxiety associated with procedures. This study evaluates the effectiveness of VR as a distraction tool for decreasing fear, anxiety, and pain in pediatric patients undergoing common outpatient orthopaedic procedures.METHODS: A total of 210 patients were recruited from a single orthopaedic clinic between October 2017 and July 2019. Patients were randomized to the VR group or to the control group (standard of care). Outpatient procedures included cast and/or pin removals. Primary outcome measures were collected preprocedure and postprocedure using validated surveys, and included: fear (Children's Fear Scale), anxiety (Children's Anxiety Meter-State), and pain (Numerical Rating Scale). Patients and caregivers in the VR group completed a satisfaction survey at the end of their appointment. Fear, anxiety, and pain scores between the 2 groups were analyzed using multivariable linear regression models, and the satisfaction survey was analyzed using descriptive statistics.RESULTS: One hundred twenty nine patients were included in the final analysis, with 85 patients in the VR group and 44 patients in the control group. During the procedure, patients in the VR group reported significantly lower average fear scores (P<0.001) and anxiety scores (P=0.003) as compared with controls. There were no differences between the groups in fear and anxiety scores before and after the procedure, or pain scores before, during, or after the procedure. Overall, patients and caregivers in the VR group reported high satisfaction scores, with 97% of patients and 95% of caregivers recommending this intervention to others.CONCLUSION: VR technology was found to be an effective distraction tool to improve fear and anxiety during cast removal procedures. Findings build on a body of evidence that supports the use of distraction tools in clinics, specifically pediatric orthopaedics, to improve fear and anxiety. The distraction tools can be easily translated into current practices.LEVEL OF EVIDENCE: Level I.

  View details for DOI 10.1097/BPO.0000000000002250

  View details for PubMedID 36040069

• Complication risks and costs associated with Ponte osteotomies in surgical treatment of adolescent idiopathic scoliosis: insights from a national database. Spine deformity Shaheen, M., Koltsov, J. C., Cohen, S. A., Langner, J. L., Kaur, J., Segovia, N. A., Vorhies, J. S. 2022

  Abstract

  PURPOSE: Risks of Ponte osteotomies (POs) used for posterior spinal fusion (PSF) for Adolescent Idiopathic Scoliosis (AIS) are challenging to assess because of the rarity of complications. Using a national administrative claims database, we evaluated trends, costs and complications associated with PO used in PSF for AIS patients.METHODS: Using ICD-9/CPT codes, we identified patients (ages 10-18) with AIS who underwent PSF (±PO) between 2007 and 2015 in the IBM MarketScan Commercial Databases. Costs and trends of POs were evaluated. Odds of neurological complications and readmissions within 90days and reoperations within 90days and 2years were assessed.RESULTS: We identified 8881 AIS patients who had undergone PSF, of which 8193 had 90-day follow-up and 4248 had 2-year follow-up. Overall, 28.8% had PO. Annual rate of POs increased from 17.3 to 35.2% from 2007 to 2015 (p<0.001). Risk-adjusted multivariable logistic regression demonstrated no relationship between POs and neurologic complications (p=0.543). POs were associated with higher odds for readmission (1.52 [1.21-1.91]; p<0.001) and reoperation (2.03 [1.13-3.59]; p=0.015) within 90days, but there were no differences in the odds of reoperation within 2years (p=0.836). Median hospital costs were $15,854 (17.4%) higher for patients with POs (p<0.001) and multivariable modeling demonstrated POs to be an independent predictor of increased costs (p<0.001).CONCLUSION: Annual rate of POs increased steadily from 2007 to 2015. POs were not associated with increased odds of neurological complications but had higher costs and higher rates of readmissions and reoperations within 90days. By 2years, differences in reoperation rate were not significant.LEVEL OF EVIDENCE: III.

  View details for DOI 10.1007/s43390-022-00534-4

  View details for PubMedID 35810408

• Innovative technique for early-onset scoliosis casting using Jackson table. Spine deformity Montgomery, B. K., Tileston, K., Kaur, J., Kym, D., Segovia, N. A., Imrie, M., Policy, J., Rinsky, L., Vorhies, J. 2022

  Abstract

  PURPOSE: Early-onset scoliosis (EOS) can have harmful effects on pulmonary function. Serial elongation, derotation, and flexion (EDF) casting can cure EOS or delay surgical intervention. Most described casting techniques call for specialized tables, which are not available at many institutions. We describe an innovative technique for EDF casting utilizing a modified Jackson table (MJ) and compare results to a Risser frame (RF).METHODS: All patients who underwent EDF casting at our institution between January 2015 and January 2019 were identified and retrospectively reviewed. Patients were stratified by type of table used and clinical and radiographic outcomes were compared. Standard descriptive statistics were calculated.RESULTS: We identified 25 patients who underwent 77 casting events, 11 on an MJ table and 14 on a RF. Mean follow-up was 32months (range 11-61months). 28% of patients had idiopathic scoliosis. There was no significant difference in age at initiation of casting (P=0.3), initial Cobb angle (equivalence, P=0.009), or rate of idiopathic scoliosis between the MJ and RF groups. There was no significant difference in initial coronal Cobb angle percent correction (equivalence, P=0.045) or percent correction at 1-year follow-up (equivalence, P=0.010) between the two groups. There was no difference in cast related complications. There was a significant difference in surgical time, with the MJ group 11min shorter than the RF (P=0.005).CONCLUSION: The MJ table is a safe and effective alternative for applying EDF casts under traction without the need for a specialized table.LEVEL OF EVIDENCE: III.

  View details for DOI 10.1007/s43390-022-00526-4

  View details for PubMedID 35776363

• Quantifying the Relationship Between the Medial Quadriceps Tendon-Femoral Ligament and Patellar Borders: A Pediatric Cadaveric Study. The American journal of sports medicine Baskar, D., Stavinoha, T. J., Sanchez, M., Gupta, A., Randhawa, S. D., Rohde, M. S., Vuong, B., Tompkins, M. A., Ganley, T. J., Ellis, H. B., Wilson, P. L., Fabricant, P. D., VandenBerg, C., Green, D. W., Segovia, N. A., Shea, K. G. 2022: 3635465221103250

  Abstract

  The medial patellofemoral complex (MPFC) is a structure composed of the medial quadriceps tendon-femoral ligament (MQTFL) superiorly and the medial patellofemoral ligament (MPFL) inferiorly. The pediatric MPFL anatomy has been well described, but the precise anatomy of the MQTFL has only recently been described and studied in skeletally immature patients.To describe the anatomic relationship between the MQTFL and its insertion on the quadriceps tendon and patella in pediatric specimens.Descriptive laboratory study.A total of 22 pediatric cadaveric knee specimens were dissected to analyze attachment of the MQTFL to the quadriceps tendon and patella. Dissection was facilitated using lateral parapatellar arthrotomy followed by eversion of the extensor mechanism to evaluate MQTFL fibers from its undersurface.The mean specimen age was 7.4 years. Specimens were divided based on age into a younger cohort (1-2 years), middle cohort (4-8 years), and older cohort (9-12 years). The quadriceps tendon attachment (QTA) of the MQTFL proximal to the patella extended a median of 5.0 mm in the younger cohort, 11.4 mm in the middle cohort, and 12.0 mm in the older cohort, with significant differences found between the younger and middle cohorts (P < .047) and the younger and older cohorts (P < .001). The QTA as a percentage of patellar articular height averaged 44.4% across all specimens. The vertical height of the patella measured a median of 14.0 mm, 22.3 mm, and 27.3 mm in the younger, middle, and older cohorts, respectively.This study expands on the recently described anatomy of the pediatric MPFC to quantify the anatomic relationship between the MQTFL attachment to the quadriceps tendon and patella in a more clinically relevant cohort of donor specimens.As access to pediatric cadaveric tissue is extremely limited, a better understanding of MPFC and MQTFL anatomy will support surgeons in preoperative planning and intraoperative considerations for their approach to MQTFL and MPFL reconstruction. This may facilitate improved anatomic surgical stabilization of the patellofemoral joint in pediatric patients.

  View details for DOI 10.1177/03635465221103250

  View details for PubMedID 35763589

• Characterization of Trapezial Pommel in Relation to Radiographic and Wear Patterns in Carpometacarpal Osteoarthritis. Hand (New York, N.Y.) Bourdillon, A. T., Shapiro, L., Kerkhof, F. D., Segovia, N. A., Weiss, A. P., Ladd, A. L. 2022: 15589447221093670

  Abstract

  Trapezial pommel, or ulnar osteophyte positioned at the vertex of the saddle-shaped facet, is a consistent structural appearance in osteoarthritis (OA) of the first carpometacarpal. This study investigates its relation to radiographic measures (modified Eaton staging and thumb OA [ThOA] index) and wear patterns (trapezial surface morphology and cartilaginous eburnation).In all, 137 whole trapezia were explanted from 116 patients and evaluated for Eaton staging, morphology (saddle, cirque, or dish), and eburnation (degree of cartilaginous effacement) of the articular surface of the trapezium. In total, 131 Robert's views and 126 stress views were reviewed by 2 blinded senior surgeons for ThOA index and pommel size. Statistical analyses included Spearman correlation and linear regression.Standardized pommel size achieved good intrarater reliability (correlation coefficient: 0.80-0.98) and moderate interrater reliability (correlation coefficient: 0.60-0.67). The ThOA index and pommel size were significantly correlated across Robert's (rs = 0.51) and stress views (rs = 0.64). The ThOA index better distinguished between stages compared with pommel size. All the radiographic measures inversely correlated with preserved cartilage and varied across morphologies. Pommel size differed significantly between dish and saddle, and the ThOA index was significantly different between all morphologies when using stress views.We reliably quantified the pommel feature and demonstrated significant correlations with other radiographic and topologic measures of arthritic disease. If future studies can demonstrate that the pommel is a pathogenic process in ThOA and its correction can curb disease progression, the identification of the pommel feature may help guide targeted intervention.

  View details for DOI 10.1177/15589447221093670

  View details for PubMedID 35642728

• Does healthcare system device volume correlate with price paid for spinal implants: a cross-sectional analysis of a national purchasing database. BMJ open Cahan, E., McFarlane, K., Segovia, N., Chawla, A., Wall, J., Shea, K. 2022; 12 (4): e057547

  Abstract

  OBJECTIVES: Amid continuously rising US healthcare costs, particularly for inpatient and surgical services, strategies to more effectively manage supply chain expenses are urgently necessary. Across industries, the 'economy of scale' principle indicates that larger purchasing volumes should correspond to lower prices due to 'bulk discounts'. Even as such advantages of scale have driven health system mergers in the USA, it is not clear whether they are being achieved, including for specialised products like surgical implants which may be more vulnerable to cost inefficiency. The objective of this observational cross-sectional study was to investigate whether purchasing volumes for spinal implants was correlated with price paid.SETTING: USA.PARTICIPANTS: Market data based on pricing levels for spine implants were reviewed from industry implant price databases. Filters were applied to narrow the sample to include comparable institutions based on procedural volume, patient characteristics and geographical considerations. Information on the attributes of 619 health systems representing 12471 provider locations was derived from national databases and analytics platforms.PRIMARY OUTCOME MEASURE: Institution-specific price index paid for spinal implants, normalised to the national average price point achieved.RESULTS: A Spearman's correlation test indicated a weak relationship between purchasing volume and price index paid (rho=-0.35, p<0.001). Multivariable linear regression adjusting for institutional characteristics including type of hospital, accountable care organisation status, payer-mix, geography, number of staffed beds, number of affiliated physicians and volume of patient throughput also did not exhibit a statistically significant relationship between purchasing volume and price index performance (p=0.085).CONCLUSIONS: National supply chain data revealed that there was no significant relationship between purchasing volume and price paid by health systems for spinal implants. These findings suggest that factors other than purchasing or patient volume are responsible for setting prices paid by health systems to surgical vendors and/or larger healthcare systems are not negotiating in a way to consistently achieve optimal pricing.

  View details for DOI 10.1136/bmjopen-2021-057547

  View details for PubMedID 35473724

• Metastatic Pattern of Truncal and Extremity Leiomyosarcoma: Retrospective Analysis of Predictors, Outcomes, and Detection. Journal of personalized medicine Tigchelaar, S. S., Frey, C., Sivaraj, D., Segovia, N. A., Mohler, D. G., Steffner, R. J., Avedian, R. S. 2022; 12 (3)

  Abstract

  Leiomyosarcomas (LMS) are a heterogenous group of malignant mesenchymal neoplasms with smooth muscle origin and are classified as either non-uterine (NULMS) or uterine (ULMS). Metastatic pattern, prognostic factors, and ideal staging/surveillance studies for truncal and extremity LMS have not been defined. A retrospective analysis of patients diagnosed with histopathology-confirmed truncal or extremity LMS between 2009 and 2019 was conducted. Data collected included demographics, tumor characteristics, staging, surveillance, and survival endpoints. The primary site was defined as: (1) extremity, (2) flank/Pelvis, or (3) chest wall/Spine. We identified 73 patients, 23.3% of which had metastatic LMS at primary diagnosis, while 68.5% developed metastatic disease at any point. The mean metastatic-free survival from primary diagnosis of localized LMS was 3.0 ± 2.8 years. Analysis of prognostic factors revealed that greater age (≥50 years) at initial diagnosis (OR = 3.74, p = 0.0003), higher tumor differentiation scores (OR = 12.09, p = 0.002), and higher tumor necrosis scores (OR = 3.65, p = 0.026) were significantly associated with metastases. Older patients (≥50 years, OR = 4.76, p = 0.017), patients with larger tumors (≥5 cm or ≥10 cm, OR = 2.12, p = 0.02, OR = 1.92, p = 0.029, respectively), higher differentiation scores (OR = 15.92, p = 0.013), and higher necrosis scores (OR = 4.68, p = 0.044) show worse survival outcomes. Analysis of imaging modality during initial staging and during surveillance showed greater tumor detection frequency when PET imaging was employed, compared to CT imaging (p < 0.0001). In conclusion, truncal and peripheral extremity LMS is an aggressive tumor with high metastatic potential and mortality. While there is a significant risk of metastases to lungs, extra-pulmonary tumors are relatively frequent, and broad surveillance may be warranted.

  View details for DOI 10.3390/jpm12030345

  View details for PubMedID 35330345

• Femoral acetabular impingement labral pathology on MRI is correlated with greater hip flexion and decreased abduction in collegiate water polo players: A pilot study. Journal of ISAKOS : joint disorders & orthopaedic sports medicine Hall, K. E., Langner, J., Segovia, N., Schultz, B., Andriacchi, T., Gold, G., Safran, M. R. 2022; 7 (1): 7-12

  Abstract

  Femoroacetabular impingement (FAI) morphology is associated with hip pain and disability. Water polo players utilise the egg beater motion (method of treading water with legs rotating like an "egg beater"), and it is currently unclear what the relationship is between an egg beater and FAI morphology. Our objective was to associate hip range of motion during egg beater motion to MRI findings.Eight National Collegiate Athletic Association (NCAA) Division 1 varsity water polo athletes (5 females and 3 males) were filmed at orthogonal views performing the egg beater motion using two waterproof cameras in synchrony. A model-based image-matching technique was used to determine hip joint angles which were recorded from the software. These athletes also underwent noncontrast MRI scans of both hips using a 3T MRI scanner and completed an 33-item International Hip Outcome Tool (iHOT-33) hip pain outcomes questionnaire. Descriptive statistics are reported as counts and percentages for categorical variables and as means, standard deviations, and a five-number summary for continuous variables. Relationships between the range of motion measures with MRI measures and with iHOT33 scores were analysed using linear regression models. All statistical analyses were completes using a two-sided level of significance of 0.05.The average alpha angles for the right and left hips were 71.80 ±7.50 and 74.10 ±8.40, respectively. There was no statistically significant correlation between hip range of motion in any plane and alpha angle or lateral centre edge angle (CEA) on MRI. The average iHOT33 was 85.9 ± 18.9. Participants who had a labral tear had significantly smaller hip abduction ranges than participants who did not have a labral tear (29° ± 4.1 vs. 35.3° ± 0.6, p = 0.02), and those who had a labral tear had significantly increased hip flexion during egg beater kicking as compared with participants who did not have a labral tear (28.2° ± 6.1 vs. 16.3° ± 4, p = 0.02). There were no differences between right and left alpha angles or between right and left CEA.There were no significant correlations between hip range of motion and alpha angle or CEA, but hips with labral pathology had greater hip flexion and more limited hip abduction ranges.

  View details for DOI 10.1016/j.jisako.2021.10.003

  View details for PubMedID 35543660

• Clubfoot Activity and Recurrence Exercise Study (CARES). Journal of pediatric orthopedics El-Banna, G., Baskar, D., Segovia, N., Frick, S. 2022; 42 (1): e91-e96

  Abstract

  BACKGROUND: Approximately half of treated clubfoot patients initially corrected with the Ponseti method experience relapse that requires additional treatment. The consequences of relapse on childhood activity levels have not been well studied. Ponseti noted lower functional ratings at 18-year follow-up in clubfoot patients who had undergone tibialis anterior tendon transfer for relapse.METHODS: Clubfoot Activity and Recurrence Exercise study (CARES) is an observational, prospective cohort study that compares physical activity in 30 clubfoot patients without and with relapse. Eligible participants were 5 to 10 years old, diagnosed with idiopathic clubfoot at birth, and had not received any clubfoot treatment for at least 6 months before study. Recruitment for this study occurred in-person and through Facebook clubfoot groups. Consented participants wore Fitbits secured to their wrists for at least 14 days, and completed a demographic survey, Child Health Questionnaire (CHQ), and the clubfoot disease-specific instrument (CDSI). Participants' daily activity was monitored through Fitabase.RESULTS: Participants without and with clubfoot relapse had similar daily step counts, distance walked, and step intensities, except for moderately active step intensity, which was higher in the clubfoot relapse group. Total steps, total distance, distances (very active, moderately active), minutes (very active, fairly active), and lightly active intensity of steps were significantly higher for participants whose families earn more than $100,000 per year. Various physical activities and sports were reported by both groups in daily activity sheets. Neither demographics nor the CDSI or the CHQ scores significantly differed between the 2 groups. Step counts of children with clubfoot with or without relapse were similar to published levels for healthy children.CONCLUSION: Children with clubfoot initially treated with the Ponseti method who undergo treatment for relapse have comparable physical activity to those who have not relapsed. They also have comparable step counts to that of the general pediatric population. These reassuring findings can guide conversations with parents when addressing concerns regarding their children's physical activity after treatment for relapse of clubfoot deformity.LEVEL OF EVIDENCE: Level II-therapeutic studies-investigating the results of treatment.

  View details for DOI 10.1097/BPO.0000000000001973

  View details for PubMedID 34889836

• Factors Associated With a Prolonged Time to Return to Play After a Concussion. The American journal of sports medicine Wang, E. X., Hwang, C. E., Nguyen, J. N., Segovia, N. A., Abrams, G. D., Kussman, A. 2022: 3635465221083646

  Abstract

  Prognosticating recovery times for individual athletes with a concussion remains a challenge for health care providers. Several preinjury and postinjury factors have been proposed to be predictive of prolonged return-to-play (RTP) times, but the data in this area are still sparse.This study aimed to identify risk factors associated with prolonged recovery times and determine which are most predictive of prolonged recovery times in a head-to-head comparison.Case-control study; Level of evidence, 3.All concussions occurring between September 2017 and August 2020 at a single National Collegiate Athletic Association Division I institution were reviewed and included in this study. Preinjury modifiers including age, sex, sport, concussion history, and past medical problems were collected from the electronic medical records. Postinjury modifiers analyzed included initial and follow-up Sport Concussion Assessment Tool 5th Edition scores, vestibular evaluation findings, and eye tracking results.A total of 159 athletes and 187 concussion cases were included. Preinjury factors that were correlated with prolonged RTP times included a history of concussions (P = .015), a history of migraines (P = .013), and whether an athlete participated in an individual sport (P = .009). Postinjury factors correlated with prolonged RTP times included the total number (P = .020) and severity (P = .023) of symptoms as well as abnormal Vestibular Ocular Motor Screening findings (P = .002). Overall, 6 different symptoms (balance problems, difficulty concentrating, light sensitivity, drowsiness, fatigue/low energy, and difficulty remembering) were significantly correlated with prolonged RTP times. The study also found that the number and severity of symptoms were additive in a dose-dependent fashion. On multivariable analysis of all these factors, a history of concussions was found to be the most predictive of prolonged RTP times, while participation in an individual sport had the largest effect on recovery times.Several preinjury and postinjury risk factors were identified as being correlated with prolonged recovery times. Many of these risk factors were also found to be additive in nature. This information provides clinicians with a valuable tool in prognosticating and estimating recovery times for athletes. The study also revealed that athletes participating in individual sports had longer RTP times compared with athletes in team sports, which is a novel finding that requires further research.

  View details for DOI 10.1177/03635465221083646

  View details for PubMedID 35316113

• Female gender, decreased lateral center edge angle and a positive hyperextension-external rotation test are associated with ease of hip distractability at time of hip arthroscopy. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA Curtis, D. M., Pullen, W. M., Murray, I. R., Money, A. J., Segovia, N., Safran, M. R. 2022

  Abstract

  To identify factors associated with ease of hip distraction at the time of hip arthroscopy.A retrospective review of patients 17-50 years old undergoing hip arthroscopy with a single high-volume hip arthroscopist was performed from 2014 to 2020. Demographics, clinical history, examination, and imaging findings were collected. Distractibility was quantified using turns of fine traction (1 turn = 4 mm axial distraction) with the patient paralyzed on a fracture table with a well-padded perineal post Fine axial traction was applied after the patient's perineum contacted the post. Demographic and clinical predictors of ease of distractibility were analyzed with simple linear regression models. Significant predictors were subsequently added to a multivariable linear regression model, estimating the effect of each variable.In total, 453 patients were included, with an average age of 31.6 years (± 9.2) and 45.9% females. In univariate analysis, gender, race, BMI, range of motion, hyperextension-external rotation (HEER) test, the abduction-extension-external rotation test, and lateral center edge angle (LCEA) were associated with the number of fine traction turns required to distract the hip. On multivariable analysis, lower LCEA (p = 0.002), female gender (p < 0.001), and a positive HEER test (p = 0.045) were associated with decreased turns required for adequate hip distraction.Female gender, decreased LCEA, and a positive HEER test are associated with decreased axial traction required for adequate hip distraction at the time of hip arthroscopy. As ease of distractibility has been associated with hip microinstability, these findings may allow pre-operative identification of hip instability patients and aid in pre-operative counseling, risk stratification and capsular management planning.IV.Preoperative identification of risk factors for ease of hip distraction may raise pre-surgical suspicion and, when coupled with other intraoperative findings, may aid in the diagnosis and management of hip microinstability.

  View details for DOI 10.1007/s00167-022-06925-4

  View details for PubMedID 35316369

• Epidemiological Study of the Discoid Meniscus: Investigating Demographic-Based Predictors in Large-Scale Claims Database CUREUS Randhawa, S. S., Tran, E. P., Segovia, N. A., Ganley, T. J., Tompkins, M., Ellis, H., Shea, K. G. 2021; 13 (11)

  View details for DOI 10.7759/cureus.20050

  View details for Web of Science ID 000725475500023

• Use of Bedside Entertainment and Relaxation Theater (BERT) to Reduce Fear and Anxiety Associated With Outpatient Procedures in Pediatric Orthopaedics. Journal of pediatric orthopedics Richey, A. E., Khoury, M., Segovia, N. A., Hastings, K. G., Caruso, T. J., Frick, S., Rodriguez, S. 2021

  Abstract

  BACKGROUND: The aim of the present study was to evaluate the effectiveness of the Bedside Entertainment and Relaxation Theater (BERT) on fear, anxiety, and pain outcomes in pediatric orthopaedic patients associated with cast removal and/or pin removal in the outpatient clinic setting.METHODS: A total of 66 pediatric patients between the ages of 2 and 6 undergoing clinic procedures were recruited for this study and randomized into the control group or the intervention (BERT) group. Patients in the control group received standard of care during the cast room procedure; patients in the BERT group were given headphones and watched a movie on a projector during the procedure. Fear, anxiety, and pain were measured before and after the procedure. Procedures included cast removal, pin removal, or a combination of the 2.RESULTS: Patients in the BERT group reported less fear and anxiety overall after the procedure than patients in the control group (P=0.009, 0.015). Adjusting for procedure type (ie, pin removal), patients in the BERT group reported a 0.67 point decrease (95% confidence interval: 0.04, 1.30) on the fear scale after the procedure (P=0.039) and a 1.81 point decrease (95% confidence interval: 0.04, 3.59) on the anxiety scale associated with the procedure (P=0.045), compared with the control group. Patients and caregivers reported high satisfaction with BERT.CONCLUSION: This randomized, controlled trial demonstrates an evidence-based distraction tool that can be implemented across medical centers for pediatric patients undergoing office based orthopaedic procedures. BERT can be used to reduce fear and anxiety associated with these procedures, and increased patient and parent satisfaction.LEVEL OF EVIDENCE: Level I.

  View details for DOI 10.1097/BPO.0000000000002005

  View details for PubMedID 34739431

• Epidemiological Study of the Discoid Meniscus: Investigating Demographic-Based Predictors in Large-Scale Claims Database. Cureus Randhawa, S., Tran, E., Segovia, N. A., Ganley, T., Tompkins, M., Ellis, H., Shea, K. G. 2021; 13 (11): e20050

  Abstract

  Purpose To better define the epidemiology of discoid meniscus by analyzing a large, national database for incidence rates and associations with demographic variables. Methods From Optum's Clinformatics® Data Mart Database, incidence rates and proportions of reported racial categories - Asian, Black, Hispanic, and Caucasian - of diagnosed discoid meniscus cases (n = 198) in the study population of patients receiving arthroscopic meniscectomy or repair procedures (n = 60,042) were calculated and compared via chi-square tests to the total population. To control for age, sex, and socioeconomic factors such as income, multivariable logistic regression analysis was performed. Results Proportions of discoid meniscus patients who were Asian, Black, Hispanic, or Caucasian were <6%, <7%, 15.7%, and 73.7%, respectively; proportions of each racial category in the study population were 2.2%, 7.4%, 9.9%, and 80.5%, respectively. Incidence rates per 1000 for these were 5.95, 2.92, 5.19, and 3.01, respectively. After adjusting for age, sex, and income, race was not a statistically significant predictor. Odds of a discoid meniscus diagnosis decreased by 6% for each increment in age (p <0.001) and by 40% if male (p <0.001) in our total study population. In patients <=20 years old, sex was not a significant risk factor. Conclusions Younger age and female sex were identified as significant predictors for symptomatic discoid meniscus in the total study population. Unlike prior studies, this investigation did not show a significant association between this condition and race in the US, potentially increasing the diagnostic accuracy and estimated pretest probabilities for this condition based on patient demographics. What this study adds to existing knowledge This study provides new data on the role racial category plays in estimating the risk of having a symptomatic discoid meniscus requiring arthroscopic management, finding that it is unlikely to be a significant factor when controlling for other demographic variables. Furthermore, we report incidence statistics for this pathology in Black and Latinx populations, which so far have had little representation in peer-reviewed published literature on discoid meniscus epidemiology. In addition, this study suggests that age and sex possess statistically significant associations with a diagnosis of discoid meniscus requiring arthroscopic management, with the risk of diagnosis decreasing with age and increasing if female.

  View details for DOI 10.7759/cureus.20050

  View details for PubMedID 34993027

  View details for PubMedCentralID PMC8720039

• Predicting Return To Play In NCAA Division 1 Athletes With Neurogenic Thoracic Outlet Syndrome Dyrek, P., Olson, E., Fereydooni, A., Harris, T., Kussman, A., Roh, E., Lee, J. T., Segovia, N. LIPPINCOTT WILLIAMS & WILKINS. 2021: 390

  View details for Web of Science ID 000693955700448

• Opiate prescribing patterns in the adolescent population following anterior cruciate ligament reconstruction. Journal of opioid management Karius, A., Cahan, E. M., Segovia, N. A., Fan, A., Chan, C. M. 2021; 17 (4): 321-325

  Abstract

  OBJECTIVE: We sought to determine prescribing patterns for opioid analgesia following anterior cruciate ligament (ACL) reconstruction among age- and gender-stratified adolescents in a nationally representative database.DESIGN: A retrospective study.SETTING: PearlDiver Patient Records.PATIENTS, PARTICIPANTS: Outpatient opioid claims within 30 days of surgery were extracted. The patients were defined into age groups 10-14 ("younger") and 15-19 ("older"). A total of 1,139 patients were included in this study (536 female and 603 males) with 108 patients in the 10-14 age category and 1,034 patients in the 15-19 category.MAIN OUTCOME MEASURE(S): The primary study outcome measures the average number of opioid pills administered, average total morphine milligram equivalents (MMEs) prescribed, and the average prescription strength (MMEs/pill).RESULTS: No difference was found in the average number of pills (p = 0.26) or normalized total MMEs (p = 0.312) prescribed by age group. Normalized total morphine equivalents per prescription was significantly lower in females than males (p = 0.005). Multivariate linear regression analysis demonstrated that increasing patient age was predictive of fewer total pills (p = 0.017), after accounting for gender.CONCLUSIONS: There are age- and gender-based disparities in prescription patterns for adolescent ACL reconstruction. Our findings indicate that patients in the older age group on average received fewer pills than the younger age group, which consequently trended toward receiving higher total MMEs prescribed. This suggests that surgeons may be inadvertently overprescribing in the younger cohort. Additional studies that account for concurrent factors should be conducted to observe potentially similar trends.

  View details for DOI 10.5055/jom.2021.0664

  View details for PubMedID 34533826

• Influence of team composition on turnover and efficiency of total hip and knee arthroplasty. The bone & joint journal Cahan, E. M., Cousins, H. C., Steere, J. T., Segovia, N. A., Miller, M. D., Amanatullah, D. F. 2021; 103-B (2): 347–52

  Abstract

  AIMS: Surgical costs are a major component of healthcare expenditures in the USA. Intraoperative communication is a key factor contributing to patient outcomes. However, the effectiveness of communication is only partially determined by the surgeon, and understanding how non-surgeon personnel affect intraoperative communication is critical for the development of safe and cost-effective staffing guidelines. Operative efficiency is also dependent on high-functioning teams and can offer a proxy for effective communication in highly standardized procedures like primary total hip and knee arthroplasty. We aimed to evaluate how the composition and dynamics of surgical teams impact operative efficiency during arthroplasty.METHODS: We performed a retrospective review of staff characteristics and operating times for 112 surgeries (70 primary total hip arthroplasties (THAs) and 42 primary total knee arthroplasties (TKAs)) conducted by a single surgeon over a one-year period. Each surgery was evaluated in terms of operative duration, presence of surgeon-preferred staff, and turnover of trainees, nurses, and other non-surgical personnel, controlling cases for body mass index, presence of osteoarthritis, and American Society of Anesthesiologists (ASA) score.RESULTS: Turnover among specific types of operating room staff, including the anaesthesiologist (p = 0.011), circulating nurse (p = 0.027), and scrub nurse (p = 0.006), was significantly associated with increased operative duration. Furthermore, the presence of medical students and nursing students were associated with improved intraoperative efficiency in TKA (p = 0.048) and THA (p = 0.015), respectively. The presence of surgical fellows (p > 0.05), vendor representatives (p > 0.05), and physician assistants (p > 0.05) had no effect on intraoperative efficiency. Finally, the presence of the surgeon's 'preferred' staff did not significantly shorten operative duration, except in the case of residents (p = 0.043).CONCLUSION: Our findings suggest that active management of surgical team turnover and composition may provide a means of improving intraoperative efficiency during THA and TKA. Cite this article: Bone Joint J 2021;103-B(2):347-352.

  View details for DOI 10.1302/0301-620X.103B2.BJJ-2020-0170.R2

  View details for PubMedID 33517742

• Rod-Screw Constructs Composed of Dissimilar Metals Do Not Affect Complication Rates in Posterior Fusion Surgery Performed for Adult Spinal Deformity. Clinical spine surgery Denduluri, S. K., Koltsov, J. C., Ziino, C. n., Segovia, N. n., McMains, C. n., Falakassa, J. n., Ratliff, J. n., Wood, K. B., Alamin, T. n., Cheng, I. n., Hu, S. S. 2021; 34 (2): E121–E125

  Abstract

  This was a retrospective cohort study.The objective of this study was to compare implant-related complications between mixed-metal and same-metal rod-screw constructs in patients who underwent posterior fusion for adult spinal deformity.Contact between dissimilar metals is discouraged due to potential for galvanic corrosion, increasing the risk for metal toxicity, infection, and implant failure. In spine surgery, titanium (Ti) screws are most commonly used, but Ti rods are notch sensitive and likely more susceptible to fracture after contouring for deformity constructs. Cobalt chrome (CC) and stainless steel (SS) rods may be suitable alternatives. No studies have yet evaluated implant-related complications among mixed-metal constructs (SS or CC rods with Ti screws).Adults with spinal deformity who underwent at least 5-level thoracic and/or lumbar posterior fusion or 3-column osteotomy between January 2013 and May 2015 were reviewed, excluding neuromuscular deformity, tumor, acute trauma or infection. Implant-related complications included pseudarthrosis, proximal junctional kyphosis, hardware failure (rod fracture, screw pullout or haloing), symptomatic hardware, and infection.A total of 61 cases met inclusion criteria: 24 patients received Ti rods with Ti screws (Ti-Ti, 39%), 31 SS rods (SS-Ti, 51%), and 6 CC rods (CC-Ti, 9.8%). Median follow-up was 37-42 months for all groups. Because of the limited number of cases, the CC-Ti group was not included in statistical analyses. There were no differences between Ti-Ti and SS-Ti groups with regard to age, body mass index, or smokers. Implant-related complications did not differ between the Ti-Ti and SS-Ti groups (P=0.080). Among the Ti-Ti group, there were 15 implant-related complications (63%). In the SS-Ti group, there were 12 implant-related complications (39%). There were 3 implant-related complications in the CC-Ti group (50%).We found no evidence that combining Ti screws with SS rods increases the risk for implant-related complications.

  View details for DOI 10.1097/BSD.0000000000001058

  View details for PubMedID 33633069

• Anterior Cruciate Ligament Length in Pediatric Populations: An MRI Study. Orthopaedic journal of sports medicine Tran, E. P., Dingel, A. B., Terhune, E. B., Segovia, N. A., Vuong, B., Ganley, T. J., Fabricant, P. D., Green, D. W., Stavinoha, T. J., Shea, K. G. 2021; 9 (4): 23259671211002286

  Abstract

  As regards anterior cruciate ligament (ACL) reconstruction (ACLR), graft diameter has been identified as a major predictor of failure in skeletally mature patients; however, this topic has not been well-studied in the higher risk pediatric population. Hamstring tendon autograft configuration can be adjusted to increase graft diameter, but tendon length must be adequate for ACLR. Historical parameters of expected tendon length have been variable, and no study has quantified pediatric ACL morphology with other osseous parameters.To develop magnetic resonance imaging (MRI)-derived predictors of native ACL graft length in pediatric patients so as to enhance preoperative planning for graft preparation in this skeletally immature patient population.Cross-sectional study; Level of evidence, 3.MRI scans of 110 patients were included (64 girls, 46 boys; median age, 10 years; range, 1-13 years). Patients with musculoskeletal diseases or prior knee injuries were excluded. The following measurements were taken on MRI: ACL length; sagittal and coronal ACL inclination; intercondylar notch width and inclination; and femoral condyle depth and width. Associations between these measurements and patient sex and age were investigated. Univariate linear regression and multivariable regression models were created for each radiographic ACL measure to compare R 2.Female ACL length was most strongly associated with the depth of the lateral femoral condyle as viewed in the sagittal plane (R 2 = 0.65; P < .001). Other statistically significant covariates of interest included distal femoral condylar width, age, and coronal notch width (P < .05). For males, the ACL length was most strongly associated with the distal femoral condyle width as viewed in the coronal plane (R 2 = 0.70; P < .001). Other statistically significant covariates of interest for male ACL lengths were lateral femoral condyle depth, age, and coronal notch width (P < .05).In pediatric populations, femoral condylar depth/width and patient age may be valuable in assessing ACL size and determining appropriate graft dimensions and configuration for ACLRs. The use of this information to optimize graft diameter may lower the rates of ACL graft failure in this high-risk group.

  View details for DOI 10.1177/23259671211002286

  View details for PubMedID 35146026

  View details for PubMedCentralID PMC8822022

• Mindset correlates with health-related quality of life assessment in patients with adolescent idiopathic scoliosis. Spine deformity Joseph, G. P., Segovia, N. A., Wright, R. C., Mueller, C., Tileston, K. R. 2020

  Abstract

  PURPOSE: Mindset theory describes two different belief systems regarding ability: "fixed", in which a particular personal characteristic is seen as unchangeable, and "growth", in which the characteristic is viewed as malleable and subject to improvement. The purpose of this study is to evaluate how that mindset toward one's health correlates with health-related quality of life assessments (HRQoL) in patients with adolescent idiopathic scoliosis (AIS).METHODS: Patients undergoing brace treatment for AIS were prospectively recruited for this study and completed both an SRS-30 andHealth Mindset Scale questionnaire. Inclusion criteria for patients are based on Scoliosis Research Society standardized criteria for bracing studies: diagnosis of AIS, a prescribed TLSO brace for full-time wear, skeletal immaturity at brace initiation (Risser 0-2), Cobb angles 25-50 degrees, no prior treatment, and, if female, no more than 1year post-menarchal at the time of brace initiation. Statistical analysis was performed utilizing Mann-Whitney U tests for skewed data and two-sample t tests for normally distributed data.Multivariable models were also used to evaluate the relationships of SRS-30 subscores with health mindset, adjusting for age, gender, and pre-treatment curve magnitudes.RESULTS: Among the 110 enrolled patients, a stronger growth mindset was associated with significantly higher SRS-30 scores overall (p=0.001), as well as in the appearance (p=0.003), and mental (p=0.001) subscores.CONCLUSION: We demonstrate that health mindset affects an AIS patients' HRQoL. Prior studies have demonstrated that mindset is malleable and can be altered. Further studies are required to determine whether changing health mindset from a fixed to a growth mindset can also improve HRQoL in patients with scoliosis.

  View details for DOI 10.1007/s43390-020-00243-w

  View details for PubMedID 33201496

• Rod-Screw Constructs Composed of Dissimilar Metals Do Not Affect Complication Rates in Posterior Fusion Surgery Performed for Adult Spinal Deformity. Clinical spine surgery Denduluri, S. K., Koltsov, J. C., Ziino, C., Segovia, N., McMains, C., Falakassa, J., Ratliff, J., Wood, K. B., Alamin, T., Cheng, I., Hu, S. S. 2020

  Abstract

  STUDY DESIGN: This was a retrospective cohort study.OBJECTIVE: The objective of this study was to compare implant-related complications between mixed-metal and same-metal rod-screw constructs in patients who underwent posterior fusion for adult spinal deformity.SUMMARY OF BACKGROUND DATA: Contact between dissimilar metals is discouraged due to potential for galvanic corrosion, increasing the risk for metal toxicity, infection, and implant failure. In spine surgery, titanium (Ti) screws are most commonly used, but Ti rods are notch sensitive and likely more susceptible to fracture after contouring for deformity constructs. Cobalt chrome (CC) and stainless steel (SS) rods may be suitable alternatives. No studies have yet evaluated implant-related complications among mixed-metal constructs (SS or CC rods with Ti screws).METHODS: Adults with spinal deformity who underwent at least 5-level thoracic and/or lumbar posterior fusion or 3-column osteotomy between January 2013 and May 2015 were reviewed, excluding neuromuscular deformity, tumor, acute trauma or infection. Implant-related complications included pseudarthrosis, proximal junctional kyphosis, hardware failure (rod fracture, screw pullout or haloing), symptomatic hardware, and infection.RESULTS: A total of 61 cases met inclusion criteria: 24 patients received Ti rods with Ti screws (Ti-Ti, 39%), 31 SS rods (SS-Ti, 51%), and 6 CC rods (CC-Ti, 9.8%). Median follow-up was 37-42 months for all groups. Because of the limited number of cases, the CC-Ti group was not included in statistical analyses. There were no differences between Ti-Ti and SS-Ti groups with regard to age, body mass index, or smokers. Implant-related complications did not differ between the Ti-Ti and SS-Ti groups (P=0.080). Among the Ti-Ti group, there were 15 implant-related complications (63%). In the SS-Ti group, there were 12 implant-related complications (39%). There were 3 implant-related complications in the CC-Ti group (50%).CONCLUSION: We found no evidence that combining Ti screws with SS rods increases the risk for implant-related complications.

  View details for DOI 10.1097/BSD.0000000000001058

  View details for PubMedID 32925188

• Does the location of short-arm cast univalve effect pressure of the three-point mould? Journal of children's orthopaedics Montgomery, B. K., Perrone, K. H., Yang, S., Segovia, N. A., Rinsky, L., Pugh, C. M., Frick, S. L. 2020; 14 (3): 236–40

  Abstract

  Purpose: Forearm and distal radius fractures are among the most common fractures in children. Many fractures are definitively treated with closed reduction and casting, however, the risk for re-displacement is high (7% to 39%). Proper cast application and the three-point moulding technique are modifiable factors that improve the ability of a cast to maintain the fracture reduction. Many providers univalve the cast to accommodate swelling. This study describes how the location of the univalve cut impacts the pressure at three-point mould sites for a typical dorsally displaced distal radius fracture.Methods: We placed nine force-sensing resistors on an arm model to collect pressure data at the three-point mould sites. Sensory inputs were sampled at 15 Hz. Cast padding and a three-point moulded short arm fibreglass cast was applied. The cast was then univalved on the dorsal, volar, radial or ulnar aspect. Pressure recordings were obtained throughout the procedure.Results: A total of 24 casts were analyzed. Casts univalved in the sagittal plane (dorsal or volar surface) retained up to 16% more pressure across the three moulding sites compared with casts univalved in the coronal plane (radial or ulnar border).Conclusion: Maintaining pressure at the three-point mould prevents loss of reduction at the fracture site. This study shows that univalving the cast dorsally or volarly results in less pressure loss at moulding sites. This should improve the chances of maintaining fracture reductions when compared with radial or ulnar cuts in the cast. Sagittal plane univalving of forearm casts is recommended.

  View details for DOI 10.1302/1863-2548.14.200034

  View details for PubMedID 32582392

• Single Assessment Numeric Evaluation (SANE) in Hand Surgery: Does a One-Question Outcome Instrument Compare Favorably? The Journal of hand surgery Gire, J. D., Koltsov, J. C., Segovia, N. A., Kenney, D. E., Yao, J., Ladd, A. L. 2020

  Abstract

  PURPOSE: Patient-reported outcome measures are increasingly used to measure patient status, impairments, and disability, but often require lengthy surveys and place a considerable burden on patients. We hypothesized that the Single Assessment Numeric Evaluation (SANE), composed of a single question, would be a valid and responsive instrument to provide a global assessment of hand function.METHODS: The SANE, Patient-Reported Outcomes Measurement Information System-Upper Extremity (PROMIS-UE), and Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) data are routinely collected electronically in our hand and upper-extremity center. To identify our cohort, we used Current Procedural Terminology codes to query our electronic medical record research data repository for the 7 most common hand surgery procedures performed over 2 years from December 2016 to 2018. These procedures included carpal tunnel release, trigger finger release, thumb carpometacarpal arthroplasty, wrist arthroscopy, distal radius fracture fixation, first dorsal compartment release, and cubital tunnel release. Patients undergoing a single isolated procedure with questionnaires obtained in the preoperative and/or postoperative period were included in the analysis. Convergent validity, coverage, and responsiveness for each instrument were assessed.RESULTS: We identified 214 patients for inclusion. The SANE score had a moderate to strong correlation with the QuickDASH and PROMIS-UE. Floor and ceiling effects for the SANE were less than 10% at baseline and follow-up. Overall, the QuickDASH was the most responsive, followed by SANE and PROMIS-UE; all 3 instruments exceeded the acceptable thresholds for responsiveness and demonstrated significant changes before to after surgery. Responsiveness of the SANE varied by procedure and was acceptable for carpal tunnel release, carpometacarpal arthroplasty, wrist arthroscopy, and trigger finger release.CONCLUSIONS: The single-item SANE is a reasonable measure of global function in patients undergoing common hand procedures and demonstrates psychometric properties comparable to those of the PROMIS-UE and QuickDASH outcome scores.CLINICAL RELEVANCE: The SANE score is a reasonable outcome measure of global hand function that may have utility in demonstrating response to treatment in a practice setting and may provide a useful adjunct to multiple-item measures in clinical research studies.

  View details for DOI 10.1016/j.jhsa.2020.03.024

  View details for PubMedID 32482496

• Test of Strength: Figure-of-Eight versus Spiral Wrapping Technique for Fiberglass Casts CUREUS Montgomery, B. K., Storaci, H., Segovia, N. A., Young, J. 2020; 12 (4)

  View details for DOI 10.7759/cureus.7843

  View details for Web of Science ID 000528561800010

• Test of Strength: Figure-of-Eight versus Spiral Wrapping Technique for Fiberglass Casts. Cureus Montgomery, B. K., Storaci, H. W., Segovia, N. A., Young, J. 2020; 12 (4): e7843

  Abstract

  Pediatric fractures are a common injury, and treatment often includes cast immobilization. For pediatric patients being treated in a cast, cast damage is among the most common reasons patients return to the emergency room. The figure-of-eight wrapping technique interdigitates layers of fiberglass which may create a stronger cast. The aim of this study was to assess the strength of the figure-of-eight wrapping technique in comparison to the spiral wrapping technique. A total of 10 casts were wrapped with a three-inch fiberglass using the spiral technique and 10 casts were wrapped using the figure-of-eight technique. Each cast was then subjected to a three-point bending test and loaded until failure using an Instron machine. The figure-of-eight technique had an average load to failure of 278.2 + 27.6 N/mm which was similar to the spiral technique's load to failure of 281.2 + 25.4 N/mm (p=0.795). Prior to normalizing for thickness, the load to failure of the figure-of-eight technique was 949.8 + 109.5 N, which was significantly higher than the spiral technique of 868.2 + 65.1 N (p=0.038). The figure-of-eight casts were slightly thicker than the spiral casts (average 0.3 mm, p=0.004). This suggests that the thickness of the fiberglass cast may improve the strength. The figure-of-eight wrapping technique had similar biomechanical characteristics to spiral wrapping techniques. Providers should wrap in whichever technique they feel most comfortable performing as there is no difference in strength of the cast. If a stronger cast is desired, then thickness of the cast can be increased.

  View details for DOI 10.7759/cureus.7843

  View details for PubMedID 32483494

  View details for PubMedCentralID PMC7253080

• Outcomes of Arthroscopic All-Inside Repair Versus Observation in Older Patients With Meniscus Root Tears. The American journal of sports medicine Dragoo, J. L., Konopka, J. A., Guzman, R. A., Segovia, N., Kandil, A., Pappas, G. P. 2020: 363546520909828

  Abstract

  BACKGROUND: Meniscus root tears lead to de-tensioning of the meniscus, increased contact forces, and cartilage damage. Management of older patients with root tears is controversial and the efficacy of different treatment options is unclear.PURPOSE: To compare the clinical outcomes of patients with moderate knee osteoarthritis who underwent an all-inside meniscus root repair technique versus nonoperative management for either medial or lateral meniscus root tears.STUDY DESIGN: Cohort study; Level of evidence, 2.METHODS: Patients with a diagnosed posterior meniscus root tear who underwent arthroscopic repair (AR: 30 knees) or nonoperative treatment with observation (O: 18 knees) were followed for a minimum of 2 years (mean follow-up, 4.4 years). The arthroscopic repair included all-inside sutures to reduce the root back to its remnant (reduction sutures), thereby re-tensioning the meniscus, and 1 mattress suture to strengthen the repair by reapproximating the construct to the posterior capsule. The data collected included the Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm, Tegner, and Veterans RAND 12-Item Health Survey (VR-12) Physical Component Summary (PCS) and Mental Component Summary (MCS) scores and conversion to total knee arthroplasty (TKA).RESULTS: Medial meniscus root tears comprised 80.0% of the AR group and 77.8% of the O group. The average Kellgren-Lawrence grade was 2 in both groups. The baseline scores for the KOOS Symptoms subscale were lower for AR (50.2 ± 19.3) than for O (66.5 ± 16.1) (P = .003), as were the KOOS Knee-Related Quality of Life scores (AR, 26.7 ± 16.1; O, 39.6 ± 22.1) (P = .046). No differences were found between groups for the absolute values at follow-up except that follow-up Tegner scores were lower in the O group than in the AR group (P = .004). Significant improvements were seen in the AR group from baseline to ultimate follow-up in average KOOS subscale scores (P < .001), Lysholm scores (P < .001), Tegner scores (P = .0002), and VR-12 PCS scores (P < .001), whereas the O group had a significant improvement only in average KOOS Pain (P = .003), KOOS Function in Daily Living (P = .006), and VR-12 PCS (P = .038) scores. Compared with the O group, the AR group had a significantly larger improvement from baseline to follow-up in average KOOS Pain (P = .009), KOOS Symptoms (P = .029), and Lysholm scores (P = .016). During follow-up, 3.3% of the AR group underwent a TKA compared with 33.3% of the O group (P = .008). The hazard ratio of TKA conversion was 93.2% lower for the AR group compared with the O group (P = .013).CONCLUSION: All-inside medial or lateral meniscus root repair showed improved functional outcomes and decreased TKA conversion rates compared with nonoperative treatment and may be considered as a treatment option for the management of meniscus root tears in older patients with moderate osteoarthritis.

  View details for DOI 10.1177/0363546520909828

  View details for PubMedID 32182103

• Deciding Without Data: Clinical Decision Making in Pediatric Orthopaedic Surgery. International journal for quality in health care : journal of the International Society for Quality in Health Care Nathan, K. n., Uzosike, M. n., Sanchez, U. n., Karius, A. n., Leyden, J. n., Nicole, S. n., Sara, E. n., Hastings, K. G., Kamal, R. n., Frick, S. n. 2020

  Abstract

  Objective.Identifying when and how often decisions are made based on high-quality evidence can inform the development of evidence-based treatment plans and care pathways, which have been shown to improve quality of care and patient safety. Evidence to guide decision making, national guidelines, and clinical pathways for many conditions in pediatric orthopaedic surgery are limited. This study investigated decision making rationale and quantified the evidence supporting decisions made by pediatric orthopaedic surgeons in an outpatient clinic.Design/Setting/Participants/Intervention(s)/Main Outcome Measure(s).We recorded decisions made by eight pediatric orthopaedic surgeons in an outpatient clinic and the surgeon's reported rationale behind the decisions. Surgeons categorized the rationale for each decision as one or a combination of 12 possibilities (e.g. "Experience/anecdote", "First Principles", "Trained to do it", "Arbitrary/Instinct", "General Study", "Specific Study").Results.Out of 1150 total decisions, the most frequent decisions were follow-up scheduling, followed by bracing prescription/removal. The most common decision rationales were "First principles" (N=310, 27.0%) and "Experience/anecdote" (N=253, 22.0%). Only 17.8% of decisions were attributed to scientific studies, with 7.3% based on studies specific to the decision. 34.6% of surgical intervention decisions were based on scientific studies, while only 10.4% of follow-up scheduling decisions were made with studies in mind. Decision category was significantly associated with a basis in scientific studies: surgical intervention and medication prescription decisions were more likely to be based on scientific studies than all other decisions.Conclusions.With increasing emphasis on high value, evidence-based care, understanding the rationale behind physician decision-making can educate physicians, identify common decisions without supporting evidence, and help create clinical care pathways in pediatric orthopaedic surgery. Decisions based on evidence or consensus between surgeons can inform pathways and national guidelines that minimize unwarranted variation in care and waste. Decision support tools & aids could also be implemented to guide these decisions.

  View details for DOI 10.1093/intqhc/mzaa119

  View details for PubMedID 32986101

• Day of the Week of Surgery Affects Time to Discharge for Patients With Adolescent Idiopathic Scoliosis ORTHOPEDICS Tileston, K. R., Uzosike, M., Segovia, N., Rinsky, L. A., Imrie, M. N. 2020; 43 (1): 8–12

  Abstract

  Unnecessary delays in discharge are extraordinarily common in the current US health care system. These delays are even more protracted for patients undergoing orthopedic procedures. A traditional hospital staffing model is heavily weighted toward increased resources on weekdays and minimal coverage on the weekend. This study examined the effect of this traditional staffing model on time to discharge for patients undergoing posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis. Patients undergoing surgery later in the week had a significantly longer hospital stay compared with patients undergoing surgery early in the week (5.5 days vs 4.9 days, respectively; P=.003). This discrepancy resulted in a mean cost increase of $7749.50 for patients undergoing surgery later in the week. A subsequent quality, safety, value initiative (QSVI) was undertaken to balance physical therapy resources alone. Following the QSVI, patients undergoing surgery later in the week had a decreased mean length of stay of 3.78 days (P=.002). Patients undergoing fusion early in the week also had a decreased mean length of stay of 3.66 days (P<.001). There was no longer a significant difference in length of stay between the "early" and the "late" groups (P=.84). This study demonstrates that simply having surgery later in the week in a hospital with a traditional staffing model adversely affects the timing of discharge, resulting in a significantly longer and more costly hospital course. By increasing physical therapy availability on the weekend, the length of stay and the cost of hospitalization decrease precipitously for these patients. [Orthopedics. 2020; 43(1);8-12.].

  View details for DOI 10.3928/01477447-20191001-06

  View details for Web of Science ID 000508434100012

  View details for PubMedID 31587077

• Patient-Reported Outcome Measures (PROMs): Influence of Motor Tasks and Psychosocial Factors on FAAM Scores in Foot and Ankle Trauma Patients. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons Schultz, B. J., Tanner, N. n., Shapiro, L. M., Segovia, N. A., Kamal, R. N., Bishop, J. A., Gardner, M. J. 2020

  Abstract

  Patient-reported outcome measures (PROMS) are being increasingly used as a quality of care metric. However, the validity and consistency of PROMS remain undefined. The study sought to determine whether Foot and Ankle Ability Measure (FAAM) scores improve after patients complete motor tasks evaluated on the survey and to examine the relationship between depression and self-efficacy and FAAM scores or change in scores. We conducted a prospective comparison study of adults with isolated foot, ankle, or distal tibia fractures treated operatively at level I trauma center. Twenty-seven patients completed the FAAM survey at the first clinic visit after being made weightbearing as tolerated (mean 3 months). Patients then completed 6 motor tasks queried on FAAM (standing, walking without shoes, squatting, stairs, up to toes), followed by a repeat FAAM and General Self-Efficacy scale (GSE) and Patient Health Questionnaire-2 (PHQ-2) instruments. FAAM scores before and after intervention; GSE and PHQ-2 scores compared with baseline FAAM and change in FAAM scores. Performing motor tasks significantly improved postintervention scores for squatting (P = .044) and coming up to toes (P = .012), the 2 most strenuous tasks. No difference was found for the remaining tasks. Higher depression ratings correlated with worse FAAM scores overall (P < .05). Higher self-efficacy ratings correlated with increase in FAAM Sports subscale postintervention (P = .020). FAAM scores are influenced by performing motor tasks. Self-reported depression influences baseline FAAM scores and self-efficacy may influence change in FAAM scores. Context and patient factors (modifiable and nonmodifiable) affect PROM implementation, with implications for clinical care, reimbursement models, and use of quality measure.

  View details for DOI 10.1053/j.jfas.2020.01.008

  View details for PubMedID 32173179

• Prevalence of Female Athlete Triad Risk Factors and Iron Supplementation Among High School Distance Runners: Results From a Triad Risk Screening Tool. Orthopaedic journal of sports medicine Skorseth, P. n., Segovia, N. n., Hastings, K. n., Kraus, E. n. 2020; 8 (10): 2325967120959725

  Abstract

  Investigations of the female athlete triad (Triad) in high school athletes have found that 36% had low energy availability, 54% had menstrual abnormalities, and 16% had low bone mineral density (BMD). Limited data are available showing the prevalence of these risk factors in high school distance runners or regarding best practice on screening for the Triad in the adolescent population.To (1) evaluate the prevalence of Triad risk factors and iron supplementation in high school distance runners and (2) pilot a screening tool for Triad risk score.Descriptive epidemiology study.The study population included female high school athletes who participated in cross-country/track. Participants completed a survey including questions regarding dietary habits, menstrual history, and bone stress injury (BSI) history. They then underwent evaluation of 25-hydroxyvitamin D, free triiodothyronine (T3), and dual-energy x-ray absorptiometry scan to measure body fat and BMD through use of age-, sex-, and ethnicity-matched Z scores. Triad scores were calculated. Relationships were analyzed using Spearman correlation coefficient.There were 38 study participants (mean age, 16.9 years). Average body mass index was 19.8 kg/m2. Disordered eating or eating disorders were reported in 76.3% of runners; in addition, 23.7% reported delayed menarche, 45.9% had a history of amenorrhea or oligomenorrhea, 42.1% had low BMD (Z score < -1.0), and 15.8% reported prior BSI. Low free T3 was significantly associated with higher Triad risk scores (rS = -0.36; P = .028). More than 42% of athletes were supplementing iron.The prevalence of Triad risk factors in high school distance runners was high. Free T3 was inversely associated with Triad score, which may serve as an indicator of low energy availability. Nearly half of the athletes were using iron supplementation.

  View details for DOI 10.1177/2325967120959725

  View details for PubMedID 33195716

  View details for PubMedCentralID PMC7605010

• Posterior Sternoclavicular Dislocation: Do We Need "Cardiothoracic Backup"? Insights from a National Sample. Journal of orthopaedic trauma Leonard, D. A., Segovia, N., Kaur, J., Lucas, J., Bishop, J., Vorhies, J. S. 2019

  Abstract

  OBJECTIVES: To describe the incidence of and risk factors for vascular injury associated with P-SCD.METHODS: We used data from the HCUP-NIS from 2015-2016 and defined a cohort of patients with sternoclavicular dislocation (SCD) using ICD-10-CM diagnosis codes. We further isolated a subset with P-SCD. We describe the incidence of thoracic vascular injury, demographics and injury severity score (ISS) in this cohort.RESULTS: Of an estimated 550 patients who had SCD, 140 (25%) were identified as having a P-SCD. No vascular injuries occurred in the P-SCD cohort. Among all patients with SCD, < 2% of patients had a vascular injury, all of whom had an ISS ≥ 15, independent of the vascular injury itself (Figure 1). Among patients with an isolated P-SCD injury (55), overall length of stay was 1.8 days and total charges averaged $29,724.45. There was no mortality among patients with isolated P-SCD.CONCLUSION: Here we report no vascular injuries in the largest known series of P-SCD. Among all patients with SCD, vascular injury was rare, occurring only in severely polytraumatized patients. The recommendation for routine involvement of cardiothoracic surgeons in all cases of P-SCD should be re-examined.LEVEL OF EVIDENCE: Level III.

  View details for DOI 10.1097/BOT.0000000000001685

  View details for PubMedID 31764407

• Successful Implementation of an Accelerated Recovery and Outpatient Total Joint Arthroplasty Program at a County Hospital. Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews Schultz, B. J., Segovia, N., Castillo, T. N. 2019; 3 (9): e110

  Abstract

  Outpatient and accelerated recovery total joint arthroplasty (TJA) programs have become standard for private and academic practices. County hospitals traditionally serve patients with limited access to TJA and psychosocial factors which create challenges for accelerated recovery. The effectiveness of such programs at a county hospital has not been reported.Methods: In 2017, our county hospital implemented an accelerated recovery protocol for all TJA patients. This protocol consisted of standardized, preoperative medical and psychosocial optimization, perioperative spinal anesthesia, tranexamic acid and local infiltration analgesia use, postoperative emphasis on non-narcotic analgesia, and early mobilization. LOS, complications, disposition, and cost were compared between patients treated before and after protocol implementation.Results: In 15 months, 108 primary TJA patients were treated. Compared with the previous 108 TJA patients, LOS dropped from 3.4 to 1.6 days (P < 0.001), more patients discharged home (92% versus 72%, P < 0.001), average hospitalization and procedure-specific costs decreased 24.7% and 22.1%, respectively, and were significantly fewer complications (7% versus 21%, P = 0.007).Conclusions: Implementation of an accelerated recovery TJA program at a County Hospital is novel. This implementation requires careful patient selection and a coordinated multidisciplinary approach and is a safe and cost-effective method of delivering high-quality care to an underserved cohort.

  View details for DOI 10.5435/JAAOSGlobal-D-19-00110

  View details for PubMedID 31773082

• Iron Supplementation and the Female Athlete Triad in High School Distance Runners Skorseth, P., Dingel, A., Hastings, K., Segovia, N., Kraus, E. LIPPINCOTT WILLIAMS & WILKINS. 2019: 736

  View details for Web of Science ID 000481662802675