The Drivers of Persistent Opioid Use and Its Impact on Healthcare Utilization After Elective Spine Surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to determine the incidence of and risk factors for persistent opioid use after elective cervical and lumbar spine procedures and to quantify postoperative healthcare utilization in this patient population.

METHODS

Patients were retrospectively identified who underwent elective spine surgery for either cervical or lumbar degenerative pathology between November 1, 2013, and September 30, 2018, at a single academic center. Patients were split into 2 cohorts, including patients with and without opioid use at 180-days postoperatively. Baseline patient demographics, underlying comorbidities, surgical variables, and preoperative/postoperative opioid use were assessed. Health resource utilization metrics within 1 year postoperatively (ie, imaging studies, emergency and urgent care visits, hospital readmissions, opioid prescriptions, etc.) were compared between these 2 groups.

RESULTS

583 patients met inclusion criteria, of which 16.6% had opioid persistence after surgery. Opioid persistence was associated with ASA score ≥3 (P = .004), diabetes (P = .019), class I obesity (P = .012), and an opioid prescription in the 60 days prior to surgery (P = .006). Independent risk factors for opioid persistence assessed via multivariate regression included multi-level lumbar fusion (RR = 2.957), cervical central stenosis (RR = 2.761), and pre-operative opioid use (RR = 2.668). Opioid persistence was associated with higher rates of health care utilization, including more radiographs (P < .001), computed tomography (CT) scans (.007), magnetic resonance imaging (MRI) studies (P = .014), emergency department (ED) visits (.009), pain medicine referrals (P < .001), and spinal injections (P = .003).

CONCLUSIONS

Opioid persistence is associated with higher rates of health care utilization within 1 year after elective spine surgery.

Characteristics of Team Physicians in the National Football League: The Road to Success and a Call for Diversity

Background

The role of team physician (TP) in professional sports is a highly coveted position within sports medicine. There is currently limited research on the demographic characteristics of TPs within the National Football League (NFL).

Purpose

To identify demographic characteristics and educational backgrounds of NFL head TPs (HTPs) and assistant TPs (ATPs).

Study Design

Cross-sectional study.

Methods

A list of TPs was identified through the National Football League Physicians Society (NFLPS). Variables investigated include age, gender, race, medical specialty, location and year of residency and fellowship training, leadership among medical societies and editorial boards, academic rank, and personal Scopus Hirsch index (h-index). Linear regression was performed to determine correlation, and t tests were used to assess differences in the h-index.

Results

Of the 170 TPs, 21.2% were HTPs and 78.8% were ATPs. TPs were 97.6% male, 91.2% were non-Hispanic White, and 60% had attained an academic rank. The mean ages of the HTPs and ATPs were a 56.2 ± 9.6 and 52.6 ± 9.6 years, respectively (P = .047). Among orthopaedic surgeons, the most common subspecialties were sports medicine (70.5%), foot and ankle (7.6%), and spine (5.7%). Of the TPs, 48.2% and 32.9% worked for a team in the same state in which they graduated residency and fellowship, respectively. HTPs and ATPs had been in the NFLPS for a mean of 16.9 ± 10.8 and 8.8 ± 8.3 years, respectively (P < .001). Further, TPs holding an academic rank had a mean h-index of 14.0 ± 19.3, while those without an academic rank had a mean h-index of 6.2 ± 8.8 (P < .01). HTPs and ATPs had mean h-indices of 15.7 ± 15.9 and 9.6 ± 16.3 (P = .0503), respectively.

Conclusion

TPs in the NFL are typically White men in their mid-50s who have trained at specific high-ranking institutions and obtained a fellowship in sports medicine. HTPs were likely to be older with longer tenures within the NFLPS and with more impactful research than their ATP counterparts.

Social Media Posts Pertaining to Anterior Cervical Discectomy and Fusion (ACDF) Surgery: A Cross-sectional Analysis of Patient and Surgeon Perceptions

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To analyze publicly available content on a major social media outlet related to anterior cervical discectomy and fusion (ACDF) surgery based on perspective, location, timing, content, tone, and patient satisfaction.

SUMMARY OF BACKGROUND DATA

Social media offers a powerful platform for sharing the patient experience with the public through an unfiltered perspective. Social media content may influence future perceptions around surgical care and postings around ACDF have not been previously reported.

METHODS

A query of content from a major social media outlet was performed for the study period January 1, 2018, to January 1, 2020, and returned 6500 publicly available posts. Content was identified by the hashtags "#acdf" or "#acdfsurgery." Content was ranked by number of "likes." Of the 1500 most popular posts, 1136 related to ACDF surgery and were included. Post content was characterized and classified.

RESULTS

Patients created 85% of ACDF-related content and spine surgeons created 11.8%. Most posts portrayed the patient experience in the postoperative period and depicted patients performing activities of daily living, participating in sports, or completing work activities (54.4%). The connotation of posts was deemed to be positive in 79.2% of cases. In regard to their care or state of health as it related to ACDF surgery, 59.8% of patients expressed satisfaction, whereas 14.1% expressed dissatisfaction. Female patients were >4 times as likely to express dissatisfaction (odds ratio=4.16, P =<0.0001), with their clinical course compared with their male counterparts.

CONCLUSIONS

Patients were the source of most posts on a major social media outlet that pertained to ACDF surgery with a majority reporting positive tone and satisfaction. These mechanisms of communication offer surgeons unique insights into patient experience and may provide an opportunity for surgeons to assess patient feedback, influence patient perceptions, and enhance delivery of cervical spine care.

Patient and Surgeon Perceptions Regarding Microdiscectomy Surgery: A Cross-Sectional Analysis of Social Media Posts

BACKGROUND

Social media offers a powerful and expanding platform for sharing the patient experience with a large audience through an unsolicited perspective. The content may influence future perceptions around surgical care.

OBJECTIVE

To analyze publicly available content on a major social media outlet related to microdiscectomy surgery based on perspective, location, timing, content, tone, and patient satisfaction.

METHODS

A query of content was performed for the study period 1 January 2019 to 1 January 2021. Relevant content was identified by hashtag "#microdiscectomy." The initial query returned 10,050 publicly available posts, and the 1500 most "liked" posts were included for evaluation. Content was subsequently classified, characterized, and analyzed.

RESULTS

Patients created 72.9% of microdiscectomy-related content, and spine surgeons created 23.5%. Regarding region, 77.0% of posts originated in the United States. The majority portrayed the patient experience in the postoperative phase of care (86.0%), with the primary reference to activities of daily living (56.9%). Only 1.7% of posts depicted the surgical incision site. The connotation of posts was deemed positive in 78.5% of cases. Of the posts referencing satisfaction, 98.3% depicted patient satisfaction with the surgical outcome. Patient posts in the postoperative phase of care (>1 week after surgery) were more than 2 times as likely to express positive tone (OR = 2.07, P ≤ 0.013) with their clinical course compared with patient posts outside the postoperative period.

CONCLUSIONS AND CLINICAL RELEVANCE

Overall, social media posts are written in a positive tone, express satisfaction with surgical outcome, typically occur in the postoperative period of care, and depict activities of daily living. These popular mechanisms of communication, such as Instagram, offer spine surgeons unique insights into the true patient experience and may provide an opportunity for surgeons to assess patient feedback, influence patient perceptions, and enhance delivery of lumbar spine care.

LEVEL OF EVIDENCE: 5

Predictive Analysis of Healthcare Resource Utilization after Elective Spine Surgery

Introduction

The management of degenerative spine pathology continues to be a significant source of costs to the US healthcare system. Besides surgery, utilization of healthcare resources after spine surgery drives costs. The responsibility of managing costs is gradually shifting to patients and providers. Patient-centered predictors of healthcare utilization after elective spine surgery may identify targets for cost reduction and value creation. Therefore, our study aims to quantify patterns of healthcare utilization and identify risk factors that predict high healthcare utilization after elective spine surgery.

Methods

A total of 623 patients who underwent elective spine surgery at a tertiary academic medical center by one of three fellowship-trained orthopedic spine surgeons between 2013 and 2018 were identified in this retrospective cohort study. Healthcare utilization was quantified including advanced spine imaging, emergency and urgent care visits, hospital readmission, reoperation, PT/OT referrals, opioid prescriptions, epidural steroid injections, and pain management referrals. Patient variables, namely, the Charlson comorbidity index (CCI) and the American Society of Anesthesiologists (ASA) classification system, were assessed as potential predictors for healthcare utilization.

Results

Among all patients, a wide range of health utilization was identified. Age, body mass index, Charlson Comorbidity Index, and American Society of Anesthesiology class were identified as positive predictors of postoperative healthcare utilization including emergency department visits, spine imaging studies, opioid and nerve blocker prescriptions, inpatient rehabilitation, any referrals, and pain management referrals.

Conclusions

Markers of patient health-such as CCI and ASA class-may be used to predict healthcare utilization following elective spine surgery. Identifying at-risk patients and addressing these challenges prior to surgery is an important step to deliver efficient postoperative care.

Level of Evidence

3.

Increased 30-Day Postoperative Readmission and Medical Complication Rates Among Patients 65 Years and Older Following Arthroscopic Rotator Cuff Repair

Purpose

Methods

Results

Conclusions

Revision ACL reconstruction has higher incidence of 30-day hospital readmission, reoperation, and surgical complications relative to primary procedures

PURPOSE

Although there has been substantial improvement in ACL reconstructive surgery, graft failure remains a devastating complication for some patients. Revision procedures are inherently more complex and technically challenging. The purpose of this study is to determine the incidence of short-term complications after these procedures and to compare trends in operative length, relative valuation, and reimbursement after primary versus revision ACL reconstruction.

METHODS

Primary and revision arthroscopic ACL reconstruction cases were identified on the American College of Surgeons' NSQIP database using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes between January 1, 2012 and December 31, 2017. Demographics, patient variables, and surgical variables were compared between primary and revision groups using Chi-squared tests. Logistic regression was used to identify independent risk factors for revision ACL reconstruction. Various 30-day outcome measures were compared between the primary and revision ACL reconstruction groups. Various measures of valuation-including total relative value units (RVU) and reimbursement per minute-were calculated and compared between the two groups.

RESULTS

A total of 8292 patients-8135 primary and 157 revision procedures-were included in the final cohort. Higher ASA scores were associated with revision ACL reconstructions. Patients undergoing revision procedures were less likely to have an ASA score of 1 (p < 0.001) and more likely to have an ASA score of 2 (p = 0.004) or 3 (p = 0.020). Revision ACL reconstruction was associated with higher rates of poor 30-day outcome measures, including unplanned readmission (p = 0.029), reoperation (p = 0.012), return to the OR (p = 0.012), and surgical complications (p = 0.021). The total RVUs and reimbursement for revision procedures were significantly greater than those for primary procedures (p < 0.001). However, when accounting for operative time, the RVU/minute and reimbursement/minute were similar between the two groups (n.s.).

CONCLUSIONS

Relative to primary ACL reconstruction, revision ACL procedures are associated with worse short-term outcomes-including unplanned readmission, reoperation, return to the OR, and surgical complications. A greater ASA score was independently predictive of revision ACL surgery. The current RVU system undervalues revision ACL procedures, considering the increased operative time and complexity of such procedures.

LEVEL OF EVIDENCE

Level III.

Comparison of Lumbar Fusion With and Without Interbody Fusion for Lumbar Stenosis Using Patient-Reported Outcomes Measurement Information System (PROMIS) Computer Adaptive Testing (CAT)

Study design

This was a retrospective analysis of patient-reported outcomes across a two-year period.

Summary of background data

Patients suffering from lumbar stenosis may experience low back pain, neurogenic claudication, and weakness. Patients can benefit from surgical intervention, including decompression with or without fusion. However, the superiority of any single fusion construct remains controversial.

Objective

The goal of this study was to compare Patient-Reported Outcomes Measurement Information System (PROMIS®) Computer Adaptive Testing (CAT) measures in patients with lumbar spinal stenosis treated surgically with lumbar decompression and fusion with or without interbody fusion.

Methods

A retrospective review of patients with lumbar stenosis undergoing lumbar decompression and one-level fusion was performed. PROMIS® CAT Physical Function (PF) and Pain Interference (PI) assessments were administered using a web-based platform pre and postoperatively.

Results

Sixty patients with lumbar stenosis undergoing one-level lumbar fusion were identified. Twenty-seven patients underwent posterior lumbar fusion (PSF) alone and 33 underwent one-level lumbar interbody fusion (IF). Patients undergoing IF had better absolute PF scores compared to patients undergoing PSF at one-year postoperatively (48.9 v 41.6, p=0.002) and greater relative improvement in PF scores from baseline at one-year postoperatively (D13.6 v D8.6, p=0.02). A subgroup analysis of patients undergoing TLIF v PSF showed better absolute PF scores at the one-year follow-up in the TLIF group (47.1 v 42.3, p=0.04). No differences were found in PI scores at any time point between the PSF and IF groups. Patients undergoing IF had significantly shorter hospital stays (2.5 v 3.3 days, p=0.02) compared to patients undergoing PSF.

Conclusions

Patients with lumbar spinal stenosis treated with one-level IF reported higher absolute PF scores and experienced greater relative improvement in PF scores from baseline at one-year follow-up compared to patients treated with PSF alone. Additionally, IF is associated with a decreased length of hospital stay as compared to PSF.

Trends in leadership at shoulder and elbow fellowships: a cross-sectional demographic review

OBJECTIVE

To determine educational characteristics, trends, and demographics among shoulder and elbow fellowship leaders (FLs).

BACKGROUND

Fellowship leaders in shoulder and elbow impart lasting impact on trainees and field development. Four previous studies have analyzed the characteristics and career path trends among orthopedic surgery subspecialty FLs (spine, adult reconstruction, trauma, and sports medicine). We characterized the educational backgrounds and demographic composition of all 40 FLs including fellowship directors (FD), fellowship co-directors (co-FD), and associate fellowship directors (associate FD) of 31 American Shoulder and Elbow Surgeons (ASES)-accredited shoulder and elbow fellowships in the United States. We additionally compiled the residency and fellowship institutions that trained FLs as framework for aspiring leaders in orthopedic surgery.

METHODS

Using the American Shoulder and Elbow Surgeons (ASES) directory website page "ASES-Recognized Shoulder and Elbow Fellowship Programs," we identified all active shoulder and elbow fellowships within the United States as well as associated FL identifiers. Compiled data points include age, sex, ethnicity, residency/fellowship training location, time since education completion until FL appointment, length in FL role, personal research Scopus H-index, and major society and journal leadership position history.

RESULTS

We analyzed data from all 40 active FLs across 31 ASES-accredited shoulder and elbow fellowships, encompassing 26 FDs, 13 co-FDs, and 1 associate FD. The majority of FLs (97.5%) were male whereas 2.5% were female, with racial/ethnic identification of 80.0% Caucasian, 10.0% Asian/Pacific Islander, and 10.0% Middle Eastern. The mean Scopus H-index of the FLs was 24.63 ± 16.43. The top residency programs for producing future FLs were the University of Pittsburgh, University of Pennsylvania, University of Nebraska/Creighton, Hospital for Special Surgery, and Brown University (all n = 2). The top fellowship programs for producing future FLs were Mayo Clinic (n = 6), Columbia University (n = 6), San Francisco/California Pacific (n = 4), and Washington University in St Louis (n = 4).

CONCLUSION

Shoulder and elbow fellowship leaders graduate with increased frequency from certain fellowship programs with lesser correlation to residency institutions. Programs demonstrate high retention of prior trainees as future FLs. All FLs are distinguished by high indices of research productivity; however, demographic diversity remains limited, which is comparable to prior orthopedic subspecialty FL investigations.

Spine Surgery and COVID-19: The Influence of Practice Type on Preparedness, Response, and Economic Impact

STUDY DESIGN

Cross-sectional observational cohort study.

OBJECTIVE

To investigate preparation, response, and economic impact of COVID-19 on private, public, academic, and privademic spine surgeons.

METHODS

AO Spine COVID-19 and Spine Surgeon Global Impact Survey includes domains on surgeon demographics, location of practice, type of practice, COVID-19 perceptions, institutional preparedness and response, personal and practice impact, and future perceptions. The survey was distributed by AO Spine via email to members (n = 3805). Univariate and multivariate analyses were performed to identify differences between practice settings.

RESULTS

A total of 902 surgeons completed the survey. In all, 45.4% of respondents worked in an academic setting, 22.9% in privademics, 16.1% in private practice, and 15.6% in public hospitals. Academic practice setting was independently associated with performing elective and emergent spine surgeries at the time of survey distribution. A majority of surgeons reported a >75% decrease in case volume. Private practice and privademic surgeons reported losing income at a higher rate compared with academic or public surgeons. Practice setting was associated with personal protective equipment availability and economic issues as a source of stress.

CONCLUSIONS

The current study indicates that practice setting affected both preparedness and response to COVID-19. Surgeons in private and privademic practices reported increased worry about the economic implications of the current crisis compared with surgeons in academic and public hospitals. COVID-19 decreased overall clinical productivity, revenue, and income. Government response to the current pandemic and preparation for future pandemics needs to be adaptable to surgeons in all practice settings.

Determining the incidence and risk factors for short-term complications following distal biceps tendon repair

Background

Distal biceps rupture is a relatively uncommon injury that can significantly affect quality of life. Early complications following biceps tendon repair are not well described in the literature. This study utilizes a national surgical database to determine the incidence of and predictors for short-term complications following distal biceps tendon repair.

Methods

The American College of Surgeons’ National Surgical Quality Improvement Program database was used to identify patients undergoing distal biceps repair between January 1, 2011, and December 31, 2017. Patient demographic variables of sex, age, body mass index, American Society of Anesthesiologists class, functional status, and several comorbidities were collected for each patient, along with 30-day postoperative complications. Binary logistic regression was used to calculate risk ratios for these complications using patient predictor variables.

Results

Early postoperative surgical complications (0.5%)—which were mostly infections (0.4%)—and medical complications (0.3%) were rare. A readmission risk factor was diabetes (risk ratio [RR], 4.238; 95% confidence interval [CI], 1.180–15.218). Non-home discharge risk factors were smoking (RR, 3.006; 95% CI, 1.123–8.044) and ≥60 years of age (RR, 4.150; 95% CI, 1.611– 10.686). Maleness was protective for medical complications (RR, 0.024; 95% CI, 0.005–0.126). Surgical complication risk factors were obese class II (RR, 4.120; 95% CI, 1.123–15.120), chronic obstructive pulmonary disease (COPD; RR, 21.981; 95% CI, 3.719–129.924), and inpatient surgery (RR, 8.606; 95% CI, 2.266–32.689).

Conclusions

Complication rates after distal biceps repair are low. Various patient demographics, medical comorbidities, and surgical factors were all predictive of short-term complications.

Determining the Impact of the COVID-19 Pandemic on Hand Surgery Fellowship Education

The purpose of this study is to report the impact of COVID-19 on hand surgery fellow learning and preparedness for practice. A multi-dimensional questionnaire was distributed to current hand fellows and fellowship directors across the United States. Survey questions included fellowship location, institutional response, impact on practice, education and job search. Thirty-two hand surgery fellows and 14 fellowship directors completed the survey. Of fellows, 59% reported a greater than 75% decrease in case volume. Mean hours worked per week per fellow decreased by 52%. All fellowship directors and 94% of fellows did not expect COVID-19 to impact their ability to graduate, and nearly all fellows felt prepared to start practice after fellowship training. However, many fellows expressed concern about job opportunities. The work hours and exposure of hand surgery fellows to elective surgical cases have been adversely impacted by COVID-19. Nevertheless, current hand fellows feel prepared to enter practice. (Journal of Surgical Orthopaedic Advances 31(1):048-052, 2022).

The content and accessibility of spine surgery fellowship websites and the North American Spine Surgery (NASS) fellowship directory

BACKGROUND CONTEXT

The North American Spine Society (NASS) spine fellowship directory is an established resource that provides applicants with access to important information about different fellowship programs. Additionally, some programs have created websites to provide information about their fellowship program. There has been limited research on the amount and breadth of information provided by these different resources.

PURPOSE

To assess and compare the scope of information provided by the North American Spine Society (NASS) fellowship directory and individual fellowship program websites.

STUDY DESIGN/SETTING

Web Content Accessibility Study.

PATIENT SAMPLE

There were no patient data used in this study. All reported data were accessed from public websites and the NASS fellowship directory (August 2022 fellowships).

OUTCOME MEASURES

Outcome measures were reported as the presence or lack thereof of 22 topics pertaining to the specifics of each individual spine fellowship program on both the NASS fellowship directory and individual fellowship program websites.

METHODS

The NASS fellowship directory (August 2022 fellowships) and individual program websites were evaluated by two independent reviewers. Program websites were identified via Google search with a systematic protocol. Within each platform, the availability of various data were recorded. Twenty-four different data points were assessed for each program and were categorized into four main categories-general program information, fellow profiles, clinical roles, and nonclinical roles of the fellow. Chi-squared tests were used to compare differences in the availability of specific data provided by the NASS fellowship directory and individual program websites.

RESULTS

Seventy-four fellowship programs were identified. The NASS fellowship directory was more likely to provide information about the application process, a description of the program, fellow salary, faculty members, case descriptions, and research requirements (p<.05). The program websites were more likely to provide information about current and previous fellows-including a list of current fellow(s), their education/training, and a list of the previous fellows and their job choice (p<.05). Program websites were also more likely to discuss rotation schedules, clinic expectations, research opportunities, journal club, institutional meetings, sponsored national meetings, and current/previous research (p<.05). However, certain information, including specific clinical responsibilities (eg, rotation schedule, call expectations, clinic expectations) and the profiles of current and previous fellows, were not well represented on either platform.

CONCLUSIONS

There were significant differences in the type of information provided by the NASS fellowship directory and program websites. Furthermore, there were key pieces of information that were not well represented on either platform.

Short-Term Outcomes After Total Shoulder Arthroplasty in Octogenarians: A Matched Analysis

Introduction

Studies have shown that the use of total shoulder arthroplasty is increasing every year in the United Stated at a rate higher than that of total hip or total knee arthroplasty. As the population of the United States continues to age, it is becoming more important for surgeons to understand the true impact of age on outcomes and complications following procedures such a total shoulder arthroplasty. The purpose of this study was to determine if octogenarians have poorer outcomes after total shoulder arthroplasty compared to a younger, matched control group.

Methods

Data was obtained through the American College of Surgeons National Surgical Quality Improvement Program database (ACS NSQIP). Patients who had undergone total shoulder arthroplasty were identified by Current Procedural Terminology code (23472). Indication for arthroplasty was determined by ICD9/10 code (osteoarthritis, fracture, other). Each octogenarian was matched 1:1 to a non-octogenarian based on sex, BMI, ASA class, medical comorbidities, functional status, and surgical indication for arthroplasty by propensity scoring. A subgroup analysis was performed to compare outcomes between only those patients who underwent TSA for osteoarthritis.Outcomes of interest were assessed between the two groups for statistical significance using a chi-squared test or fisher exact test for expected values of less than 5. Statistical significance was set at p<0.05.

Results

After matching, octogenarians were found to be at higher risk of readmission (4.7% vs. 3.3%, p=0.046), non-home discharge (27.1% vs. 9.4%, p<0.001), and overall surgical (4.4% vs. 2.5%, p=0.006) and medical complications (3.7% vs. 2.4%, p=0.039). In the setting of TSA for osteoarthritis only, however, octogenarians were only at higher risk for non-home discharge (22.4% vs. 7.5%, p<0.001).

Conclusions

Octogenarians are at higher risk of some complications following total shoulder arthroplasty but fewer than has been previously reported, particularly in the setting of arthroplasty for the treatment of arthritis.

Trends in Leadership Within Orthopedic Foot and Ankle Fellowships

Background:

No study in the orthopedic literature has analyzed the demographic characteristics or surgical training of foot and ankle fellowship directors (FDs). Our group sought to illustrate demographic trends among foot and ankle fellowship leaders.

Methods:

The American Orthopaedic Foot & Ankle Society (AOFAS) Fellowship Directory for the 2021 to 2022 program year was queried in order to identify all foot and ankle fellowship leaders at programs currently offering positions in the United States and Canada. Data points gathered included age, sex, race/ethnicity, location of surgical training, time since training completion until FD appointment, length in FD role, and individual research H-index.

Results:

We identified 68 fellowship leaders, which consisted of 48 FDs and 19 co-FDs. Sixty-five individuals (95.6%) were male, and 3 (4.4%) were female. As regards race/ethnicity, 88.2% of the leadership was Caucasian (n = 60), 7.4% was Asian American (n = 5), 1.5% was Hispanic/Latino (n = 1), and 1.5% was African American (n = 1). The average age was 51.5 years, and the calculated mean Scopus H-index was 15.28. The mean duration from fellowship training to fellowship leader position was 11.23 years.

Conclusion:

Leaders within foot and ankle orthopedic surgery are characterized by research prowess and experience, but demographic diversity is lacking.

Level of Evidence:

Level III.

Assessing the Early Impact of the COVID-19 Pandemic on Spine Surgery Fellowship Education

STUDY DESIGN

This was a cross-sectional study.

OBJECTIVE

The objective of this study is to report the impact of COVID-19 on spine surgery fellow education and readiness for practice.

SUMMARY OF BACKGROUND DATA

COVID-19 has emerged as one of the most devastating global health crises of our time. To minimize transmission risk and to ensure availability of health resources, many hospitals have cancelled elective surgeries. There may be unintended consequences of this decision on the education and preparedness of current surgical trainees.

MATERIALS AND METHODS

A multidimensional survey was created and distributed to all current AO Spine fellows and fellowship directors across the United States and Canada.

RESULTS

Forty-five spine surgery fellows and 25 fellowship directors completed the survey. 62.2% of fellows reported >50% decrease in overall case volume since cancellation of elective surgeries. Mean hours worked per week decreased by 56.2%. Fellows reported completing a mean of 188.4±64.8 cases before the COVID-19 crisis and 84.1% expect at least an 11%-25% reduction in case volume compared with previous spine fellows. In all, 95.5% of fellows did not expect COVID-19 to impact their ability to complete fellowship. Only 2 directors were concerned about their fellows successfully completing fellowship; however, 32% of directors reported hearing concerns regarding preparedness from their fellows and 25% of fellows were concerned about job opportunities.

CONCLUSIONS

COVID-19 has universally impacted work hours and case volume for spine surgery fellows set to complete fellowship in the middle of 2020. Nevertheless, spine surgery fellows generally feel ready to enter practice and are supported by the confidence of their fellowship directors. The survey highlights a number of opportunities for improvement and innovation in the future training of spine surgeons.

LEVEL OF EVIDENCE

Level III.

Evaluating the Early Impact of the COVID-19 Pandemic on Sports Surgery Fellowship Education

Purpose The COVID-19 pandemic forced many hospitals to cancel elective surgeries to minimize the risk of viral transmission and ensure the availability of vital health resources. The unintended consequences of this action on the education and training of orthopaedic sports surgeons are unknown. The purpose of this study is to measure the impact of COVID-19 on orthopaedic sports surgery fellows, their education and training, and their readiness for practice. Methods A comprehensive survey was created and distributed to all U.S. fellows and fellowship directors registered with the American Orthopaedic Society for Sports Medicine. Responses were collected between April 22, 2020, and May 5, 2020. Results Fifty-one sports fellows and twenty-nine sports fellowship directors completed the survey. Over 80.4% of fellows reported a greater than 50% decrease in the case volume since the cessation of elective cases. Average hours worked per week decreased by 58.2% during the pandemic. Fellows reported completing an average of 324.6 ± 97.4 cases prior to the COVID-19 crisis and 86.0% expected to complete at least 11% to 25% fewer cases by graduation compared to previous fellows. 87.5% of fellows were not concerned about their ability to complete their fellowship training but more than one-third of fellows voiced concerns to their fellowship directors regarding their readiness for independent practice. Fellowship directors were generally not concerned that COVID-19 would prevent their fellows from completing the fellowship. At least 54.2% are somewhat concerned about the impact of COVID-19 on their future job opportunities. Conclusions The COVID-19 pandemic has universally affected work hours and case volume of sports fellows. Nevertheless, most sports fellows feel prepared to enter practice and are generally supported by the confidence of their fellowship directors. The results of this survey emphasize the importance of the fellowship year in sports training and highlight the future of online education and simulation as useful adjuncts.

COVID-19 and the rise of virtual medicine in spine surgery: a worldwide study

PURPOSE

The COVID-19 pandemic forced many surgeons to adopt "virtual medicine" practices, defined as telehealth services for patient care and online platforms for continuing medical education. The purpose of this study was to assess spine surgeon reliance on virtual medicine during the pandemic and to discuss the future of virtual medicine in spine surgery.

METHODS

A comprehensive survey addressing demographic data and virtual medicine practices was distributed to spine surgeons worldwide between March 27, 2020, and April 4, 2020.

RESULTS

902 spine surgeons representing seven global regions responded. 35.6% of surgeons were identified as "high telehealth users," conducting more than half of clinic visits virtually. Predictors of high telehealth utilization included working in an academic practice (OR = 1.68, p = 0.0015) and practicing in Europe/North America (OR 3.42, p < 0.0001). 80.1% of all surgeons were interested in online education. Dedicating more than 25% of one's practice to teaching (OR = 1.89, p = 0.037) predicted increased interest in online education. 26.2% of respondents were identified as "virtual medicine surgeons," defined as surgeons with both high telehealth usage and increased interest in online education. Living in Europe/North America and practicing in an academic practice increased odds of being a virtual medicine surgeon by 2.28 (p = 0.002) and 1.15 (p = 0.0082), respectively. 93.8% of surgeons reported interest in a centralized platform facilitating surgeon-to-surgeon communication.

CONCLUSION

COVID-19 has changed spine surgery by triggering rapid adoption of virtual medicine practices. The demonstrated global interest in virtual medicine suggests that it may become part of the "new normal" for surgeons in the post-pandemic era.

Intraoperative image guidance for lateral position surgery

Recent advances in minimally invasive spine surgery techniques have precipitated the popularity of lateral position spine surgery, such as lateral lumbar interbody fusion (LLIF) and oblique lumbar interbody fusion (OLIF). Lateral position surgery offers a unique, minimally invasive approach to the lumbar spine that allows for preservation of anterior and posterior spinal elements. Traditionally, surgeons have relied upon fluoroscopy for triangulation and implant placement. Over the last decade, intraoperative 3-dimensional navigation (ION) has risen to the forefront of innovation in LLIF and OLIF. This technology utilizes intra-operative advanced imaging, such as comminuted tomography (CT), to map the patient’s 3D anatomy and allows the surgeon to accurately visualize instruments and implants in spatial relationship to the patient’s anatomy in real time. ION has the potential to improve accuracy during instrumentation, decrease operating room times, lower radiation exposure to the surgeon and staff, and increase feasibility of single-position surgery during which the spine is instrumented both laterally and posteriorly while the patient remains in the lateral decubitus position. Despite the advantages of ION, the intra-operative radiation exposure risk to patients is controversial. Future directions include continued innovation in ultra low radiation imaging (ULRI) techniques and image enhancement technology and in uses of robot-assisted navigation in single-position spine surgery.

Learning from the past: did experience with previous epidemics help mitigate the impact of COVID-19 among spine surgeons worldwide?

Purpose

Spine surgeons around the world have been universally impacted by COVID-19. The current study addressed whether prior experience with disease epidemics among the spine surgeon community had an impact on preparedness and response toward COVID-19.

Methods

A 73-item survey was distributed to spine surgeons worldwide via AO Spine. Questions focused on: demographics, COVID-19 preparedness, response, and impact. Respondents with and without prior epidemic experience (e.g., SARS, H1NI, MERS) were assessed on preparedness and response via univariate and multivariate modeling. Results of the survey were compared against the Global Health Security Index.

Results

Totally, 902 surgeons from 7 global regions completed the survey. 24.2% of respondents had prior experience with global health crises. Only 49.6% reported adequate access to personal protective equipment. There were no differences in preparedness reported by respondents with prior epidemic exposure. Government and hospital responses were fairly consistent around the world. Prior epidemic experience did not impact the presence of preparedness guidelines. There were subtle differences in sources of stress, coping strategies, performance of elective surgeries, and impact on income driven by prior epidemic exposure. 94.7% expressed a need for formal, international guidelines to help mitigate the impact of the current and future pandemics.

Conclusions

This is the first study to note that prior experience with infectious disease crises did not appear to help spine surgeons prepare for the current COVID-19 pandemic. Based on survey results, the GHSI was not an effective measure of COVID-19 preparedness. Formal international guidelines for crisis preparedness are needed to mitigate future pandemics.

Effect of Posthospital Syndrome on Discharge Disposition and Healthcare Utilization After Primary Total Joint Arthroplasty

BACKGROUND

The aim of this study is to evaluate the impact of posthospital syndrome (PHS), a physiologically deconditioned state experienced by patients after hospitalizations, on postoperative healthcare utilization and discharge disposition following total hip (THA) and knee (TKA) arthroplasty.

METHODS

Insurance claims from the Truven MarketScan Databases were used to perform this cross-sectional study of patients who underwent unilateral, primary THA or TKA between January 2010 and December 2016. PHS, defined as a hospitalization within 90 days before surgery, and non-PHS cohorts were compared. Multivariable logistic regression analyses were used to identify risk of postoperative discharge to an extended care facility (ECF), hospital readmissions, and emergency department visits within 90 days.

RESULTS

This study included 115,465 THA and 190,398 TKA patients who underwent elective surgery for osteoarthritis. PHS was identified in 1.9% and 1.6% of cohorts, respectively, and was more common in patients with higher comorbidities. The PHS cohort had higher crude rates of discharge to ECF (THA 38.8% and TKA 33.8%) and readmissions (21.8% and 18%). Adjusted odds ratios showed that PHS increased risk of disposition to ECF (THA 1.9 and TKA 1.4), readmission (2.8 and 2.0), and emergency department encounters (1.6 and 1.4). Among PHS patients, acute hospitalizations within 30 days of surgery and those lasting greater than 5 days had the highest risk of postoperative healthcare utilization.

CONCLUSION

In this study of commercially insured patients, those with an acute hospitalization within 90 days before elective total joint arthroplasty were nearly twice as likely to be discharged to an ECF and twice as likely to be readmitted in the global postoperative period.

Biomechanical Analysis of Stand-alone Lateral Lumbar Interbody Fusion for Lumbar Adjacent Segment Disease

Study design

Biomechanical cadaveric study 

Objective

To compare biomechanical properties of a single stand-alone interbody fusion and a single-level pedicle screw construct above a previous lumbar pedicle fusion.

Summary of background data

Adjacent segment disease (ASD) is spondylosis of adjacent vertebral segments after previous spinal fusion. Despite the consensus that ASD is clinically significant, the surgical treatment of ASD is controversial.

Methods

Lateral lumbar interbody fusion (LLIF) and posterior spinal fusion (PSF) with pedicle screws were analyzed within a validated cadaveric lumbar fusion model. L3-4 vertebral segment motion was analyzed within the following simulations: without implants (intact), L3-4 LLIF-only, L3-4 LLIF with previous L4-S1 PSF, L3-4 PSF with previous L4-S1 PSF, and L4-S1 PSF alone. L3-4 motion values were measured during flexion/extension with and without axial load, side bending, and axial rotation.

Results

L3-4 motion in the intact model was found to be 4.7 ± 1.2 degrees. L3-4 LLIF-only decreased motion to 1.9 ± 1.1 degrees. L3-4 LLIF with previous L4-S1 fusion demonstrated less motion in all planes with and without loading (p < 0.05) compared to an intact spine. However, L3-4 motion with flexion/extension and lateral bending was noted to be greater compared to the L3-S1 construct (p < 0.5). The L3-S1 PSF construct decreased motion to less than 1° in all planes of motion with or without loading (p < 0.05). The L3-4 PSF with previous L4-S1 PSF constructs decreased the flexion/extension motion by 92.4% compared to the intact spine, whereas the L3-4 LLIF with previous L4-S1 PSF constructs decreased motion by 61.2%.

Conclusions

Stand-alone LLIF above a previous posterolateral fusion significantly decreases motion at the adjacent segment, demonstrating its utility in treating ASD without necessitating revision. The stand-alone LLIF is a biomechanically sound option in the treatment of ASD and is advantageous in patient populations who may benefit from less invasive surgical options.

Risk Factors for Undergoing Elective Abdominal Contouring Surgery Shortly After Hospitalization

BACKGROUND

Having posthospital syndrome (PHS) at the time of an elective surgery increases the risk of postoperative adverse outcomes. The purpose of this article was to identify incidence and risk factors for having PHS at the time of abdominal contouring surgeries.

METHODS

Insurance claims from the Truven MarketScan Databases were used to identify patients who underwent outpatient abdominoplasty, liposuction, or panniculectomy between April 2010 and August 2015. Patients were presumed to have PHS if they were hospitalized within 90 d before surgery. Incidence rates of having PHS were calculated for patient groups defined by demographic data and comorbidities. Statistical inference based on adjusted odds ratios was used to evaluate the association of potential risk factors with PHS. A nonparametric regression method was used to demonstrate nonlinear effects of patient covariates on the risk of PHS.

RESULTS

This study included 18,947 patients who underwent abdominal contouring; 77% were female, and the mean age was 48.7 y (SD = 14.7). Six percent (n = 1045) of patients had PHS at the time of surgery. A significantly stronger association with PHS (P < 0.001) was observed in patients with deep venous thrombosis (adjusted odds ratio = 3.56), Elixhauser score > 8 (3.28), and smokers (2.16). Age was found to have a piecewise linear effect on PHS, with odds increasing by 2.1% per year over the age of 45 y.

CONCLUSIONS

Older patients have an increased risk of undergoing abdominal contouring surgery in a deconditioned state. Screening at-risk populations for PHS would help identify patients who need rehabilitation before operative intervention.

Emergency Department Wait Time and Treatment of Traumatic Digit Amputation: Do Race and Insurance Matter?

BACKGROUND

Little is known about the association between the quality of trauma care and management of nonfatal injuries. The authors used emergency department wait times as a proxy for hospital structure, process, and availability of on-call surgeons with microsurgical skills. They evaluated the association between average hospital emergency department wait times and likelihood of undergoing digit replantation for patients with traumatic amputation digit injuries. The authors hypothesized that hospitals with shorter emergency department wait times were associated with higher odds of replantation.

METHODS

Using the 2007 to 2012 National Trauma Data Bank, the authors' final sample included 12,126 patients. Regression modeling was used to first determine factors that were associated with longer emergency department wait times among patients with digit amputation injuries. Second, the authors examined the association between emergency department wait times for this population at a hospital level and replantation after all types of digit amputation and after complicated thumb amputation injuries only.

RESULTS

For patients with simple and complicated thumb amputation injuries, and patients with complicated thumb amputation injuries only, longer emergency department wait times were associated with lower odds of replantation. In addition, being minority and having no insurance were associated with longer emergency department wait times; teaching hospitals were associated with shorter emergency department wait times; and finally, for patients with complicated thumb amputation injuries only, there was no association between patients' minority or insurance status and replantation.

CONCLUSION

Variation in emergency department wait time and its effects on treatment of traumatic digit amputation may reflect maldistribution of hand or plastic surgeons with the required microsurgical skills among trauma centers across the United States.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Utilization of Preoperative Electrodiagnostic Studies for Carpal Tunnel Syndrome: An Analysis of National Practice Patterns

PURPOSE

Given the lack of a reference standard diagnostic tool for carpal tunnel syndrome (CTS), we conducted a population-level analysis of patients undergoing carpal tunnel release to characterize the utilization of preoperative electrodiagnostic studies (EDS). Secondarily, we sought to determine the impact of EDS utilization on timeliness of surgery, number of preoperative physician visits, and costs.

METHODS

The 2009-2013 Truven MarketScan databases were used to identify a national cohort of adult patients undergoing carpal tunnel release. Three multivariable regression models were designed to evaluate the relationship between preoperative EDS use and timing of surgical release, the number of preoperative physician visits, and total costs for CTS-related visits, while controlling for sociodemographic variables, insurance type, comorbid conditions, and treatment characteristics.

RESULTS

The final study cohort included 62,894 patients who underwent carpal tunnel release, of whom 58% had preoperative EDS. Patients undergoing EDS waited 36% longer for surgical release than patients without EDS. The mean time between diagnosis and surgery was predicted to be 183 days for patients who underwent preoperative EDS and 135 days for patients who did not. Patients having EDS experienced 1 additional visit, $996 greater total costs, and $112 additional out-of-pocket costs on average. Occupational therapy consultation and steroid injection were also associated with increased time to surgery, but with one-fourth and one-third the added cost of EDS, respectively.

CONCLUSIONS

On the basis of national practice trends, providers do not consistently agree with the practice of performing EDS before carpal tunnel release. Given the uncertain utility of routine EDS before carpal tunnel release and its association with delays to surgery and increased costs, further evaluation of EDS in relation to patient preferences and value of care is warranted.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

National Utilization Patterns of Steroid Injection and Operative Intervention for Treatment of Common Hand Conditions

PURPOSE

To conduct a population-level analysis of practice trends and probability of surgery based on the number of steroid injections for common hand conditions.

METHODS

Patients aged at least 18 years receiving injection or surgery for carpal tunnel syndrome (CTS), trigger finger (TF), or de Quervain tenovaginitis (DQ) were identified for inclusion using the 2009 to 2013 Truven MarketScan databases. The researchers counted the number of injections performed and calculated the time between injection and operation for patients receiving both treatments. A multivariable logistic regression model was created to evaluate the odds of undergoing surgery based on the number of injections performed, controlling for patient age, sex, comorbidities, and insurance type.

RESULTS

The study sample included 251,030 patients who underwent steroid injection or operative release for CTS (n = 129,917), TF (n = 102,778), and DQ (n = 18,335). Most patients with CTS were managed with immediate surgery (71%), whereas most patients with TF and DQ were managed initially with injection (74% and 84%, respectively). Among patients receiving both an injection and an operation, a single injection was the most common practice before surgery (69%, 58%, and 67% of patients with CTS, TF, and DQ, respectively). Multiple injections for DQ and TF were associated with relatively low predicted probability of surgery (17% and 26%, respectively, after 2 injections). However, the predicted probability of surgery after 2 injections was higher in patients with CTS (44%).

CONCLUSIONS

Given the associated probability of surgery after multiple injections for the 3 hand conditions examined, the practice of repeat injections should be critically examined to determine whether underuse or overuse is present and whether efficiency and use of resources can be improved upon.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.