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Maheu AR, Shih YC, LeBrun DG, Fabricant PD, Atanda AW. A Telemedicine Solution to Minimize Unnecessary Emergency Department Transfers for Low-acuity Pediatric Orthopaedic Patients: A Model for Cost Minimization. J Am Acad Orthop Surg 2024; 32:e443-e451. [PMID: 37793173 DOI: 10.5435/jaaos-d-21-01201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 08/24/2023] [Indexed: 10/06/2023] Open
Abstract
INTRODUCTION Unnecessary emergency department (ED) transfers represent a notable source of excess costs and misutilization of healthcare resources, particularly with management of acute pediatric musculoskeletal injuries. This study used institutional data to create a model investigating the expected costs of a formal peer-to-peer telemedicine intervention designed to triage pediatric orthopaedic transfers, which we hypothesized would decrease healthcare costs by minimizing unwarranted ED-to-ED transfers. METHODS In this retrospective modeling analysis, 350 pediatric orthopaedic trauma patients transferred to two in-network referral hospitals from outside facilities were identified and stratified into three groups representing how patients theoretically optimally could have been treated. Group 1 patients required ambulance transfer, group 2 patients required ED-level care but no ambulance transfer, and group 3 patients did not require ED-level care. Base case estimates for the proportions of patients in each group, probability of ambulance transport, and direct costs of care for each patient were derived from the database. A decision tree was developed to evaluate the expected costs of two triaging strategies: (1) transfer everyone or (2) triage first using e-consultation. Probabilistic sensitivity analyses were used to determine how the results of the decision analysis varied across ranges of cost and probability estimates. RESULTS In the base case analysis, the telemedicine triage strategy was cheaper than the transfer-all strategy ($4,858 versus $6,610). In a 2-way sensitivity analysis comparing cost of a telemedicine visit and proportion of telemedicine triaged patients requiring ambulance transport, the telemedicine triage strategy remained cheaper than the transfer-all strategy across almost all possibilities for both variables. Additional potential benefits of triage before transfer, such as decreased length of time to completion of ED visit, cost to the family, and patient comfort and satisfaction, were not incorporated into this analysis. The potential for misdiagnosis related to telehealth and its potential costs were not included. DISCUSSION We revealed substantial cost savings for the healthcare system from implementing a telehealth platform for peer-to-peer consultation when considering patient transfer for musculoskeletal trauma. Initial peer-to-peer e-consultations cost less than reflexive ambulance transfer in most situations. LEVEL OF EVIDENCE Economic Level II.
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Affiliation(s)
- Arlene R Maheu
- From the Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA (Maheu), the Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE (Shih, and Atanda), and the Hospital for Special Surgery, New York, NY (LeBrun, and Fabricant)
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Davis E, LeBrun DG, McCarthy T, Westrich GH. Femoral Neck Anteversion: Which Distal Femur Landmark Matters? Arthroplast Today 2024; 26:101318. [PMID: 38440289 PMCID: PMC10910236 DOI: 10.1016/j.artd.2024.101318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/05/2023] [Accepted: 01/21/2024] [Indexed: 03/06/2024] Open
Abstract
Background Femoral neck anteversion has traditionally been measured by the angle between the distal femur posterior condylar axis (PCA) and a line drawn through the center of the femoral head and neck. While less common, the transepicondylar axis (TEA) has also been used to reference femoral neck anteversion. The purpose of this study was to compare femoral neck version of the PCA vs the TEA using computerized tomography (CT). Methods A total of 1507 femoral CTs were included. Precise bony landmarks were established: lateral epicondyle, medial epicondyle, posteromedial condyle, posterolateral condyle, center of the femoral neck, and center of the femoral head. Femoral version was calculated between the head and neck axis and either the PCA or TEA. Differences between sex and ethnicity were evaluated. Results The mean femoral anteversion was 12.7° ± 9.1° based on the PCA and 11.5° ± 7.9° based on the TEA (mean difference 1.2° ± 1.9°, P < .001). Males were less anteverted than females (9.8° ± 7.6° vs 13.5° ± 7.8°, P < .001). African Americans had less anteversion than other groups (8.1° ± 9.2° vs 11.5° ± 7.8°, P = .04), while Asians were more anteverted than other groups (12.1° ± 9.0° vs 11.2° ± 7.3°, P = .04). These values were referenced on the TEA. Conclusions In this series of over 1500 femoral CT scans, the mean difference between anteversion measurements referencing the PCA and TEA was 1.2°. Native femoral version varied widely between gender and ethnic groups. Extreme femoral version, defined as <0° or >30°, was present in 11.8% of patients referencing the PCA.
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Affiliation(s)
- Elizabeth Davis
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Drake G. LeBrun
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | | | - Geoffrey H. Westrich
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
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LaValva SM, LeBrun DG, Canoles HG, Ren R, Padgett DE, Su EP. Clinical outcomes and return to dance after total hip arthroplasty or hip resurfacing in professional dancers. Bone Joint J 2024; 106-B:17-23. [PMID: 38425296 DOI: 10.1302/0301-620x.106b3.bjj-2023-0854.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Aims Professional dancers represent a unique patient population in the setting of hip arthroplasty, given the high degree of hip strength and mobility required by their profession. We sought to determine the clinical outcomes and ability to return to professional dance after total hip arthroplasty (THA) or hip resurfacing arthroplasty (HRA). Methods Active professional dancers who underwent primary THA or HRA at a single institution with minimum one-year follow-up were included in the study. Primary outcomes included the rate of return to professional dance, three patient-reported outcome measures (PROMs) (modified Harris Hip Score (mHHS), Hip disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR), and Lower Extremity Activity Scale (LEAS)), and postoperative complications. Results A total of 49 hips in 39 patients (mean age 56 years (SD 13); 80% female (n = 39)) were included. Mean follow-up was 4.9 years (SD 5.1). Of these 49 hips, 37 THAs and 12 HRAs were performed. In all, 96% of hips returned to professional dance activities postoperatively. With regard to PROMs, there were statistically significant improvements in mHHS, HOOS-JR, and LEAS from baseline to ≥ one year postoperatively. There were complications in 7/49 hips postoperatively (14%), five of which required revision surgery (10%). There were no revisions for instability after the index procedure. Two complications (5.4%) occurred in hips that underwent THA compared with five (42%) after HRA (p = 0.007), though the difference by procedure was not significantly different when including only contemporary implant designs (p = 0.334). Conclusion Active professional dancers experienced significant improvements in functional outcome scores after THA or HRA, with a 96% rate of return to professional dance. However, the revision rate at short- to mid-term follow-up highlights the challenges of performing hip arthroplasty in this demanding patient population. Further investigation is required to determine the results of THA versus HRA using contemporary implant designs in these patients.
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Affiliation(s)
- Scott M LaValva
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York, USA
| | - Drake G LeBrun
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York, USA
| | - Haley G Canoles
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York, USA
| | - Renee Ren
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York, USA
| | - Douglas E Padgett
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York, USA
| | - Edwin P Su
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York, USA
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LeBrun DG. CORR Insights: What Are the Mortality, Infection, and Nonunion Rates After Periprosthetic Femoral Fractures in the United States? Clin Orthop Relat Res 2024; 482:484-486. [PMID: 37847412 PMCID: PMC10871792 DOI: 10.1097/corr.0000000000002893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 09/18/2023] [Indexed: 10/18/2023]
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LeBrun DG, Grubel J, Ong J, Chiu YF, Blevins JL, Haas SB, Rodriguez JA, Gausden EB, Cushner FD, Lee GC, Gonzalez Della Valle A, Chalmers BP. The John N. Insall Award: Does Melatonin Improve Subjective Sleep Quality After Total Knee Arthroplasty? A Randomized, Placebo-Controlled Trial. J Arthroplasty 2024:S0883-5403(24)00018-4. [PMID: 38237875 DOI: 10.1016/j.arth.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/28/2023] [Accepted: 01/09/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Sleep disturbance is a common problem following total knee arthroplasty (TKA). The objective of this study was to determine if exogenous melatonin improves sleep quality following primary TKA. METHODS A randomized, double-blind, placebo-controlled trial was conducted. A total of 172 patients undergoing unilateral TKA for primary knee osteoarthritis were randomized to receive either 5 mg melatonin (n = 86) or 125 mg vitamin C placebo (n = 86) nightly for 6 weeks. The primary outcome was the Pittsburgh Sleep Quality Index (PSQI) at 6 weeks and 90 days postoperatively. Secondary outcomes included 6-week and 90-day patient-reported outcome measures (PROMs), morphine milligram equivalents prescribed, medication compliance, adverse events, and 90-day readmissions. RESULTS Mean PSQI scores worsened at 6 weeks before returning to the preoperative baseline at 90 days in both groups. There were no differences in PSQI scores between melatonin and placebo groups at 6 weeks (10.2 ± 4.2 versus 10.5 ± 4.4, P = .66) or 90 days (8.1 ± 4.1 versus 7.5 ± 4.0, P = .43). Melatonin did not improve the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, Lower Extremity Activity Scale, Visual Analog Scale for pain, or Veterans Rand 12 Physical Component Score or Mental Component Score at 6 weeks or 90 days. Poor sleep quality was associated with worse PROMs at 6 weeks and 90 days on univariate and multivariable analyses, but melatonin did not modify these associations. There were no differences in morphine milligram equivalents prescribed, medication compliances, adverse events, or 90-day readmissions between both groups. CONCLUSIONS Exogenous melatonin did not improve subjective sleep quality or PROMs at 6 weeks or 90 days following TKA. Poor sleep quality was associated with worse patient-reported function and pain. Our results do not support the routine use of melatonin after TKA.
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Affiliation(s)
- Drake G LeBrun
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Jacqueline Grubel
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Justin Ong
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Yu-Fen Chiu
- Epidemiology & Biostatistics, Hospital for Special Surgery, New York, New York
| | - Jason L Blevins
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Steven B Haas
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Jose A Rodriguez
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Elizabeth B Gausden
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Fred D Cushner
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Gwo-Chin Lee
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | | | - Brian P Chalmers
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
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LeBrun DG. Residency Diary: Fifth Year-Reflection. Clin Orthop Relat Res 2023:00003086-990000000-01244. [PMID: 37358484 PMCID: PMC10344478 DOI: 10.1097/corr.0000000000002762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/06/2023] [Indexed: 06/27/2023]
Affiliation(s)
- Drake G LeBrun
- Resident, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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LeBrun DG, Nguyen J, Fisher C, Tuohy S, Lyman S, Gonzalez Della Valle A, Ast MP, Carli AV. The Risk Assessment and Prediction Tool (RAPT) Score Predicts Discharge Destination, Length of Stay, and Postoperative Mobility after Total Joint Arthroplasty. J Arthroplasty 2023:S0883-5403(23)00479-5. [PMID: 37182588 DOI: 10.1016/j.arth.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 05/04/2023] [Accepted: 05/05/2023] [Indexed: 05/16/2023] Open
Abstract
INTRODUCTION Predicting an arthroplasty patient's discharge disposition, length of stay, and physical function is helpful because it allows for preoperative patient optimization, expectation management, and discharge planning. The goal of this study was to evaluate the ability of the Risk Assessment and Prediction Tool (RAPT) score to predict discharge destination, length of stay, and postoperative mobility in patients undergoing primary total knee arthroplasty (TKA) and total hip arthroplasty (THA). METHODS Primary unilateral TKAs (n=9,064) and THAs (n=8,649) performed for primary osteoarthritis at our institution from 2018 to 2021 (excluding March to June 2020) were identified using a prospectively maintained institutional registry. We evaluated the associations between preoperative RAPT score and (1) discharge destination, (2) length of stay, and postoperative mobility as measured by (3) successful ambulation on the day of surgery and (4) Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" score. RESULTS On multivariable analyses adjusting for multiple covariates, every one-point increase in RAPT score among TKA patients was associated with a 1.82-fold increased odds of home discharge (P<0.001), 0.22 days shorter length of stay (P<0.001), 1.13-fold increased odds of ambulating on postoperative day 0 (P<0.001), and 0.25-point higher AM-PAC score (P<0.001). Similar findings were seen among THAs. A RAPT score of 8 or higher was the most sensitive and specific cutoff to predict home discharge. CONCLUSION Among nearly 18,000 TKA and THA patients, RAPT score was predictive of discharge disposition, length of stay, and postoperative mobility. A RAPT score of 8 or higher was the most sensitive and specific cutoff to predict discharge to home. In contrast to prior studies of the RAPT score which have grouped TKAs and THAs together, this study ran separate analyses for TKAs and THAs and found that THA patients seemed to perform better than TKA patients with equal RAPT scores, suggesting that RAPT may behave differently between TKAs and THAs, particularly in the intermediate risk RAPT range.
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Affiliation(s)
- Drake G LeBrun
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, 535 E 70(th) Street, New York, NY 10021.
| | - Joseph Nguyen
- Biostatistics, Hospital for Special Surgery, 535 E 70(th) Street, New York, NY, 10021
| | - Charles Fisher
- Acute Care Rehabilitation, Hospital for Special Surgery, 535 E 70(th) Street, New York, NY, 10021
| | - Sharlynn Tuohy
- Acute Care Rehabilitation, Hospital for Special Surgery, 535 E 70(th) Street, New York, NY, 10021
| | - Stephen Lyman
- Biostatistics, Hospital for Special Surgery, 535 E 70(th) Street, New York, NY, 10021
| | | | - Michael P Ast
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, 535 E 70(th) Street, New York, NY 10021
| | - Alberto V Carli
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, 535 E 70(th) Street, New York, NY 10021
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LeBrun DG. Residency Diary: Fifth Year-Australia. Clin Orthop Relat Res 2023; 481:863-864. [PMID: 36995292 PMCID: PMC10097577 DOI: 10.1097/corr.0000000000002642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 03/07/2023] [Indexed: 03/31/2023]
Affiliation(s)
- Drake G LeBrun
- Resident, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY USA
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Shen TS, Rodriguez S, LeBrun DG, Yu JS, Gonzalez Della Valle A, Ast MP, Rodriguez JA. Reasons and Risk Factors for Failed Same-Day Discharge After Primary Total Knee Arthroplasty. J Arthroplasty 2023; 38:668-672. [PMID: 36332890 DOI: 10.1016/j.arth.2022.10.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/24/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND As ambulatory total knee arthroplasty (TKA) becomes increasingly common, unplanned admission after surgery presents a challenge for the health care system. Studies evaluating the reasons and risk factors for this occurrence are limited. We sought to evaluate the reasons for unplanned admission after surgery and identify risk factors associated with this occurrence. METHODS Patients registered in an institutional ambulatory joint arthroplasty program who underwent a TKA from 2017-2020 were retrospectively reviewed. The criteria for enrollment include candidates for unilateral TKA between the ages of 18 and 70 years, with a body mass index (BMI) of less than 35, and appropriate social and material support at home. Patients who had certain comorbidities including coronary artery disease, valvular heart disease, and opioid dependence were not eligible. A total of 274 patients who underwent TKA with planned same-day discharge (SDD) were identified in the medical record and reviewed. In this cohort, 140 patients (51.1%) were discharged on the day of surgery and 134 patients (48.9%) required a minimum 1-night admission. Demographics, comorbidities, and perioperative data were collected. Factors associated with failed SDD were identified using multivariate logistic regression. RESULTS The most common reasons for failed SDD were failure to meet ambulation goals (25%) and logistical issues related to a late-day case (19%). Risk factors for failed SDD include general anesthesia (odds ratio (OR) 12.60, P = .047), procedure start time after 11:00 am (OR 5.16, P < .001), highest postoperative pain score >8 (visual analogue scale, OR 5.78, P = .001). Willingness to accept a higher pain threshold before discharge (visual analogue scale 4 to 10) was associated with successful SDD (OR 3.0, P < .001). Age and American Society of Anesthesiologists (ASA) classification were not associated with failed SDD. CONCLUSIONS The most common reasons for failed SDD were related to logistical issues and postoperative mobilization. Risk factors for failed SDD involve case timing and pain control. Modifiable perioperative factors may play an important role in successful SDD after TKA.
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Affiliation(s)
- Tony S Shen
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Samuel Rodriguez
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Drake G LeBrun
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Jonathan S Yu
- Weill Cornell Medicine, Cornell University, New York, New York
| | | | - Michael P Ast
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Jose A Rodriguez
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
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LeBrun DG, Ondeck NT, Nessler JP, Marchand RC, Illgen RL, Westrich GH. Variability of pre-operative functional pelvic tilt in total hip arthroplasty patients. Int Orthop 2023; 47:1243-1247. [PMID: 36864185 DOI: 10.1007/s00264-023-05748-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 02/22/2023] [Indexed: 03/04/2023]
Abstract
PURPOSE Pelvic tilt (PT) is important to consider when planning total hip arthroplasty (THA) due to its dynamic impact on acetabular orientation. The degree of sagittal pelvic rotation varies during functional activities and can be difficult to measure without proper imaging. The purpose of this study was to evaluate PT variation in the supine, standing, and seated positions. METHODS A multi-centre cross-sectional study was performed that included 358 THA patients who had preo-perative PT measured from supine CT scan and standing and upright seated lateral radiographs. Supine, standing, and seated PT and associated changes between functional positions were evaluated. Anterior PT was assigned a positive value. RESULTS In the supine position, mean PT was 4° (range, -35° to 20°), where 23% had posterior PT and 69% anterior PT. In the standing position, mean PT was 1° (range, -23° to 29°), where 40% had posterior PT and 54% anterior PT. In the seated position, mean PT was -18° (range, -43° to 47°), where 95% had posterior PT and 4% anterior PT. From standing to seated, the pelvis rotated posteriorly in 97% of cases (maximum 60°) with 16% of cases considered stiff (change ≤ 10°) and 18% of cases considered hypermobile (change ≥ 30°). CONCLUSION Patients undergoing THA have marked PT variation in the supine, standing, and seated positions. There was wide variability in PT change from standing to seated, with 16% of patients considered stiff and 18% considered hypermobile. Functional imaging should be performed on patients prior to THA to allow for more accurate planning.
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Affiliation(s)
- Drake G LeBrun
- Adult Reconstruction Joint Replacement Service, Hospital for Special Surgery, 535 East 70 th Street, New York, NY, 10021, USA.
| | - Nathaniel T Ondeck
- Adult Reconstruction Joint Replacement Service, Hospital for Special Surgery, 535 East 70 th Street, New York, NY, 10021, USA
| | - Joseph P Nessler
- St. Cloud Orthopedics, 1901 Connecticut Ave S, MN, 56377, Sartell, USA
| | - Robert C Marchand
- Ortho Rhode Island, 285 Promenade Street, RI, 02908, Providence, USA
| | - Richard L Illgen
- University of Wisconsin-Madison, 4602 Eastpark Blvd, Madison, WI, 53706, USA
| | - Geoffrey H Westrich
- Adult Reconstruction Joint Replacement Service, Hospital for Special Surgery, 535 East 70 th Street, New York, NY, 10021, USA
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LeBrun DG. Residency Diary: Fifth Year-Fracture Chief. Clin Orthop Relat Res 2023; 481:28-29. [PMID: 36455099 PMCID: PMC9750699 DOI: 10.1097/corr.0000000000002498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 10/28/2022] [Indexed: 12/03/2022]
Affiliation(s)
- Drake G LeBrun
- Resident, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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LeBrun DG. Residency Diary: Fourth Year-Feedback Is Not Easy. Clin Orthop Relat Res 2022; 480:1664-1665. [PMID: 35916754 PMCID: PMC9384921 DOI: 10.1097/corr.0000000000002346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 07/12/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Drake G LeBrun
- Resident, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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Abstract
BACKGROUND The orthopedic in-training examination (OITE) continues to evolve over time. It is important for orthopedic residents and residency programs to have an up-to-date understanding of the content and resources being used on the OITE to study and tailor curricula accordingly. This study presents an updated analysis of the OITE hand domain from 2014 to 2019. METHODS All OITE questions related to hand surgery from 2014 to 2019 were analyzed for topic, subtopic, taxonomy, imaging modalities, and bibliometric factors related to cited references. RESULTS Of the 1600 OITE questions, there were 113 hand surgery questions (7.1%) over a 6-year period. The most commonly tested topics were nerve (n = 22; 19%), fracture/dislocation (n = 21; 19%), and tendon/ligament (n = 19; 17%). Complex clinical management questions were the most common taxonomic category (n = 66; 58%). Two hundred fifty-two references were cited, the most common of which were from the Journal of Hand Surgery (American Volume) (n = 76; 30%), Journal of the American Academy of Orthopaedic Surgeons (n = 27; 11%), and Hand Clinics (n = 21; 8%). Publication lag decreased over the study period (P = .009). Twenty-five questions (22%) used imaging modalities, and 21 (19%) used clinical photos. Compared with a prior analysis from 2002 to 2006, there were more questions related to nerves (19.5% vs 9.8%, P = .041). CONCLUSIONS Residents and residency programs can benefit from an updated understanding of OITE hand surgery content and resources. The current analysis identifies high-yield topics and resources that can guide resident preparation for the OITE.
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LeBrun DG, LaValva SM, Waddell BS, Mayman DJ, Jerabek SA, Alexiades MM, Ast MP. No Effect of Surgical Approach on Discharge Outcomes in Outpatient Total Hip Arthroplasty. HSS J 2022; 18:338-343. [PMID: 35846259 PMCID: PMC9247591 DOI: 10.1177/15563316211055069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 09/17/2021] [Indexed: 02/07/2023]
Abstract
Background: The interest in ambulatory total hip arthroplasty (THA) has increased recently due to a national focus on value-based care and improved rapid recovery protocols. Purpose: We sought to determine if surgical approach had an effect on discharge outcomes in outpatient THA. Methods: We performed a retrospective cohort study examining patients who underwent unilateral THA at a single institution using a standardized perioperative care pathway who were discharged home within 24 hours. In total, we compared 106 patients who underwent THA using the direct anterior approach (ATHA) and 90 patients who underwent THA using the posterior approach (PTHA). Univariate and multivariable analyses were used to compare time to ambulation, length of surgery, readmissions, and 90-day complications. Results:Time to ambulation in the ATHA and PTHA groups was 3.9 hours and 4.1 hours, respectively, and time to discharge was 5.9 hours and 6.0 hours, respectively. Length of surgery was shorter in the ATHA group than in the PTHA group (78 minutes vs 86 minutes, respectively). Complications occurred in 3 patients (3%) in the ATHA group vs 4 patients (4%) in PTHA group. In both groups, early ambulation (within 5 hours) predicted earlier time to discharge. Surgical approach was not associated with time to ambulation or time to discharge on multivariable analysis. Conclusion: In this retrospective study, outpatient THA was feasible in a well-selected population of patients undergoing anterior or posterior approaches. Further study is warranted.
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Affiliation(s)
- Drake G. LeBrun
- Department of Orthopedic Surgery, Adult
Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY,
USA,Drake G. LeBrun, MD, MPH, Department of
Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for
Special Surgery, New York, NY 10021, USA.
| | - Scott M. LaValva
- Department of Orthopedic Surgery, Adult
Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY,
USA
| | - Bradford S. Waddell
- Department of Orthopedic Surgery, Adult
Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY,
USA
| | - David J. Mayman
- Department of Orthopedic Surgery, Adult
Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY,
USA
| | - Seth A. Jerabek
- Department of Orthopedic Surgery, Adult
Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY,
USA
| | - Michael M. Alexiades
- Department of Orthopedic Surgery, Adult
Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY,
USA
| | - Michael P. Ast
- Department of Orthopedic Surgery, Adult
Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY,
USA
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LeBrun DG. Letter to the Editor: Editorial: Should Orthopaedic Residents Be Required to Do Research, or Would Critical Reading Programs Be a Better Use of Their Time? Clin Orthop Relat Res 2022; 480:1619-1620. [PMID: 35675566 PMCID: PMC9278945 DOI: 10.1097/corr.0000000000002270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Drake G LeBrun
- Resident, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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Chalmers BP, LeBrun DG, Lebowitz J, Chiu YF, Joseph AD, Gonzalez Della Valle A. The Effect of Preoperative Tramadol Use on Postoperative Opioid Prescriptions After Primary Total Hip and Knee Arthroplasty: An Institutional Experience of 11,000 Patients. J Arthroplasty 2022; 37:S465-S470. [PMID: 35240282 DOI: 10.1016/j.arth.2022.02.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/13/2022] [Accepted: 02/21/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Preoperative opioid use increases opioid consumption postoperatively, but the effect of tramadol is poorly understood. METHODS We retrospectively reviewed 11,667 patients undergoing primary unilateral THA and TKA at a single institution. Preoperatively, there were 8,201 opioid-naïve patients (70.3%), 1,315 on tramadol (11.3%), 1,408 on narcotics (12.1%) and 743 on narcotics and tramadol (6.3%). We compared morphine milligram equivalents (MMEs) used during hospitalization, prescribed at discharge, and refilled during the first 90 days. We used multivariate analysis to assess whether preoperative tramadol use was associated with increased number of refills and total refilled MMEs. RESULTS Total in-hospital MMEs and daily MMEs was lowest for the opioid naïve patients and significantly increased for the remaining three groups (total in-hospital use: 119, 152, 211, and 196 MMEs, respectively-P < .001) (daily in-hospital use: 66, 74, 100, and 86 MMEs, respectively-P < .001). Opioid refill rate was significantly higher for all patients who were not opioid naïve (32%, 42%, 41%, and 52%, respectively-P < .001). Total MMEs prescribed after discharge was lowest for opioid naïve patients (477, 528, 590 and 658, respectively-P < .001). Logistic and linear regression controlling for age, sex, history of anxiety/depression revealed that THA patients taking tramadol preoperatively were 2.5 times more likely to require post-discharge refills and refilled 80 additional MMEs than opioid naïve patients (P < .001). CONCLUSION Tramadol is not recommended for pain beforeTKA or THA, and surgeons and patients should be aware that it is associated with a substantial increase in postoperative opioid use.
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Affiliation(s)
- Brian P Chalmers
- Department of Orthopaedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - Drake G LeBrun
- Department of Orthopaedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - Juliana Lebowitz
- Department of Orthopaedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - Yu-Fen Chiu
- Biostatistics Core, Research Administration, Hospital for Special Surgery, New York, NY
| | - Amethia D Joseph
- Department of Orthopaedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - Alejandro Gonzalez Della Valle
- Department of Orthopaedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
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LeBrun DG, Salvati EA, Gonzalez Della Valle A. Multimodal Thromboprophylaxis in Patients With a History of Venous Thromboembolism Undergoing Primary and Revision Knee Arthroplasty. HSS J 2022; 18:212-218. [PMID: 35645638 PMCID: PMC9097001 DOI: 10.1177/15563316211055465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 10/03/2021] [Indexed: 02/07/2023]
Abstract
Background: Patients with a history of venous thromboembolism (VTE) undergoing total knee arthroplasty (TKA) are at a high risk of postoperative VTE. Purpose: In this high-risk population, we sought to evaluate the safety and efficacy of multimodal thromboprophylaxis. The regimen consisted of discontinuation of procoagulant medications, VTE risk stratification, regional anesthesia, rapid mobilization, perioperative use of pneumatic compression devices, vigorous ankle dorsiflexion during the recovery period, and chemoprophylaxis tailored to the patient's risk of VTE. Methods: We conducted a retrospective chart review of 141 consecutive patients with a history of VTE who underwent 177 elective TKA procedures between 2005 and 2019 by 2 arthroplasty surgeons at a single institution. The patients had a history of deep venous thrombosis (DVT) (n = 127; 72%), pulmonary embolism (PE) (n = 20; 11%), or both (n = 30; 17%). Postoperative chemoprophylaxis included aspirin (n = 20; 11%), anticoagulation (n = 135; 77%), or a combination of aspirin and anticoagulation (n = 21; 12%). Complications within 120 days, including VTE events, wound complications, bleeding, and unplanned readmissions, were recorded, as was 1-year mortality. Results: Five patients (2.8%) developed symptomatic DVT (3 distal, 2 proximal), and 4 patients (2.3%) developed symptomatic PE. The most common postdischarge complications were wound infection (n = 6; 3.4%) and stiffness requiring manipulation under anesthesia (n = 5; 2.8%). There was 1 emergency room visit and 13 unplanned readmissions; 3 patients developed intra-articular hematomas or prolonged wound drainage and recovered uneventfully. All patients were alive 1 year after surgery. Conclusion: The findings of this retrospective study suggest that multimodal prophylaxis may be safe and effective in patients with a history of VTE undergoing primary and revision TKA. More rigorous study is warranted.
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Affiliation(s)
- Drake G. LeBrun
- Hospital for Special Surgery, New York,
NY, USA,Drake G. LeBrun, MD, MPH, Hospital for
Special Surgery, 535 E 70th Street, New York, NY 10021, USA.
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18
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LeBrun DG, Nwachukwu BU, Buza SS, Gruber S, Marmor WA, Dennis ER, Shubin Stein BE. Particulated Juvenile Articular Cartilage and Matrix-Induced Autologous Chondrocyte Implantation Are Cost-Effective for Patellar Chondral Lesions. Arthroscopy 2022; 38:1252-1263.e3. [PMID: 34619304 DOI: 10.1016/j.arthro.2021.08.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 08/20/2021] [Accepted: 08/21/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the cost-effectiveness of nonoperative management, particulated juvenile allograft cartilage (PJAC), and matrix-induced autologous chondrocyte implantation (MACI) in the management of patellar chondral lesions. METHODS A Markov model was used to evaluate the cost-effectiveness of three strategies for symptomatic patellar chondral lesions: 1) nonoperative management, 2) PJAC, and 3) MACI. Model inputs (transition probabilities, utilities, and costs) were derived from literature review and an institutional cohort of 67 patients treated with PJAC for patellar chondral defects (mean age 26 years, mean lesion size 2.7 cm2). Societal and payer perspectives over a 15-year time horizon were evaluated. The principal outcome measure was the incremental cost-effectiveness ratio (ICER) using a $100,000/quality-adjusted life year (QALY) willingness-to-pay threshold. Sensitivity analyses were performed to assess the robustness of the model and the relative effects of variable estimates on base case conclusions. RESULTS From a societal perspective, nonoperative management, PJAC, and MACI cost $4,140, $52,683, and $83,073 and were associated with 5.28, 7.22, and 6.92 QALYs gained, respectively. PJAC and MACI were cost-effective relative to nonoperative management (ICERs $25,010/QALY and $48,344/QALY, respectively). PJAC dominated MACI in the base case analysis by being cheaper and more effective, but this was sensitive to the estimated effectiveness of both strategies. PJAC remained cost-effective if PJAC and MACI were considered equally effective. CONCLUSIONS In the management of symptomatic patellar cartilage defects, PJAC and MACI were both cost-effective compared to nonoperative management. Because of the need for one surgery instead of two, and less costly graft material, PJAC was cheaper than MACI. Consequently, when PJAC and MACI were considered equally effective, PJAC was more cost-effective than MACI. Sensitivity analyses accounting for the lack of robust long-term data for PJAC or MACI demonstrated that the cost-effectiveness of PJAC versus MACI depended heavily on the relative probabilities of yielding similar clinical results. LEVEL OF EVIDENCE III, economic and decision analysis.
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19
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LeBrun DG. CORR Insights®: Is Chemotherapy Associated with Improved Overall Survival in Patients with Dedifferentiated Chondrosarcoma? A SEER Database Analysis. Clin Orthop Relat Res 2022; 480:759-761. [PMID: 34870951 PMCID: PMC8923591 DOI: 10.1097/corr.0000000000002066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/05/2021] [Indexed: 01/31/2023]
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20
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DeFrancesco CJ, Tananbaum A, LeBrun DG, Fabricant PD. The Incidence of Pediatric Tibial Spine Fractures Is Greater and Peaks Later in Male Patients. Arthrosc Sports Med Rehabil 2022; 4:e639-e643. [PMID: 35494287 PMCID: PMC9042894 DOI: 10.1016/j.asmr.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 12/01/2021] [Indexed: 11/03/2022] Open
Abstract
Purpose Methods Results Conclusions Clinical Relevance
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21
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LeBrun DG, Sneag DB, Feinberg JH, McCarthy MM, Gulotta LV, Lee SK, Wolfe SW. Surgical Treatment of Iatrogenic Nerve Injury Following Arthroscopic Capsulolabral Repair. J Hand Surg Am 2021; 46:1121.e1-1121.e11. [PMID: 33902974 DOI: 10.1016/j.jhsa.2021.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 01/10/2021] [Accepted: 03/11/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Case reports of nerve injuries following arthroscopic capsulolabral repair emphasize the proximity of major nerves to the glenoid. This study describes preoperative localization using nerve-sensitive magnetic resonance imaging in a small cohort of patients with iatrogenic nerve injuries following arthroscopic capsulolabral repair and the outcomes of nerve repair in these patients. METHODS Cases of iatrogenic nerve injury following arthroscopic capsulolabral repair referred to 2 surgeons from January 2017 to December 2019 were identified. Clinical charts, electrodiagnostic testing, magnetic resonance imaging studies, and operative reports were reviewed. RESULTS Four cases of iatrogenic nerve injury were identified. The time to presentation to our institution ranged from 2 weeks to 8 years. The axillary nerves in 3 cases were tethered by a suture at the inferior glenoid, whereas 1 case had a suture tied around the radial and median nerves inferior to the glenohumeral joint capsule. One case underwent excision and nerve transfer, 1 underwent excision and nerve repair, and 2 underwent suture removal and neurolysis. Open and arthroscopic approaches, including a recently described approach to the axillary nerve in the "blind zone," were used. Three cases demonstrated good recovery of all affected motor and sensory functions after surgery. At the 10-month follow-up, 1 case had persistent weakness, but there was evidence of axonal regeneration on electrodiagnostic testing. CONCLUSIONS Arthroscopic capsulolabral repair places regional nerves, particularly the axillary nerve, at risk owing to their proximity to the joint capsule and inferior glenoid. Patients with neuropathic pain in the distribution of affected nerves with corresponding sensorimotor loss following arthroscopic capsulolabral surgery should undergo focused magnetic resonance imaging with nerve-sensitive sequences and electrodiagnostic testing to localize the injury. The use of multiple surgical windows to the axillary nerve in the "blind zone" enables full visualization for neurolysis, suture removal, and nerve repair or transfer. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.
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Affiliation(s)
- Drake G LeBrun
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY.
| | - Darryl B Sneag
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY
| | | | - Moira M McCarthy
- Department of Orthopedic Surgery, Sports Medicine, Hospital for Special Surgery, New York, NY
| | - Lawrence V Gulotta
- Department of Orthopedic Surgery, Sports Medicine, Hospital for Special Surgery, New York, NY
| | - Steve K Lee
- Department of Orthopedic Surgery, Hand and Upper Extremity, Hospital for Special Surgery, New York, NY
| | - Scott W Wolfe
- Department of Orthopedic Surgery, Hand and Upper Extremity, Hospital for Special Surgery, New York, NY
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22
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LeBrun DG. Residency Diary: Fourth Year-Milestones. Clin Orthop Relat Res 2021; 479:2597-2598. [PMID: 34677163 PMCID: PMC8726559 DOI: 10.1097/corr.0000000000002027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/05/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Drake G LeBrun
- Resident, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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23
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LeBrun DG, Shen TS, Bovonratwet P, Morgenstern R, Su EP. Hip Resurfacing vs Total Hip Arthroplasty in Patients Younger than 35 Years: A Comparison of Revision Rates and Patient-Reported Outcomes. Arthroplast Today 2021; 11:229-233. [PMID: 34692960 PMCID: PMC8516816 DOI: 10.1016/j.artd.2021.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 08/24/2021] [Accepted: 09/07/2021] [Indexed: 11/24/2022] Open
Abstract
Background Hip resurfacing arthroplasty (HRA) and total hip arthroplasty (THA) are two treatment options for end-stage degenerative hip conditions. The objective of this single-center retrospective cohort study was to compare implant survival and patient-reported outcomes (PROs) in young patients (≤35 years) who underwent HRA or THA. Methods All patients aged 35 years or younger who underwent HRA or THA with a single high-volume arthroplasty surgeon between 2004 and 2015 were reviewed. The sample included 33 THAs (26 patients) and 76 HRAs (65 patients). Five-year implant survival and minimum 2-year PROs were compared between patient cohorts. Results Three patients in the THA group (9%) were revised within 5 years for instability (n = 1), squeaking (n = 1), or squeaking with a ceramic liner fracture (n = 1). No patients who underwent HRA were revised. The University of California, Los Angeles, activity score, modified Harris Hip score, and Hip Dysfunction and Osteoarthritis Outcome Scores for Joint Replacement increased by 74%, 64%, and 49%, respectively, among all patients. Compared to the HRA cohort, patients who underwent THA had lower preoperative and postoperative University of California, Los Angeles, activity, modified Harris Hip score, and Hip Dysfunction and Osteoarthritis Outcome Scores for Joint Replacement scores, yet there were no differences in the absolute improvements in any of the three measures between the two groups. Conclusions Excellent functional outcomes were seen in young patients undergoing either HRA or THA. Although young patients undergoing THA started at lower preoperative baseline and postoperative PROs than patients undergoing HRA, both groups improved by an equal amount after surgery, suggesting that both HRA and THA afford a similar degree of potential improvement in a young population.
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Affiliation(s)
- Drake G LeBrun
- Department of Orthopaedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Tony S Shen
- Department of Orthopaedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Patawut Bovonratwet
- Department of Orthopaedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Rachelle Morgenstern
- Department of Orthopaedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Edwin P Su
- Department of Orthopaedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
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24
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LeBrun DG. CORR Insights®: Does Medical Students' Sense of Belonging Affect Their Interest in Orthopaedic Surgery Careers? A Qualitative Investigation. Clin Orthop Relat Res 2021; 479:2253-2255. [PMID: 34398856 PMCID: PMC8445584 DOI: 10.1097/corr.0000000000001833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 04/29/2021] [Indexed: 01/31/2023]
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25
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LeBrun DG, Konnaris MA, Ghahramani GC, Premkumar A, DeFrancesco CJ, Gruskay JA, Dvorzhinskiy A, Sandhu MS, Goldwyn EM, Mendias CL, Ricci WM. Increased Comorbidity Burden Among Hip Fracture Patients During the COVID-19 Pandemic in New York City. Geriatr Orthop Surg Rehabil 2021; 12:21514593211040611. [PMID: 34522445 PMCID: PMC8436002 DOI: 10.1177/21514593211040611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 07/26/2021] [Indexed: 12/14/2022] Open
Abstract
Background The coronavirus disease 19 (COVID-19) pandemic had a devastating effect on New York City in the spring of 2020. Several global reports suggested worse early outcomes among COVID-positive patients with hip fractures. However, there is limited data comparing baseline comorbidities among patients treated during the pandemic relative to those treated in non-pandemic conditions. Materials and Methods A multicenter retrospective cohort study was performed at two Level 1 Trauma centers and one orthopedic specialty hospital to assess demographics, comorbidities, and outcomes among 67 hip fracture patients treated (OTA/AO 31, 32.1) during the peak of the COVID-19 pandemic in New York City (March 20, 2020 to April 24, 2020), including 9 who were diagnosed with COVID-19. These patients were compared to a cohort of 76 hip fracture patients treated 1 year prior (March 20, 2019 to April 24, 2019). Baseline demographics, comorbidities, treatment characteristics, and respiratory symptomatology were evaluated. The primary outcome was inpatient mortality. Results Relative to patients treated in 2019, patients with hip fractures during the pandemic had worse Charlson Comorbidity Indices (median 5.0 vs 6.0, P = .03) and American Society of Anesthesiologists (ASA) scores (mean 2.4 vs 2.7, P = .04). Patients during the COVID-19 pandemic were more likely to have decreased ambulatory status (P<.01) and a smoking history (P = .04). Patients in 2020 had longer inpatient stays (median 5 vs 7 days, P = .01), and were more likely to be discharged home (61% vs 9%, P<.01). Inpatient mortality was significantly increased during the COVID-19 pandemic (12% vs 0%, P = .002). Conclusions Patients with hip fractures during the COVID-19 pandemic had worse comorbidity profiles and decreased functional status compared to patients treated the year prior. This information may be relevant in negotiations regarding reimbursement for cost of care of hip fracture patients with COVID-19, as these patients may require more expensive care.
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Affiliation(s)
- Drake G LeBrun
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | | | - Gregory C Ghahramani
- HSS Research Institute, Hospital for Special Surgery, New York, NY, USA.,Department of Physiology and Biophysics, Weill Cornell Medical College, New York, NY, USA
| | - Ajay Premkumar
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Chris J DeFrancesco
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Jordan A Gruskay
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Aleksey Dvorzhinskiy
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | | | - Elan M Goldwyn
- Department of Orthopaedic Surgery, Orthopaedic Trauma Service, NewYork Presbyterian Queens, Flushing, NY, USA
| | - Christopher L Mendias
- HSS Research Institute, Hospital for Special Surgery, New York, NY, USA.,Department of Physiology and Biophysics, Weill Cornell Medical College, New York, NY, USA
| | - William M Ricci
- Department of Orthopaedic Surgery, Orthopaedic Trauma Service, Hospital for Special Surgery, New York, NY, USA
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26
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LeBrun DG. Residency Diary: Third Year-Fatherhood. Clin Orthop Relat Res 2021; 479:1677-1678. [PMID: 34156988 PMCID: PMC8277273 DOI: 10.1097/corr.0000000000001885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 06/08/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Drake G LeBrun
- Resident, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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27
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LeBrun DG, Malfer C, Wilson M, Carroll KM, Wang, MS V, Mayman DJ, Cross MB, Alexiades MM, Jerabek SA, Cushner FD, Vigdorchik JM, Haas SB, Ast MP. Telemedicine in an Outpatient Arthroplasty Setting During the COVID-19 Pandemic: Early Lessons from New York City. HSS J 2021; 17:25-30. [PMID: 33967638 PMCID: PMC8077980 DOI: 10.1177/1556331620972659] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 10/07/2020] [Indexed: 12/22/2022]
Abstract
Background: The early months of the coronavirus disease 19 (COVID-19) pandemic in New York City led to a rapid transition of non-essential in-person health care, including outpatient arthroplasty visits, to a telemedicine context. Questions/Purposes: Based on our initial experiences with telemedicine in an outpatient arthroplasty setting, we sought to determine early lessons learned that may be applicable to other providers adopting or expanding telemedicine services. Methods: A cross-sectional study was performed by surveying all patients undergoing telemedicine visits with 8 arthroplasty surgeons at 1 orthopedic specialty hospital in New York City from April 8 to May 19, 2020. Descriptive statistics were used to analyze demographic data, satisfaction with the telemedicine visit, and positive and negative takeaways. Results: In all, 164 patients completed the survey. The most common reasons for the telemedicine visit were short-term (less than 6 months), postoperative appointment (n = 88; 54%), and new patient consultation (n = 32; 20%). A total of 84 patients (51%) noted a reduction in expenses versus standard outpatient care. Several positive themes emerged from patient feedback, including less anxiety and stress related to traveling (n = 82; 50%), feeling more at ease in a familiar environment (n = 54; 33%), and the ability to assess postoperative home environment (n = 13; 8%). However, patients also expressed concerns about the difficulty addressing symptoms in the absence of an in-person examination (n = 28; 17%), a decreased sense of interpersonal connection with the physician (n = 20; 12%), and technical difficulties (n = 14; 9%). Conclusions: Patients were satisfied with their telemedicine experience during the COVID-19 pandemic; however, we identified several areas amenable to improvement. Further study is warranted.
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Gruskay JA, Dvorzhinskiy A, Konnaris MA, LeBrun DG, Ghahramani GC, Premkumar A, DeFrancesco CJ, Mendias CL, Ricci WM. Universal Testing for COVID-19 in Essential Orthopaedic Surgery Reveals a High Percentage of Asymptomatic Infections. J Bone Joint Surg Am 2020; 102:1379-1388. [PMID: 32516279 DOI: 10.2106/jbjs.20.01053] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The long incubation period and asymptomatic spread of COVID-19 present considerable challenges for health-care institutions. The identification of infected individuals is vital to prevent the spread of illness to staff and other patients as well as to identify those who may be at risk for disease-related complications. This is particularly relevant with the resumption of elective orthopaedic surgery around the world. We report the results of a universal testing protocol for COVID-19 in patients undergoing orthopaedic surgery during the coronavirus pandemic and to describe the postoperative course of asymptomatic patients who were positive for COVID-19. METHODS A retrospective review of adult operative cases between March 25, 2020, and April 24, 2020, at an orthopaedic specialty hospital in New York City was performed. Initially, a screening questionnaire consisting of relevant signs and symptoms (e.g., fever, cough, shortness of breath) or exposure dictated the need for nasopharyngeal swab real-time quantitative polymerase chain reaction (RT-PCR) testing for all admitted patients. An institutional policy change occurred on April 5, 2020, that indicated nasopharyngeal swab RT-PCR testing for all orthopaedic admissions. Screening and testing data for COVID-19 as well as relevant imaging, laboratory values, and postoperative complications were reviewed for all patients. RESULTS From April 5, 2020, to April 24, 2020, 99 patients underwent routine nasopharyngeal swab testing for COVID-19 prior to their planned orthopaedic surgical procedure. Of the 12.1% of patients who tested positive for COVID-19, 58.3% were asymptomatic. Three asymptomatic patients developed postoperative hypoxia, with 2 requiring intubation. The negative predictive value of using the signs and symptoms of disease to predict a negative test result was 91.4% (95% confidence interval [CI], 81.0% to 97.1%). Including a positive chest radiographic finding as a screening criterion did not improve the negative predictive value of screening (92.5% [95% CI, 81.8% to 97.9%]). CONCLUSIONS A protocol for universal testing of all orthopaedic surgery admissions at 1 hospital in New York City during a 3-week period revealed a high rate of COVID-19 infections. Importantly, the majority of these patients were asymptomatic. Using chest radiography did not significantly improve the negative predictive value of screening. These results have important implications as hospitals anticipate the resumption of elective surgical procedures. LEVEL OF EVIDENCE Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jordan A Gruskay
- Department of Orthopaedic Surgery (J.A.G., A.D., D.G.L., A.P., C.J.D., and W.M.R.) and the HSS Research Institute (M.A.K., G.C.G., and C.L.M.), Hospital for Special Surgery, New York, NY
| | - Aleksey Dvorzhinskiy
- Department of Orthopaedic Surgery (J.A.G., A.D., D.G.L., A.P., C.J.D., and W.M.R.) and the HSS Research Institute (M.A.K., G.C.G., and C.L.M.), Hospital for Special Surgery, New York, NY
| | - Maxwell A Konnaris
- Department of Orthopaedic Surgery (J.A.G., A.D., D.G.L., A.P., C.J.D., and W.M.R.) and the HSS Research Institute (M.A.K., G.C.G., and C.L.M.), Hospital for Special Surgery, New York, NY
| | - Drake G LeBrun
- Department of Orthopaedic Surgery (J.A.G., A.D., D.G.L., A.P., C.J.D., and W.M.R.) and the HSS Research Institute (M.A.K., G.C.G., and C.L.M.), Hospital for Special Surgery, New York, NY
| | - Gregory C Ghahramani
- Department of Orthopaedic Surgery (J.A.G., A.D., D.G.L., A.P., C.J.D., and W.M.R.) and the HSS Research Institute (M.A.K., G.C.G., and C.L.M.), Hospital for Special Surgery, New York, NY.,Department of Physiology & Biophysics, Weill Cornell Medical College, New York, NY
| | - Ajay Premkumar
- Department of Orthopaedic Surgery (J.A.G., A.D., D.G.L., A.P., C.J.D., and W.M.R.) and the HSS Research Institute (M.A.K., G.C.G., and C.L.M.), Hospital for Special Surgery, New York, NY
| | - Christopher J DeFrancesco
- Department of Orthopaedic Surgery (J.A.G., A.D., D.G.L., A.P., C.J.D., and W.M.R.) and the HSS Research Institute (M.A.K., G.C.G., and C.L.M.), Hospital for Special Surgery, New York, NY
| | - Christopher L Mendias
- Department of Orthopaedic Surgery (J.A.G., A.D., D.G.L., A.P., C.J.D., and W.M.R.) and the HSS Research Institute (M.A.K., G.C.G., and C.L.M.), Hospital for Special Surgery, New York, NY.,Department of Physiology & Biophysics, Weill Cornell Medical College, New York, NY
| | - William M Ricci
- Department of Orthopaedic Surgery (J.A.G., A.D., D.G.L., A.P., C.J.D., and W.M.R.) and the HSS Research Institute (M.A.K., G.C.G., and C.L.M.), Hospital for Special Surgery, New York, NY
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LeBrun DG, Konnaris MA, Ghahramani GC, Premkumar A, DeFrancesco CJ, Gruskay JA, Dvorzhinskiy A, Sandhu MS, Goldwyn EM, Mendias CL, Ricci WM. Hip Fracture Outcomes During the COVID-19 Pandemic: Early Results From New York. J Orthop Trauma 2020; 34:403-410. [PMID: 32482977 PMCID: PMC7302077 DOI: 10.1097/bot.0000000000001849] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate inpatient outcomes among patients with hip fracture treated during the COVID-19 pandemic in New York City. DESIGN Multicenter retrospective cohort study. SETTING One Level 1 trauma center and one orthopaedic specialty hospital in New York City. PATIENTS/PARTICIPANTS Fifty-nine consecutive patients (average age 85 years, range: 65-100 years) treated for a hip fracture (OTA/AO 31, 32.1) over a 5-week period, March 20, 2020, to April 24, 2020, during the height of the COVID-19 crisis. MAIN OUTCOME MEASUREMENTS COVID-19 infection status was used to stratify patients. The primary outcome was inpatient mortality. Secondary outcomes were admission to the intensive care unit, unexpected intubation, pneumonia, deep vein thrombosis, pulmonary embolus, myocardial infarction, cerebrovascular accident, urinary tract infection, and transfusion. Baseline demographics, comorbidities, treatment characteristics, and COVID-related symptomatology were also evaluated. RESULTS Ten patients (15%) tested positive for COVID-19 (COVID+) (n = 9; 7 preoperatively and 2 postoperatively) or were presumed positive (n = 1), 40 (68%) patients tested negative, and 9 (15%) patients were not tested in the primary hospitalization. American Society of Anesthesiologists' scores were higher in the COVID+ group (d = -0.83; P = 0.04); however, the Charlson Comorbidity Index was similar between the study groups (d = -0.17; P = 0.63). Inpatient mortality was significantly increased in the COVID+ cohort (56% vs. 4%; odds ratio 30.0, 95% confidence interval 4.3-207; P = 0.001). Including the one presumed positive case in the COVID+ cohort increased this difference (60% vs. 2%; odds ratio 72.0, 95% confidence interval 7.9-754; P < 0.001). CONCLUSIONS Hip fracture patients with concomitant COVID-19 infection had worse American Society of Anesthesiologists' scores but similar baseline comorbidities with significantly higher rates of inpatient mortality compared with those without concomitant COVID-19 infection. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Drake G. LeBrun
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | | | - Gregory C. Ghahramani
- HSS Research Institute, Hospital for Special Surgery, New York, NY
- Department of Physiology and Biophysics, Weill Cornell Medical College, New York, NY
| | - Ajay Premkumar
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | | | - Jordan A. Gruskay
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | | | | | - Elan M. Goldwyn
- Department of Orthopaedic Surgery, Orthopaedic Trauma Service, NewYork Presbyterian Queens, Flushing, NY; and
| | - Christopher L. Mendias
- HSS Research Institute, Hospital for Special Surgery, New York, NY
- Department of Physiology and Biophysics, Weill Cornell Medical College, New York, NY
| | - William M. Ricci
- Department of Orthopaedic Surgery, Orthopaedic Trauma Service, Hospital for Special Surgery, New York, NY
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Meadows JW, Al Imran TMT, LeBrun DG, Mannan MI, Sharraf S, Gaznavee ZZ, McQueen KKA. Anesthesia Infrastructure and Resources in Bangladesh. Anesth Analg 2020; 130:233-239. [PMID: 31688078 DOI: 10.1213/ane.0000000000004493] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Monitoring improvements in nationwide anesthesia capacity over time is critical to ensuring that population anesthesia needs are being met and identifying areas for targeted health systems interventions. Anesthesia resources in Bangladesh were previously measured using a cross-sectional nationwide hospital-based survey in 2012. No follow-up studies have been conducted since then. METHODS A follow-up cross-sectional study was performed in 16 public hospitals; 8 of which are public district hospitals, and 8 are medical college (tertiary) hospitals in Bangladesh. A survey tool assessing hospital anesthesia capacity, developed by Vanderbilt University Medical Center, was utilized. Nationwide data were obtained from the Ministry of Health and Family Welfare and from the Bangladesh Society of Anaesthesiologists. Institutional Review Board approvals were obtained in the United States and Bangladesh, and informed consent was waived. RESULTS Bangladesh has 952 anesthesiologists (0.58 anesthesiologists per 100,000 people), which represents a modest increase from 850 anesthesiologists in 2012. Significant improvements in electricity and clean water availability have occurred since the 2012 survey. Severe deficiencies in patient safety and monitoring equipment (eg, pulse oximetry, electrocardiography, blood pressure, anesthesia machines, and intubation materials) were noted, primarily at the district hospital level. CONCLUSIONS Despite modest improvements in certain anesthesia metrics over the past several years, the public health care system in Bangladesh still suffers from substantial deficiencies in anesthesia care.
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Affiliation(s)
- Jonathan W Meadows
- From the Department of Emergency Medicine, Merit Health Wesley, Hattiesburg, Mississippi
| | | | | | | | - Samin Sharraf
- Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | | | - Kelly K A McQueen
- Department of Anaesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
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LeBrun DG, Del Rosario J, Kelly JD, Wren SM, Spiegel DA, Mkandawire N, Gosselin RA, Kushner AL. An Estimation of the Burden of Sports Injuries among African Adolescents. J Epidemiol Glob Health 2019; 8:171-175. [PMID: 30864759 PMCID: PMC7377560 DOI: 10.2991/j.jegh.2017.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 10/25/2017] [Indexed: 11/06/2022] Open
Abstract
The extent to which sports injuries contribute to the burden of injury among adolescents in low- and middle-income countries (LMICs) is unknown. The goal of this study was to estimate the incidence of sports injuries among adolescents in Africa. Data from the World Health Organization Global School-Based Student Health surveys were used to estimate the annual number of African adolescents sustaining sports injuries. Gender-stratified injury rates were calculated and applied to every African country’s adolescent population to estimate country-specific and continent-wide injury totals. A total of 21,858 males and 24,691 females from 14 countries were included in the analysis. Country-specific annual sports injury rates ranged from 13.5% to 38.1% in males and 5.2% to 20.2% in females. Weighted average sports injury rates for males and females were 23.7% (95% CI 23.1%–24.2%) and 12.5% (95% CI 12.1%–12.9%), respectively. When these rates were extrapolated to the adolescent populations of the African continent, an estimated 15,477,798 (95% CI 15,085,955–15,804,333) males and 7,943,625 (95% CI 7,689,429–8,197,821) females sustained sports injuries. Our findings suggest that over 23 million African adolescents sustained sports injuries annually. Further work will help to more precisely define the burden of sports injuries in LMICs and the role that surgery can play in mitigating this burden.
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Affiliation(s)
- Drake G LeBrun
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA.,Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd., Jordan Medical Education Center, Philadelphia, PA 19104, USA
| | - Julius Del Rosario
- School of Engineering and Applied Science, University of Pennsylvania, 220 South 33rd Street, 107 Towne Building, Philadelphia, PA 19104, USA
| | - John D Kelly
- Division of Sports Medicine, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, 235 S 33rd St, Philadelphia, PA 19104, USA
| | - Sherry M Wren
- Department of Surgery, Stanford University, School of Medicine, 300 Pasteur Dr, Stanford, CA 94305, USA
| | - David A Spiegel
- Department of Orthopaedic Surgery, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Nyengo Mkandawire
- Department of Orthopaedic Surgery, University of Malawi, College of Medicine, P/B 360, Chichiri, Blantyre 3, Malawi.,Flinders University School of Medicine, Sturt Rd, Bedford Park, South Australia 5042, Australia
| | - Richard A Gosselin
- Institute of Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA
| | - Adam L Kushner
- Department of Surgery, Columbia University College of Physicians and Surgeons, 177 Fort Washington Ave., New York, NY 10032, USA.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA.,Surgeons OverSeas, 99 Avenue B, Suite 5E, New York, NY 10009, USA
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LeBrun DG. Residency Diary: Intern Year (January to March)-Relearning Everything. Clin Orthop Relat Res 2019; 477:1294-1295. [PMID: 31094838 PMCID: PMC6554118 DOI: 10.1097/corr.0000000000000790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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LeBrun DG, Tran T, Wypij D, Kocher MS. How Often Do Orthopaedic Matched Case-Control Studies Use Matched Methods? A Review of Methodological Quality. Clin Orthop Relat Res 2019; 477:655-662. [PMID: 30614911 PMCID: PMC6382197 DOI: 10.1097/corr.0000000000000612] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 11/29/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Case-control studies are a common method of analyzing associations between clinical outcomes and potential risk factors. Matching cases to controls based on known confounding variables can decrease bias and allow investigators to assess the association of interest with increased precision. However, the analysis of matched data generally requires matched statistical methods, and failure to use these methods can lead to imprecise or biased results. The appropriate use of matched statistical methods in orthopaedic case-control studies has not been documented. QUESTIONS/PURPOSES (1) What proportion of matched orthopaedic case-control studies use the appropriate matched statistical analyses? (2) What study factors are associated with the use of appropriate matched statistical tests? METHODS All matched case-control studies published in the top 10 orthopaedic journals according to impact factor from 2007 to 2016 were identified by literature review. Studies using appropriate statistical techniques were identified by two independent evaluators; discrepancies were settled by a third evaluator, all with advanced training in biostatistics. The number of studies using appropriate matched statistical methods was compared with the number of studies reviewed. Logistic regression was used to identify key study factors (including journal, publication year, rank according to impact factor, number of matching factors, number of controls per case, and the inclusion of a biostatistician coauthor) associated with the use of appropriate statistical methods. Three hundred nineteen articles that were initially classified as case-control studies were screened, yielding 83 matched case-control studies. One hundred two of the excluded articles were cohort or cross-sectional studies that were misclassified as case-control studies. The median number of matching factors was 3.0 (range, 1-10) and the median number of controls per case was 1.0 (range, 0.5-6.0). Thirty studies (36%) had a statistician coauthor. RESULTS Thirty of the 83 included studies (36%) used appropriately matched methods throughout, 11 (13%) used matched methods for multivariable but not univariable analyses, and 42 (51%) used only unmatched methods, which we considered inappropriate. After controlling for the number of controls per case and publication year, we found that the inclusion of a statistician coauthor (70% versus 38%; odds ratio, 3.6; 95% confidence interval, 1.4-20.3; p = 0.01) and journal were associated with the use of appropriate methods. CONCLUSIONS Although matched case-control studies can be statistically more efficient study designs, in that they are capable of generating more precise effect size estimates than other kinds of retrospective research, most orthopaedic case-control studies use inappropriate statistical methods in their analyses. Additionally, the high degree of study misclassification indicates a need to more rigorously define differences among case-control, cohort, and cross-sectional study designs. CLINICAL RELEVANCE Failing to use matched statistical tests may lead to imprecise and/or biased effect estimates, which may lead to a tendency to overestimate or underestimate associations between possible risk factors and clinically relevant outcomes. Orthopaedic researchers should be cognizant of the risks and benefits of matching and should consult individuals with biostatistical expertise as needed to ensure that their statistical methods are appropriate and methodologically rigorous.
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Affiliation(s)
- Drake G LeBrun
- D. G. LeBrun, Hospital for Special Surgery, New York, NY, USA D. G. LeBrun, T. Tran, D. Wypij , Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA T. Tran, Alpert Medical School of Brown University, Providence, RI, USA M. S. Kocher, Division of Sports Medicine, Boston Children's Hospital, Boston, MA, USA
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Abstract
Background: Orthopaedic research may involve multiple observations from the same patient because of bilateral joint involvement, multiple disease sites, or recurrent disease episodes. These situations violate statistical independence and need to be accounted for via appropriate statistical techniques. Failing to account for nonindependence may lead to biased and overly precise effect estimates. Purpose: To determine the degree to which orthopaedic sports medicine studies analyze dependent observations and the proportion of these failing to account for nonindependence. Study Design: Cross-sectional study. Methods: Clinical studies published in The American Journal of Sports Medicine from 2012 to 2017 were reviewed. Studies reporting nonindependent observations because of multiple extremity involvement or multiple disease episodes were identified. Methods to account for nonindependence were recorded. Studies violating the assumption of independence were identified and stratified by study design, level of evidence, body part involved, and inclusion of a statistician coauthor. Univariate logistic regression was used to determine whether these factors were associated with violations of statistical independence. Results: After screening 1016 articles, 886 clinical studies were reviewed. A total of 135 (15%) studies analyzed dependent observations, and 111 (82%) of these failed to account for nonindependence. Relative to the knee, studies of the hip (odds ratio [OR], 0.21; P = .02) and the thigh or leg (OR, 0.03; P = .004) were less likely to violate statistical independence. Study design (P = .03) was also associated with violations of statistical independence. Among studies that analyzed dependent observations, the median proportion of dependent observations relative to the total number of observations in each study was 0.07 (interquartile range, 0.04-0.12). Conclusion: The analysis of dependent observations is common in the orthopaedic sports literature, but most studies do not adjust for nonindependence in these situations. Investigators should be aware of incorrect inferences arising from nonindependence and how to statistically adjust for dependent data.
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Affiliation(s)
- Drake G LeBrun
- Hospital for Special Surgery, New York, New York, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
| | - Tram Tran
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA.,Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - David Wypij
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
| | - Mininder S Kocher
- Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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LeBrun DG, del Rosario J, Kelly JD, Wren SM, Spiegel DA, Mkandawire N, Gosselin RA, Kushner AL. An Estimation of the Burden of Sports Injuries among African Adolescents. J Epidemiol Glob Health 2018. [DOI: 10.1016/j.jegh.2017.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Drake G. LeBrun
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd., Jordan Medical Education Center, Philadelphia, PA 19104, USA
| | - Julius del Rosario
- School of Engineering and Applied Science, University of Pennsylvania, 220 South 33rd Street, 107 Towne Building, Philadelphia, PA 19104, USA
| | - John D. Kelly
- Division of Sports Medicine, Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, 235 S 33rd St, Philadelphia, PA 19104, USA
| | - Sherry M. Wren
- Department of Surgery, Stanford University, School of Medicine, 300 Pasteur Dr, Stanford, CA 94305, USA
| | - David A. Spiegel
- Department of Orthopaedic Surgery, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Nyengo Mkandawire
- Department of Orthopaedic Surgery, University of Malawi, College of Medicine, P/B 360, Chichiri, Blantyre 3, Malawi
- Flinders University School of Medicine, Sturt Rd, Bedford Park, South Australia 5042, Australia
| | - Richard A. Gosselin
- Institute of Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA
| | - Adam L. Kushner
- Department of Surgery, Columbia University College of Physicians and Surgeons, 177 Fort Washington Ave., New York, NY 10032, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
- Surgeons OverSeas, 99 Avenue B, Suite 5E, New York, NY 10009, USA
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LeBrun DG, Talwar D, Pham TA, Banskota B, Spiegel DA. Predictors of healthcare seeking delays among children with chronic musculoskeletal disorders in Nepal. J Epidemiol Glob Health 2017; 7:299-304. [PMID: 29110873 PMCID: PMC7384576 DOI: 10.1016/j.jegh.2017.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 08/14/2017] [Accepted: 10/02/2017] [Indexed: 11/10/2022] Open
Abstract
Background: Healthcare seeking behaviors among children with musculoskeletal disorders are poorly understood. We sought to analyze healthcare seeking delays among children with chronic musculoskeletal conditions in Nepal and identify predictors of clinically significant delays. Methods: A cross-sectional study was conducted at a large pediatric musculoskeletal rehabilitation center in Nepal. Baseline sociodemographic data and healthcare seeking behaviors were assessed via interviews with 75 randomly selected caregivers. Delays of at least 3 months between disease recognition and presentation to a health worker were considered clinically significant. Predictors of significant delay were assessed via multivariable logistic regression. Results: Clubfoot was the most common condition seen in the study sample (N = 33; 37%). Mean and median presentation delays were 33 months and 14 months, respectively. Sixty-seven percent of children were delayed at least 3 months and 40% were delayed at least 2 years. Caregiver occupation in agriculture or unskilled labor was associated with an increased risk of delayed presentation (adjusted OR = 4.05; 95% CI: 1.36–12.09). Conclusions: Children with chronic musculoskeletal disorders in Nepal face significant delays in accessing healthcare. This poses a major clinical problem as the delayed diagnosis and treatment of childhood musculoskeletal disorders can complicate management options and decrease long-term quality of life.
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Affiliation(s)
- Drake G LeBrun
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Divya Talwar
- Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Tuyetnhi A Pham
- The Wharton School, University of Pennsylvania, Philadelphia, PA, USA.
| | - Bibek Banskota
- Department of Orthopaedics, Hospital and Rehabilitation Centre for Disabled Children, Banepa, Nepal.
| | - David A Spiegel
- Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Orthopaedics, Hospital and Rehabilitation Centre for Disabled Children, Banepa, Nepal.
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Knowlton LM, Banguti P, Chackungal S, Chanthasiri T, Chao TE, Dahn B, Derbew M, Dhar D, Esquivel MM, Evans F, Hendel S, LeBrun DG, Notrica M, Saavedra-Pozo I, Shockley R, Uribe-Leitz T, Vannavong B, McQueen KA, Spain DA, Weiser TG. A geospatial evaluation of timely access to surgical care in seven countries. Bull World Health Organ 2017; 95:437-444. [PMID: 28603310 PMCID: PMC5463808 DOI: 10.2471/blt.16.175885] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 10/19/2016] [Accepted: 01/13/2017] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To assess the consistent availability of basic surgical resources at selected facilities in seven countries. METHODS In 2010-2014, we used a situational analysis tool to collect data at district and regional hospitals in Bangladesh (n = 14), the Plurinational State of Bolivia (n = 18), Ethiopia (n = 19), Guatemala (n = 20), the Lao People's Democratic Republic (n = 12), Liberia (n = 12) and Rwanda (n = 25). Hospital sites were selected by pragmatic sampling. Data were geocoded and then analysed using an online data visualization platform. Each hospital's catchment population was defined as the people who could reach the hospital via a vehicle trip of no more than two hours. A hospital was only considered to show consistent availability of basic surgical resources if clean water, electricity, essential medications including intravenous fluids and at least one anaesthetic, analgesic and antibiotic, a functional pulse oximeter, a functional sterilizer, oxygen and providers accredited to perform surgery and anaesthesia were always available. FINDINGS Only 41 (34.2%) of the 120 study hospitals met the criteria for the provision of consistent basic surgical services. The combined catchments of the study hospitals in each study country varied between 3.3 million people in Liberia and 151.3 million people in Bangladesh. However, the combined catchments of the study hospitals in each study country that met the criteria for the provision of consistent basic surgical services were substantially smaller and varied between 1.3 million in Liberia and 79.2 million in Bangladesh. CONCLUSION Many study facilities were deficient in the basic infrastructure necessary for providing basic surgical care on a consistent basis.
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Affiliation(s)
- Lisa M Knowlton
- Department of Surgery, Division of General Surgery, Stanford University School of Medicine, 300 Pasteur Drive, S067, Stanford, CA 94305, United States of America (USA)
| | - Paulin Banguti
- Department of Anaesthesia, University of Rwanda, Butare, Rwanda
| | | | - Traychit Chanthasiri
- Department of Anaesthesia, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
| | - Tiffany E Chao
- Department of Surgery, Massachusetts General Hospital, Boston, USA
| | - Bernice Dahn
- Ministry of Health and Social Welfare, Monrovia, Liberia
| | - Milliard Derbew
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Debashish Dhar
- National Institute of Diseases of Chest and Hospital, Dhaka, Bangladesh
| | - Micaela M Esquivel
- Department of Surgery, Division of General Surgery, Stanford University School of Medicine, 300 Pasteur Drive, S067, Stanford, CA 94305, United States of America (USA)
| | - Faye Evans
- Department of Anesthesiology, Boston Children’s Hospital, Boston, USA
| | - Simon Hendel
- Department of Anaesthesiology, The Alfred Hospital, Melbourne, Australia
| | - Drake G LeBrun
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | | | - Iracema Saavedra-Pozo
- Department of Surgery, Caja Nacional de Salud Hospital, La Paz, Plurinational State of Bolivia
| | - Ross Shockley
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, USA
| | - Tarsicio Uribe-Leitz
- Department of Surgery, Division of General Surgery, Stanford University School of Medicine, 300 Pasteur Drive, S067, Stanford, CA 94305, United States of America (USA)
| | - Boualy Vannavong
- Department of Anaesthesia, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
| | - Kelly A McQueen
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, USA
| | - David A Spain
- Department of Surgery, Division of General Surgery, Stanford University School of Medicine, 300 Pasteur Drive, S067, Stanford, CA 94305, United States of America (USA)
| | - Thomas G Weiser
- Department of Surgery, Division of General Surgery, Stanford University School of Medicine, 300 Pasteur Drive, S067, Stanford, CA 94305, United States of America (USA)
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Dong H, Zhao Z, LeBrun DG, Michaely P. Identification of roles for H264, H306, H439, and H635 in acid-dependent lipoprotein release by the LDL receptor. J Lipid Res 2016; 58:364-374. [PMID: 27895090 DOI: 10.1194/jlr.m070938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 11/19/2016] [Indexed: 11/20/2022] Open
Abstract
Lipoproteins internalized by the LDL receptor (LDLR) are released from this receptor in endosomes through a process that involves acid-dependent conformational changes in the receptor ectodomain. How acidic pH promotes this release process is not well understood. Here, we assessed roles for six histidine residues for which either genetic or structural data suggested a possible role in the acid-responsiveness of the LDLR. Using assays that measured conformational change, acid-dependent lipoprotein release, LDLR recycling, and net lipoprotein uptake, we show that H635 plays important roles in acid-dependent conformational change and lipoprotein release, while H264, H306, and H439 play ancillary roles in the response of the LDLR to acidic pH.
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Affiliation(s)
- Hongyun Dong
- Department of Cell Biology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Zhenze Zhao
- Department of Cell Biology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Drake G LeBrun
- Department of Cell Biology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Peter Michaely
- Department of Cell Biology, University of Texas Southwestern Medical Center, Dallas, TX
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Knowlton LM, Esquivel M, Uribe-Leitz T, Mcqueen K, Chackungal S, LeBrun DG, Chao TE, Weiser TG, Spain DA. A Multinational Evaluation of Timely Access to Basic Surgical Services Using Geospatial Analyses. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.08.296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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LeBrun DG, Chackungal S, Chao TE, Knowlton LM, Linden AF, Notrica MR, Solis CV, McQueen KK. Prioritizing essential surgery and safe anesthesia for the Post-2015 Development Agenda: Operative capacities of 78 district hospitals in 7 low- and middle-income countries. Surgery 2014; 155:365-73. [DOI: 10.1016/j.surg.2013.10.008] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 10/08/2013] [Indexed: 11/15/2022]
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