All Publications

  • 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


    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 average grade level for all resources was above the recommended reading level based on both Microsoft Word and 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


    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

  • 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


    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-+


    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


    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


    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


    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


    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


    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-+


    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


    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
  • 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


    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


    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


    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


    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


    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


    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


    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


    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


    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


    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


    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


    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


    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


    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)


    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


    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


    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


    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


    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)
  • 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


    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


    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
  • 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


    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


    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


    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


    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


    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


    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


    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


    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)
  • 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


    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


    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


    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


    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


    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


    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


    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


    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