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Ratnasamy PP, Oghenesume OP, Joo PY, Grauer JN. Billing rules / global period affect postoperative follow-up practices following total hip arthroplasty. PLoS One 2024; 19:e0300460. [PMID: 38635750 PMCID: PMC11025944 DOI: 10.1371/journal.pone.0300460] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 02/27/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Total hip arthroplasty (THA) is a common procedure following which postoperative visits are important to optimize outcomes. The associated global billing period includes the 90 postoperative days (or approximately 13 weeks), during which professional billing is included with the surgery itself. The current study assessed clinical practice patterns relative to the global billing period. METHODS Using the PearlDiver M91Ortho dataset, the incidence and timing of Evaluation and Management (E&M) codes in the 26 weeks following THA were assessed. The follow-up visits within and beyond the global billing period, and those conducted by surgeons versus non-surgeon advanced practice providers (APPs) were determined. RESULTS 77,843 THAs were identified. Follow-up visits peaked at postoperative weeks 3, 7, and 14. The greatest week-to-week variation in the number of follow-ups was from weeks 13 to 14 immediately following the global billing period (representing a greater than 4-fold increase in visits.) During the first 13 postop weeks, 73.8% of patients were seen by orthopedic surgeons (as opposed to APPs). In the following 13 weeks, a significantly greater percentage of visits were with surgeons (86.8%, p<0.0001). CONCLUSIONS Following the THA global billing period, there was marked increase in the number of follow-ups and transition to a greater percentage being performed by the surgeons. These results provide interesting insight into the potential impact of the billing structure on how practice is pursued.
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Affiliation(s)
- Philip P. Ratnasamy
- Department of Orthopedics & Rehabilitation, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Oghenewoma P. Oghenesume
- Department of Orthopedics & Rehabilitation, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Peter Y. Joo
- Department of Orthopedics & Rehabilitation, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Jonathan N. Grauer
- Department of Orthopedics & Rehabilitation, Yale School of Medicine, New Haven, Connecticut, United States of America
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Gouzoulis MJ, Joo PY, Jeong S, Jabbouri SS, Moran J, Zhu JR, Grauer JN. A 10-year perspective on the question of whether surgeries for adolescent idiopathic scoliosis are "one and done"? Spine Deform 2024:10.1007/s43390-024-00858-3. [PMID: 38555557 DOI: 10.1007/s43390-024-00858-3] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 02/28/2024] [Indexed: 04/02/2024]
Abstract
PURPOSE Posterior scoliosis fusion (PSF) for adolescent idiopathic scoliosis (AIS) is considered a highly successful surgery with excellent outcomes. However, especially as many patients "graduate" from their pediatric surgeons, there is the need to quantify the long-term outcomes of such surgeries. METHODS The 2010-2022 Pearldiver M161 dataset was queried for those who were 10 to 18 years old with AIS undergoing PSF with at least 10 years follow-up. Patient characteristics were abstracted. Reoperations were identified based on coding for any subsequent thoracic/lumbar surgery/revision. The 10-year reoperation rate and reasons for reoperation were determined, and multivariate regression was performed to determine risk factors. RESULTS In total, 3,373 AIS PSF patients were identified. Of the study cohort, 324 (9.6%) underwent reoperation within 10-years with an interquartile range for timing of surgery of 81-658 days, of which 29.6% were done for infection. Reoperations were done within the first three months for 152 (46.9% of reoperations), three months to 2 years for 97 (29.9%), and 2 years to 10 years for 74 (22.8%). Based on multivariate regression, need for reoperation was associated with male sex (OR: 1.70), asthma (OR: 1.36) and greater than thirteen segments of instrumentation (OR: 1.48) (p < 0.05 for each) but not age, other comorbidities, or insurance. CONCLUSIONS The current study of a large national AIS PSF population found 9.6% to undergo reoperation in the 10 years following their index operation. Although specifics about the curve pattern could not be determined, the reoperation incidence and correlation with specific risk factors are notable and important for patient counselling.
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Affiliation(s)
- Michael J Gouzoulis
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, 208071, New Haven, CT, 06510, USA
| | - Peter Y Joo
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, 208071, New Haven, CT, 06510, USA
| | - Seongho Jeong
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, 208071, New Haven, CT, 06510, USA
| | - Sahir S Jabbouri
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, 208071, New Haven, CT, 06510, USA
| | - Jay Moran
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, 208071, New Haven, CT, 06510, USA
| | - Justin R Zhu
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, 208071, New Haven, CT, 06510, USA
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, 208071, New Haven, CT, 06510, USA.
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Green JS, Moran J, Marcel A, Joo PY, McLaughlin WM, Manzi JE, Yalcin S, Wang A, Porrino J, Jimenez AE, Medvecky MJ, Katz LD. Posteromedial tibial plateau bone bruises are associated with medial meniscal ramp lesions in patients with concomitant anterior cruciate ligament ruptures: a systematic review & meta-analysis. PHYSICIAN SPORTSMED 2023; 51:531-538. [PMID: 35915996 DOI: 10.1080/00913847.2022.2108350] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/18/2022] [Indexed: 10/16/2022]
Abstract
OBJECTIVE To determine if posteromedial tibial plateau (PMTP) bone bruising on pre-operative MRI is significantly associated with a ramp lesion identified during arthroscopy in patients with concomitant ACL ruptures. METHODS PubMed, CINAHL, Scopus, Web of Sciences, EMBASE, and Cochrane Library were searched systematically for studies that investigated the association between PMTP bone bruises on preoperative MRI and ramp lesions confirmed during arthroscopy. Eight studies met inclusion criteria. The Methodological Index for Nonrandomized Studies (MINORS) checklist was used to assess quality. A meta-analysis was performed to analyze odds of a ramp lesion after PMTP bone bruising identified on magnetic resonance imaging (MRI). Publication bias was assessed by funnel plot and Egger's linear regression test. RESULTS There are 2.05 greater odds of medial meniscal ramp lesions in patients with an ACL rupture when PMTP bone bruising is found on preoperative MRI (95% CI, 1.29-3.25; p = 0.002). Heterogeneity of the pooled studies may be substantial (I2 = 65%; p = 0.006). Funnel plot analysis and Egger's linear regression test (p > 0.5) determined no publication bias among the studies included in the meta-analysis. CONCLUSION Patients with acute ACL injuries and PMTP bone bruising on MRI have 2.05 times greater odds of a concomitant medial meniscal ramp lesion than those without this bone bruise pattern.
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Affiliation(s)
- Joshua S Green
- Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, CT, USA
| | - Jay Moran
- Yale School of Medicine, New Haven, CT, USA
| | - Aaron Marcel
- Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, CT, USA
| | | | - William M McLaughlin
- Department of Rehabilitation & Orthopaedics, Yale School of Medicine, New Haven, CT, USA
| | | | - Sercan Yalcin
- Department of Rehabilitation & Orthopaedics, Yale School of Medicine, New Haven, CT, USA
| | - Annie Wang
- Department of Radiology, Musculoskeletal Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Jack Porrino
- Department of Radiology, Musculoskeletal Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Andrew E Jimenez
- Department of Rehabilitation & Orthopaedics, Yale School of Medicine, New Haven, CT, USA
| | - Michael J Medvecky
- Department of Rehabilitation & Orthopaedics, Yale School of Medicine, New Haven, CT, USA
| | - Lee D Katz
- Department of Radiology, Musculoskeletal Imaging, Yale School of Medicine, New Haven, CT, USA
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Dhodapkar MM, Halperin SJ, Joo PY, Maloy GC, Jeong S, Rubio DR, Grauer JN. Weight loss makes the difference: perioperative outcomes following posterior lumbar fusion in patients with and without weight loss following bariatric surgery. Spine J 2023; 23:1506-1511. [PMID: 37302416 DOI: 10.1016/j.spinee.2023.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 04/30/2023] [Accepted: 06/02/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND CONTEXT Morbid obesity (MO) has been associated with increased risk of adverse events following procedures such as posterior lumbar fusion (PLF). While preemptive bariatric surgery (BS) has been considered for those with MO (body mass index [BMI] ≥35 kg/m2), not all undergoing such intervention have significant weight loss, and the impact of BS has been shown to correlate with weight loss after different related procedures. PURPOSE To examine outcomes following isolated single level PLF among patients with history of BS who subsequently did and did not transition out of the morbidly obese category. STUDY DESIGN/SETTING Retrospective case-control study. PATIENT SAMPLE The PearlDiver 2010-Q1 2020 MSpine database was used to identify adult patients undergoing elective isolated PLF. Patients were excluded if they had a history of infection, neoplasm, or trauma in the 90-days prior to their PLF and if they were not active in the database for at least 90 days following their surgery. Three sub-cohorts were defined: 1) MO controls without a history of BS (-BS+MO), 2) patients with prior BS procedure who remained MO (+BS+MO), and 3) patients with prior BS who were no longer MO at the time of PLF (+BS-MO). Matched 1:1:1 populations were created for these three sub-cohorts based on age, sex and Elixhauser Comorbidity Index (ECI). OUTCOME MEASURES Ninety-day adverse events and readmission rates were assessed and compared between the three sub-cohorts (-BS+MO, +BS+MO, +BS-MO). METHODS Univariable analyses and multivariable logistic regression were performed on the matched population to compare 90-day adverse events and readmission rates controlling for age, sex, and ECI. RESULTS The current study identified PLF patients who were MO at the time of surgery but did not have a history of BS (-BS+MO, n=34,236), those who had BS and remained MO (+BS+MO, n=564), and those who had MS and were no longer MO (+BS-MO, n=209 which was only 27% of those who had BS). On multivariable analysis of the matched populations, those that had BS but remained MO (+BS+MO) were not at reduced odds of 90-day adverse events. However, those that had BS and were no longer MO (+BS-MO) were at reduced odds of 90-day any, severe, and minor adverse events (OR 0.41, 0.51, and 0.37, respectively with p<0.05 for all). CONCLUSIONS Only 27% of those with a history of BS prior to PLF transitioned out of the MO category. Compared to those who were morbidly obese without BS, those who had BS were only at reduced risk of 90-day adverse events if they actually lost weight sufficient to drop out of morbidly obesity. These findings should be taken into account when counseling patients and interpreting prior studies.
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Affiliation(s)
- Meera M Dhodapkar
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT 06511, USA
| | - Scott J Halperin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT 06511, USA
| | - Peter Y Joo
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT 06511, USA
| | - Gwyneth C Maloy
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT 06511, USA
| | - Seongho Jeong
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT 06511, USA
| | - Daniel R Rubio
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT 06511, USA
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT 06511, USA.
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Joo PY, Lee W, Hoffman S, Baumhauer J, Oh I. Utilization of PROMIS Neuropathic Pain Quality for Detection and Monitoring Neuropathic Pain in Heel Pain Patients. Foot Ankle Orthop 2023; 8:24730114231213620. [PMID: 38058978 PMCID: PMC10697051 DOI: 10.1177/24730114231213620] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023] Open
Abstract
Background Diagnosis and management of neuropathic pain (NP) in foot and ankle patients remain challenging. We investigated the plausibility of using Patient-Reported Outcomes Measurement Information System (PROMIS) Neuropathic Pain Quality (PQ-Neuro) as an initial screening tool to detect NP and track the treatment effects. Methods Patients with heel pain were prospectively recruited and grouped to no-NP, mild-NP, and severe-NP based on the initial PROMIS PQ-Neuro t scores. Pain Interference (PI), Physical Function (PF), and Self-Efficacy (SE) scores were evaluated at baseline, 30-day, and 90-day follow-up. Other factors such as age, smoking, body mass index (BMI), low back/neck pain, anxiety/depression, and medications were analyzed. Linear mixed modeling was used to assess the main effects of time and NP on PROMIS t scores, comparing minimal clinically important difference (MCID). Results Forty-eight patients with mean age of 52.4 years were recruited. Using the PROMIS PQ-Neuro as the assessment tool, 33 patients (69%) were detected to have NP at baseline-23 (48%) mild and 10 (21%) severe. BMI was the only independent factor associated with NP (P = .011). Higher baseline PQ-Neuro t score was significantly associated with higher follow-up PQ-Neuro (P < .001), PI (P = .005), and lower SE (P = .04) across time points. Patients with NP showed lower PF at baseline with significantly less improvement in PF (3 vs 9.9, P = .035) and did not meet MCID. Conclusion Baseline PROMIS PQ-Neuro ≥46 was significantly associated with worse PI and SE across all time points, with less clinically significant improvements in PF. Prevalence of NP in heel pain patients was high. The PROMIS PQ-Neuro may serve as a valuable tool for detection of NP and guiding clinical treatment decision pathways for heel pain patients. Level of Evidence Level III, prospective cohort study.
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Affiliation(s)
- Peter Y Joo
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Wonyong Lee
- Department of Orthopaedic Surgery, Guthrie Clinic, Sayre, PA, USA
| | - Samantha Hoffman
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Judith Baumhauer
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Irvin Oh
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
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Joo PY, Halperin SJ, Dhodapkar MM, Adeclat GJ, Elaydi A, Wilhelm C, Grauer JN. Racial Disparities in Surgical Versus Nonsurgical Management of Distal Radius Fractures in a Medicare Population. Hand (N Y) 2023:15589447231198267. [PMID: 37737570 DOI: 10.1177/15589447231198267] [Citation(s) in RCA: 1] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
BACKGROUND As racial/ethnic disparities in management of distal radius fractures (DRFs) have not been well elucidated in the literature, this study sought to evaluate the correlation of race/ethnicity on surgical versus nonsurgical management of DRFs in a Medicare population. METHODS The PearlDiver Standard Analytical Files Medicare claims database was used to identify patients ≥65 years old with isolated DRF. Patients with polytrauma or surgery performed for upper extremity neoplasm were excluded. Surgical versus nonsurgical management was compared based on demographics, comorbidity (Elixhauser Comorbidity Index, ECI), race/ethnicity, and whether the fracture was open or closed. Univariate and multivariable analyses were used to assess for independent predictors. RESULTS Of 54 564 isolated DRFs identified, surgery was performed for 20 663 (37.9%). On multivariable analysis, patients were independently less likely to receive surgical management if they were: older (relative to 65- to 69-year-olds, incrementally decreasing by age bracket up to >85 years where odds ratio [OR] was 0.27, P < .001), higher ECI (per 2 increase OR: 0.96, P < .001), and closed fractures (OR: 0.35, P < .001). For race/ethnicity: black (OR: 0.64, P < .001), Hispanic (OR: 0.71, P < .001), and Asian (OR: 0.60, P < .001) patients were less likely to undergo surgery. CONCLUSIONS While age, comorbidities, and fracture type are known to affect surgical decision-making for DRF, race/ethnicity has not previously been reported, and its independent prediction of nonsurgical management for several groups points to a disparity in surgical decision-making/access to care. This highlights the need for increased attention to initiatives that seek to provide equitable care to all patients. LEVEL OF EVIDENCE Level III-Retrospective review of national database.
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Affiliation(s)
| | | | | | | | - Ali Elaydi
- Yale School of Medicine, New Haven, CT, USA
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Jayaram RH, Joo PY, Gouzoulis MJ, Ratnasamy PP, Caruana DL, Grauer JN. Single-level Anterior Cervical Discectomy and Fusion Results in Lower Five-year Revisions than Posterior Cervical Foraminotomy in a Large National Cohort. Spine (Phila Pa 1976) 2023; 48:1266-1271. [PMID: 37339256 DOI: 10.1097/brs.0000000000004754] [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: 04/02/2023] [Accepted: 06/05/2023] [Indexed: 06/22/2023]
Abstract
STUDY DESIGN A retrospective cohort study using the 2010-2020 MSpine PearlDiver administrative data set. OBJECTIVE To compare perioperative adverse events and five-year revisions for single-level anterior cervical discectomy and fusion (ACDF) versus posterior cervical foraminotomy (PCF). SUMMARY OF BACKGROUND DATA Cervical disk disease can often be treated surgically using single-level ACDF or PCF. Prior studies have suggested that posterior approaches provide similar short-term outcomes as ACDF; however, posterior procedures may have an increased risk of revision surgery. MATERIALS AND METHODS The database was queried for patients undergoing elective single-level ACDF or PCF (excluding cases performed for myelopathy, trauma, neoplasm, and/or infection). Outcomes, including specific complications, readmission, and reoperations, were assessed. Multivariable logistic regression was used to ascertain odds ratios (OR) of 90-day adverse events controlling for age, sex, and comorbidities. Kaplan-Meier survival analysis was performed to determine five-year rates of cervical reoperation in the ACDF and PCF cohorts. RESULTS A total of 31,953 patients treated by ACDF (29,958, 93.76%) or PCF (1995, 6.24%) were identified. Multivariable analysis, controlling for age, sex, and comorbidities, demonstrated that PCF was associated with significantly greater odds of aggregated serious adverse events (OR 2.17, P <0.001), wound dehiscence (OR 5.89, P <0.001), surgical site infection (OR 3.66, P <0.001), and pulmonary embolism (OR 1.72, P =0.04). However, PCF was associated with significantly lower odds of readmission (OR 0.32, P <0.001), dysphagia (OR 0.44, P <0.001), and pneumonia (OR 0.50, P =0.004). At five years, PCF cases had a significantly higher cumulative revision rate compared with ACDF cases (19.0% vs. 14.8%, P <0.001). CONCLUSIONS The current study is the largest to date to compare short-term adverse events and five-year revision rates between single-level ACDF and PCF for nonmyelopathy elective cases. Perioperative adverse events differed by procedure, and it was notable that the incidence of cumulative revisions was higher for PCF. These findings can be used in decision-making when there is clinical equipoise between ACDF and PCF.
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Affiliation(s)
- Rahul H Jayaram
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
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Yalcin S, Joo PY, McLaughlin W, Moran J, Caruana D, Flores M, Grauer J, Medvecky M. Factors Associated With Increased Opioid Prescriptions Following Anterior Cruciate Ligament Reconstruction in Opioid-Naïve Patients. Arthrosc Sports Med Rehabil 2023; 5:100740. [PMID: 37645399 PMCID: PMC10461142 DOI: 10.1016/j.asmr.2023.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 04/25/2023] [Indexed: 08/31/2023] Open
Abstract
Purpose To identify the mean morphine milligram equivalent (MME) opioid prescriptions for opioid-naïve patients undergoing isolated anterior cruciate ligament reconstruction (ACLR) between 4 weeks before surgery and the first 90 days after surgery and to describe opioid prescriptions filled per patient and mean MMEs per year within 90 days following ACLR. Methods Exclusion criteria were patients having concurrent other cruciate or collateral ligament repair or reconstruction, meniscus procedures (repair and debridement), any cartilage procedure, lower-extremity osteotomy, or knee procedures for fracture, infection, or neoplasms; patients with substance use disorder or chronic pain also were excluded. Opioid use between 4 weeks before surgery and the first 90 days after surgery was recorded. Prescribing physician specialty also was tracked. The correlation of patient factors and prescriber specialty of MME were compared using the Student's t-test. Significance was defined at P < .05. Results Opioid-naïve patients undergoing isolated ACLR were included. Isolated arthroscopic ACLRs performed between 2010 and Q3 2020 in opioid-naïve patients were identified within the PearlDiver M91 national database. A total of 37,200 patients were identified. Mean MME per patient was 340.9 ± 198.2, with an average MME per day of 59.9. Factors associated with increased opioid use during the 90 days following ACLR were older age (P < .001) and preoperative diagnosis of depression (P < .001). Orthopaedic surgeons were primarily responsible for the number of opioid prescriptions after ACLR (n = 29,326, 73.0%) but 27% (n = 10,797) of prescriptions came from nonorthopaedic surgeon medical providers who prescribed significantly greater MMEs of opioids than orthopaedic surgeons (456.5 vs 339.2, P < .001) per patient. Lastly, decreasing yearly opioid prescriptions per patient (2.4 to 1.6 prescriptions) and the mean MME per patient (428.4 to 257.1) occurred from 2010 to 2020. Conclusions Older age and preoperative diagnosis of depression are associated with greater opioid doses after ACLR. In addition, the vast majority of opioid prescriptions are written by orthopaedic surgeons on the day of ACLR and decreased considerably by four weeks after surgery. Patients receiving opioid prescriptions by nonorthopaedic surgeon medical providers receive significantly greater doses. Level of Evidence Level IV, retrospective cohort study.
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Affiliation(s)
- Sercan Yalcin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Peter Y Joo
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - William McLaughlin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Jay Moran
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Dennis Caruana
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Michael Flores
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Jonathan Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Michael Medvecky
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
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McLaughlin WM, Gillinov SM, Joo PY, Moran J, Jimenez AE, Grauer JN, Gardner EC. Previous Isolated Medial Bucket-Handle Meniscus Repair Significantly Increases Risk of Subsequent Ipsilateral Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2023; 5:e671-e678. [PMID: 37388885 PMCID: PMC10300536 DOI: 10.1016/j.asmr.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 03/27/2023] [Indexed: 07/01/2023] Open
Abstract
Purpose (1) To define the incidence of surgically treated isolated bucket-handle meniscus tears (BHMTs); (2) to investigate risk of subsequent ipsilateral anterior cruciate ligament reconstruction (ACLR) in patients who underwent previous isolated bucket handle (BH) meniscus repair; and (3) to investigate the risk of subsequent ACLR for various types of surgically treated meniscal tears. Methods A retrospective review of a national database was conducted to identify patients, aged 10 to 40 years, who underwent primary isolated BH meniscus surgery from 2015 to 2020. Patients were stratified by operative method. A control group of 500,000 age-matched patients was randomly selected to establish a benchmark rate of ACLR. Kaplan-Meier analysis was performed to compare the timing and incidence of subsequent ipsilateral ACLR after primary isolated BH meniscus surgery to the control group within 2 and 5 years. Results In total, 1,767 patients with isolated BHMTs treated with surgery were identified and met inclusion criteria. The incidence of isolated BHMTs among all surgically treated (repair or meniscectomy) meniscal injuries was 1.67%. Isolated BH repairs had significantly greater odds of ACLR within 5 years compared to the control group (odds ratio [OR] 6.09; 95% confidence interval [CI] 2.86-12.99; P < .001). Medial BH repairs had the greatest odds of ACLR within 5 years (OR 9.15; 95% CI 4.27-19.57; P < .001). Lateral BH repair was not associated with subsequent ipsilateral ACLR within 5 years (OR 2.63; CI 0.37-18.90; P = .340). Conclusions Isolated BHMTs comprised 1.67% of all surgically treated meniscal injuries. Patients who underwent prior surgery for isolated BHMT were at increased risk of undergoing subsequent ipsilateral ACLR compared with the general population. Isolated medial BHMTs treated with repair had the highest risk for subsequent ACLR. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
- William M. McLaughlin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Stephen M. Gillinov
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Peter Y. Joo
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Jay Moran
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Andrew E. Jimenez
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Jonathan N. Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Elizabeth C. Gardner
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
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Rudisill KE, Ratnasamy PP, Joo PY, Rubin LE, Grauer JN. Magnetic Resonance Imaging in the Year Prior to Total Knee Arthroplasty: A Potential Overutilization of Healthcare Resources. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202305000-00019. [PMID: 37205731 PMCID: PMC10566819 DOI: 10.5435/jaaosglobal-d-22-00262] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 03/26/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Total knee arthroplasty (TKA) is a common procedure for late-stage degenerative changes, a situation for which magnetic resonance imaging (MRI) is typically not considered useful. In an era attempting to contain healthcare expenditures, the rate, timing, and predictors for MRI before TKA were assessed in a large, national, administrative data set. METHODS The 2010 to Q3 2020 MKnee PearlDiver data set was used to identify patients undergoing TKA for osteoarthritis. Those with lower extremity MRI for knee indications within 1 year before TKA were then defined. Patient age, sex, Elixhauser Comorbidity Index, region in the country, and insurance plan were characterized. Predictors of having had an MRI were assessed by univariate and multivariate analyses. The costs and timing of the obtained MRIs were also assessed. RESULTS Of 731,066 TKAs, MRI was obtained within 1 year prior for 56,180 (7.68%) with 28,963 (51.9%) within the 3 months of TKA. Independent predictors of having had an MRI included younger age (odds ratio [OR], 0.74 per decade increase), female sex (OR, 1.10), higher Elixhauser Comorbidity Index (OR, 1.15), region of the country (relative to South, Northeast OR, 1.08, West OR, 1.22, Midwest OR, 1.36), and insurance (relative to Medicare, Medicaid OR, 1.36 and Commercial OR, 1.35) with P < 0.0001 for each. The total cost of MRIs among patients who received a TKA is $44,686,308. CONCLUSION Noting that TKA is typically done for advanced degenerative changes, MRI should rarely be indicated in the preoperative period for this procedure. Nonetheless, this study found that MRI was done within the year before TKA for 7.68% of the study cohort. In an era striving for evidence-based medicine, the almost $45 million dollars spent on MRI in the year before TKA may represent overutilization.
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Affiliation(s)
- Katelyn E. Rudisill
- From the Department of Orthopedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Philip P. Ratnasamy
- From the Department of Orthopedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Peter Y. Joo
- From the Department of Orthopedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Lee E. Rubin
- From the Department of Orthopedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Jonathan N. Grauer
- From the Department of Orthopedics and Rehabilitation, Yale School of Medicine, New Haven, CT
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Joo PY, Wilhelm C, Adeclat G, Halperin SJ, Moran J, Elaydi A, Rubin LE, Grauer JN. Comparing Race/Ethnicity and Zip Code Socioeconomic Status for Surgical versus Nonsurgical Management of Proximal Humerus Fractures in a Medicare Population. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202305000-00011. [PMID: 37141180 PMCID: PMC10162786 DOI: 10.5435/jaaosglobal-d-22-00205] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 01/24/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND This study evaluated the effect of race/ethnicity and socioeconomic status (SES) on surgical utilization after proximal humerus fractures in a large Medicare cohort. METHODS The PearlDiver Medicare claims database was used to identify patients aged 65years and older with isolated, closed proximal humerus fractures, for whom race/ethnicity data were available (65.5% of identified fractures). Patients with polytrauma or neoplasm were excluded. Patient demographic, race/ethnicity, comorbidity, and median household income were compared for surgical versus nonsurgical management. Univariate and multivariable logistic regressions were used to determine disparities of surgical utilization based on the abovementioned factors. RESULTS Of 133,218 patients with proximal humerus fracture identified, surgery was conducted for 4446 (3.3%). Those less likely to receive surgery were older (incrementally by increasing age bracket up to 85 years and older odds ratio [OR], 0.16, P < 0.001), male (OR, 0.79, P < 0.001), Black (OR, 0.51, P < 0.001) or Hispanic (0.61, P = 0.005), higher Elixhauser Comorbidity Index (per 2 increase OR, 0.86, P < 0.001), and low median household income (OR, 0.79, P < 0.001). CONCLUSIONS The independent significance of race/ethnicity and SES point to disparities in surgical decision making/access to care. These findings highlight the need for increased attention on initiatives and policies that seek to eliminate racial disparities and improve health equity independent of SES.
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Affiliation(s)
- Peter Y. Joo
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Christopher Wilhelm
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Giscard Adeclat
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Scott J. Halperin
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Jay Moran
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Ali Elaydi
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Lee E. Rubin
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Jonathan N. Grauer
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
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Day W, Tang K, Joo PY, Grauer JN, Yalcin S, Wilhelm CV, Medvecky MJ. Opioid Prescription Patterns 90 Days After Arthroscopic Rotator Cuff Repair: A 10-Year National Database Analysis. Orthop J Sports Med 2023; 11:23259671231159063. [PMID: 37056452 PMCID: PMC10087648 DOI: 10.1177/23259671231159063] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 01/01/2023] [Indexed: 04/15/2023] Open
Abstract
Background Arthroscopic rotator cuff repair (ARCR) is a common procedure that typically requires opioid prescription for postoperative pain management. Purpose To investigate the current prescription patterns and factors influencing 90-day postoperative opioid prescription trends for opioid-naïve patients who underwent ARCR. Study Design Case series; Level of evidence, 4. Methods Opioid-naïve adult patients who underwent ARCR between January 2010 and September 2020 and had a record of opioid prescriptions during the 90-day postoperative period were identified in the PearlDiver Mariner91 national administrative database. Exclusions included patients with prior shoulder procedures, a history of chronic pain, and opioid prescription records dated earlier than 4 weeks before surgery. Covariates included age group, sex, Elixhauser Comorbidity Index, and prescriber specialty (orthopaedic or nonorthopaedic). The primary outcome-90-day postoperative morphine milligram equivalents (MMEs) prescribed per patient-was compared using univariate and multivariate regression analyses, and 90-day postoperative opioid prescription trends over the 10-year study period were analyzed with linear regression. Results In total, 55,345 ARCR cases were identified. The mean ± SD amount prescribed within the first 90 days was 742.4 ± 256.5 MMEs, and the median was 487.5 MMEs. Multivariate linear regression analysis predicted higher 90-day postoperative MMEs for female patients and younger patients (P < .01 for both). From 2010 to 2020, there was a 66% decrease in mean MME prescribed per patient (▵ = 660.4 MME; P < .01), with a mean reduction of 55.1 MME per patient per year. In 2020, the mean 90-day postoperative amount prescribed was 341.1 MME, which is equivalent to 51 tablets of 5-mg oxycodone (Percocet). Conclusion Female sex and younger age were predictors of more MME being prescribed after ARCR. While opioid prescriptions following ARCR have substantially decreased over the past decade, the amount prescribed warrants further attention.
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Affiliation(s)
- Wesley Day
- Albert Einstein College of Medicine,
Bronx, New York, USA
| | - Kevin Tang
- Albert Einstein College of Medicine,
Bronx, New York, USA
| | - Peter Y. Joo
- Department of Orthopaedics and
Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jonathan N. Grauer
- Department of Orthopaedics and
Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sercan Yalcin
- Department of Orthopaedics and
Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
| | - Christopher V. Wilhelm
- Department of Orthopaedics and
Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael J. Medvecky
- Department of Orthopaedics and
Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
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Joo PY, Zhu JR, Wilhelm C, Tang K, Day W, Moran J, Grauer JN. Anterior Cervical Discectomy and Fusion Outcomes in Patients With and Without Bariatric Surgery-Weight Loss Does Make a Difference. Spine (Phila Pa 1976) 2023; 48:400-406. [PMID: 36735637 DOI: 10.1097/brs.0000000000004580] [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: 10/12/2022] [Accepted: 12/30/2022] [Indexed: 02/04/2023]
Abstract
STUDY DESIGN A retrospective comparative cohort study. OBJECTIVE To compare outcomes of elective non-obese anterior cervical discectomy and fusion (ACDF) patients with those that underwent bariatric surgery (BS). SUMMARY OF BACKGROUND DATA Morbid obesity (MO) has been associated with an increased risk of complications following procedures such as elective ACDF. While pre-emptive BS has been considered for those with MO (body mass index [BMI] ≥35 kg/m 2 ), the impact of this intervention on BMI and its resultant correlation with surgical outcomes remains limited. METHODS The PearlDiver 2010-Q1 2020 MSpine database was used to identify patients undergoing elective isolated ACDF. Three sub-cohorts were defined as follows: (1) Non-obese controls without a history of BS, (2) patients with BS procedure within two years with a BMI <35 kg/m 2 (BS+MO-), and (3) patients with BS procedure within the two years with a BMI ≥35 kg/m 2 (BS+MO+). Univariate and multivariate regression analyses were performed to compare 90-day adverse event rates adjusting for age, sex, Elixhauser Comorbidity Index, and length of stay. Kaplan-Meier analysis was performed to assess five-year cervical reoperation rates. RESULTS Of 160,166 elective ACDF patients, prior BS was identified for 479. Of these, 136 patients were BS+MO- and 343 were BS+MO+. On multivariate analysis, BS+MO- were not at increased odds of adverse events, but BS+MO+ were at greater odds of 90-day pulmonary embolism (odds ratio 3.28, P =0.043), wound dehiscence (5.02, P <0.001), hematomas (2.52, P =0.042), and overall minor adverse events (1.61, P =0.011) compared with controls. Five-year reoperation rates were not significantly different between the groups. CONCLUSION Twenty-eight percent of those with BS before ACDF fell out of the categorization of MO. Among this group, the odds of adverse events were similar to non-obese patients. These findings suggest that the psychological preparation and BS alone are insufficient to reduce the risk of adverse events after ACDF. Weight reduction must be achieved as well, ideally moving patients out of the BMI range for morbid obesity.
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Affiliation(s)
- Peter Y Joo
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Justin R Zhu
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Christopher Wilhelm
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Kevin Tang
- Department of Orthopaedics and Rehabilitation, Albert Einstein College of Medicine, New York, NY
| | - Wesley Day
- Department of Orthopaedics and Rehabilitation, Albert Einstein College of Medicine, New York, NY
| | - Jay Moran
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
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Kahan JB, Burroughs P, Mclaughlin WM, Schneble CA, Moran J, Joo PY, Modrak M, Richter DL, Wascher D, Treme GP, Schenck RC, Grauer JN, Medvecky MJ. Comparative Success of Repair Versus Reconstruction for Knee Extra-articular Ligament Injuries. Orthop J Sports Med 2023; 11:23259671221143539. [PMID: 36743731 PMCID: PMC9893380 DOI: 10.1177/23259671221143539] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 09/13/2022] [Indexed: 01/25/2023] Open
Abstract
Background Surgical techniques and associated outcomes in treating acute and chronic extra-articular ligament knee injuries are in evolution, and there is question as to whether repair or reconstruction is optimal. Purpose/Hypothesis The purpose of this study was to compare the subsequent surgery rate between surgical repair versus reconstruction for all extra-articular ligament injuries of the knee utilizing a large database. Our hypothesis was that overall surgical repair of both lateral and medial extra-articular knee injuries would have a higher revision rate than those treated by reconstruction. Study Design Cohort study; Level of evidence, 3. Methods The PearlDiver Mariner data set (2010-2019), with 122 million patients, was utilized to generate 2 patient cohorts: those who underwent surgical repair and those who underwent surgical reconstruction of a knee extra-articular ligament injury. All patients had a minimum of 2 years follow-up. Rates of concomitant or subsequent cruciate ligament reconstruction and rates of secondary procedures were assessed and compared between the 2 cohorts. Results In total, 3563 patients were identified: extra-articular ligament reconstruction was performed for 2405 (67.5%), and repair was performed for 1158 (32.5%). Cruciate ligament reconstruction was performed for 986 (27.7%), of which 888 of 986 (90.1%) were performed on the same day as their extra-articular ligament procedure. At 2-year follow-up, the reconstruction cohort had higher rates of revision surgery compared with the repair cohort (8.2% vs 2.5%; P < .001). Conclusion Using a large national database, knee extra-articular ligamentous reconstructions (those on both the lateral and the medial side) had a 3.3 times higher rate of revision surgery compared with repair at 2-year follow-up. Further study is needed to investigate the causes leading to revision surgery and to determine the optimal surgical treatment for both medial and lateral extra-articular knee ligament injuries.
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Affiliation(s)
- Joseph B. Kahan
- Department of Orthopaedics and Rehabilitation, Yale School of
Medicine, New Haven, Connecticut, USA
| | | | - William M. Mclaughlin
- Department of Orthopaedics and Rehabilitation, Yale School of
Medicine, New Haven, Connecticut, USA
| | - Christopher A. Schneble
- Department of Orthopaedics and Rehabilitation, Yale School of
Medicine, New Haven, Connecticut, USA
| | - Jay Moran
- Yale School of Medicine, New Haven, Connecticut, USA
| | - Peter Y. Joo
- Department of Orthopaedics and Rehabilitation, Yale School of
Medicine, New Haven, Connecticut, USA
| | - Maxwell Modrak
- Department of Orthopaedics and Rehabilitation, Yale School of
Medicine, New Haven, Connecticut, USA
| | - Dustin L. Richter
- Department of Orthopaedics and Rehabilitation, University of New
Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Daniel Wascher
- Department of Orthopaedics and Rehabilitation, University of New
Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Gehron P. Treme
- Department of Orthopaedics and Rehabilitation, University of New
Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Robert C. Schenck
- Department of Orthopaedics and Rehabilitation, University of New
Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Jonathan N. Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of
Medicine, New Haven, Connecticut, USA
| | - Michael J. Medvecky
- Department of Orthopaedics and Rehabilitation, Yale School of
Medicine, New Haven, Connecticut, USA
- Michael J. Medvecky, MD, Department of Orthopaedics and
Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT 06510,
USA ()
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15
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Kammien AJ, Galivanche AR, Joo PY, Elaydi A, Whang P, Saifi C, Grauer JN, Varthi A. Comparison of postoperative outcomes in patients with and without osteoporosis undergoing single-level anterior cervical discectomy and fusion. N Am Spine Soc J 2022; 12:100174. [PMID: 36299450 PMCID: PMC9589019 DOI: 10.1016/j.xnsj.2022.100174] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/24/2022] [Accepted: 09/26/2022] [Indexed: 11/30/2022]
Abstract
Background Osteoporosis is ubiquitous in elderly populations, such as those undergoing ACDF. Short- and longer-term outcomes might be affected in the setting of osteoporosis related to graft subsidence, bony union, and stresses on adjacent segments. Better understanding the potential correlation of osteoporosis and outcomes after ACDF might affect patient counseling and surgical planning. The current study compares 90-day adverse events and 5-year reoperations following single-level anterior cervical discectomy and fusion (ACDF) between patients with and without osteoporosis. Methods Single-level ACDF procedures were identified in a national administrative database. Exclusion criteria included age under 18 years, less than 90 days of follow-up in the database, multi-level procedures, posterior concomitant procedures, and surgeries performed for trauma, neoplasm, or infection. After matching based on patient characteristics, 90-day perioperative adverse events were compared with multivariate analyses and five-year reoperations were compared with log-rank analysis. Reasons for reoperations were also evaluated. Results Relative to age, sex, and comorbidity-matched patients without osteoporosis, those with osteoporosis had a small but statistically greater incidence of experiencing any 90-day adverse event (10.9% vs 9.4%, p < 0.001) and 5-year reoperations (19.1% vs 17.0%, p < 0.001). Of those requiring reoperation, those in the osteoporosis group had a greater proportion for nonunion (7.5% vs 5.6% p = 0.003). Conclusions Following single-level ACDF, patients with osteoporosis experience slightly greater 90-day adverse events and 5-year reoperations. These results suggest the importance of recognizing osteoporosis in the ACDF population and accounting for this with surgical planning and patient counselling.
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Affiliation(s)
- Alexander J. Kammien
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Anoop R. Galivanche
- Department of Orthopaedic Surgery, University of California San Diego Health System
| | - Peter Y. Joo
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Ali Elaydi
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Peter Whang
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Comron Saifi
- Department of Orthopedic Surgery, Houston Methodist
| | - Jonathan N. Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Arya Varthi
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
- Corresponding author at: Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA.
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Burroughs PJ, Kahan JB, Moran J, Gillinov SM, Joo PY, Schneble CA, Moore HG, Grauer JN, Medvecky MJ. Subsequent Surgery Up to 10 Years After Osteochondral Allograft and Osteochondral Autograft: An Analysis of More Than 2000 Patients. Orthop J Sports Med 2022; 10:23259671221139127. [PMID: 36582936 PMCID: PMC9793021 DOI: 10.1177/23259671221139127] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 09/08/2022] [Indexed: 12/24/2022] Open
Abstract
Background Osteochondral allograft transplant (OCA) and osteochondral autograft transfer (OAT) replace damaged cartilage with a plug of bone and overlying articular cartilage; however, limited research is available regarding the survival of these osteoarticular grafting procedures. Hypothesis We hypothesized that patients who underwent OCA would have a higher rate of subsequent surgery over the course of 5 years compared with patients who underwent OAT. Study Design Cohort study; Level of evidence, 3. Methods The PearlDiver Mariner administrative database was used to identify patients 10 to 59 years old who had undergone OCA or OAT between 2010 and 2018. All included patients were assessed for subsequent knee surgeries, defined by the occurrence of a subsequent osteochondral procedure (OCA or OAT) or any type of knee arthroplasty for the duration of the time they were included in the data set (maximum of 10 years). Analyses were performed for the total population and those with allograft versus autograft (compared using the Fisher exact test). The 5-year Kaplan-Meier survival curves for operation-free survival were compared using a Mantel-Cox log-rank test. Results In total, 2598 patients were identified: 1631 patients who underwent OCA (34.5 ± 12.1 years old; 51.6% female) and 967 patients who underwent OAT (32.1 ± 12.9 years old; 51.0% female). Both groups had similarly high rates of subsequent knee surgeries (23.9% vs 21.9%, respectively; P = .249), with no statistical differences in rates of subsequent surgery between groups. Kaplan-Meier survival curves comparing operation-free survival at 5 years indicated no significant difference between the groups (OCA, 88.0% vs OAT, 89.5%; P = .235). Conclusion Both osteochondral grafting procedures carried a relatively high rate of secondary surgery, which increased with time. The 5-year survival analysis revealed similarly high rates of subsequent surgery.
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Affiliation(s)
| | - Joseph B. Kahan
- Department of Orthopaedics and Rehabilitation, Yale School of
Medicine, New Haven, Connecticut, USA
| | - Jay Moran
- Department of Orthopaedics and Rehabilitation, Yale School of
Medicine, New Haven, Connecticut, USA
| | - Stephen M. Gillinov
- Department of Orthopaedics and Rehabilitation, Yale School of
Medicine, New Haven, Connecticut, USA
- Stephen M. Gillinov, AB, Department of Orthopaedics and
Rehabilitation, Yale School of Medicine, 367 Cedar Street, New Haven, CT 06511,
USA () (Twitter: @StephenGillinov)
| | - Peter Y. Joo
- Department of Orthopaedics and Rehabilitation, Yale School of
Medicine, New Haven, Connecticut, USA
| | - Christopher A. Schneble
- Department of Orthopaedics and Rehabilitation, Yale School of
Medicine, New Haven, Connecticut, USA
| | - Harold G. Moore
- Department of Orthopaedic Surgery, UT Southwestern, Dallas, Texas,
USA
| | - Jonathan N. Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of
Medicine, New Haven, Connecticut, USA
| | - Michael J. Medvecky
- Department of Orthopaedics and Rehabilitation, Yale School of
Medicine, New Haven, Connecticut, USA
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Joo PY, Modrak M, Park N, Brand J, Rubin LE, Grauer JN, Bernstein JA. Comparing Venous Thromboembolism Prophylactic Agents After Hip Fracture Surgery: A National Database Study. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202212000-00009. [PMID: 36732301 PMCID: PMC9746777 DOI: 10.5435/jaaosglobal-d-22-00228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Although the use of venous thromboembolism (VTE) chemoprophylaxis has markedly reduced VTE rates after hip fracture surgery, few studies have directly compared the efficacy of different anticoagulant agents in this setting. The purpose of this study was to compare outcomes of Lovenox, Eliquis, or Coumadin as VTE prophylaxis after hip fracture surgery. METHODS The PearlDiver MHip national database was queried for patients older than 60 years undergoing first-time hip fracture surgery with no concurrent pelvic or distal femoral fractures. Prescriptions for Lovenox, Eliquis, or Coumadin were identified. Univariate and multivariate analyses of patient characteristics, 90-day incidences of VTE, adverse events, and readmissions were compared. Odds ratios (ORs) were calculated, and significance was set at P < 0.01 based on Bonferroni adjustment. RESULTS A total of 11,384 patients were identified, with the Lovenox used for 6835 patients (60.0%), Eliquis for 1092 patients (9.6%), and Coumadin for 3457 patients (30.4%). The prevalence of 90-day VTE in the Lovenox, Eliquis, and Coumadin groups was 3.1%, 3.8%, and 5.0%, respectively (P < 0.001). Multivariate analyses adjusting for demographic and comorbidity profiles were conducted with Lovenox as the referent. Those on Eliquis had significantly lower transfusions (OR 0.52, P = 0.005), but similar rates of other outcomes including VTE (P > 0.01). Conversely, patients on Coumadin had significantly greater odds of any adverse event (OR 1.18, P < 0.001) and VTE (OR 1.58, P < 0.001). DISCUSSION In evaluating Lovenox, Eliquis, and Coumadin as VTE chemoprophylactic agents after hip fracture surgery in anticoagulant-naïve patients, Lovenox and Eliquis had similar 90-day VTE, whereas patients on Coumadin had greater odds of 90-day VTE. Interestingly, patients on Eliquis had nearly two-fold lower odds of transfusions compared with patients on Lovenox. Although consensus on the optimal VTE prophylactic agent after hip fracture surgery does not exist, Eliquis and Lovenox may be comparable options and seem to be more effective than Coumadin.
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18
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Joo PY, Borjali A, Chen AF, Muratoglu OK, Varadarajan KM. Defining and predicting radiographic knee osteoarthritis progression: a systematic review of findings from the osteoarthritis initiative. Knee Surg Sports Traumatol Arthrosc 2022; 30:4015-4028. [PMID: 35112180 DOI: 10.1007/s00167-021-06768-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 08/16/2021] [Accepted: 10/04/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE The purposes of this systematic review were to (1) identify the commonly used definitions of radiographic KOA progression, (2) summarize the important associative risk factors for disease progression based on findings from the OAI study and (3) summarize findings from radiographic KOA progression prediction modeling studies regarding the characterization of progression and outcomes. METHODS A systematic review was performed by conducting a literature search of definitions, risk factors and predictive models for radiographic KOA progression that utilized data from the OAI database. Radiographic progression was further characterized into "accelerated KOA" and "typical progression," as defined by included studies. RESULTS Of 314 studies identified, 41 studies were included in the present review. Twenty-eight (28) studies analyzed risk factors associated with KOA progression, and 13 studies created or validated prediction models or risk calculators for progression. Kellgren-Lawrence (KL) grade based on radiographs was most commonly used to characterize KOA progression (50%), followed by joint space width (JSW) narrowing (32%) generally over 48 months. Risk factors with the highest odds ratios (OR) for progression included periarticular bone mineral density (OR 10.40), any knee injury within 1 year (OR 9.22) and baseline bone mineral lesions (OR 7.92). Nine prediction modeling studies utilized both clinical and structural risk factors to inform their models, and combined models outperformed purely clinical or structural models. CONCLUSION The cumulative evidence suggests that combinations of structural and clinical risk factors may be able to predict radiographic KOA progression, particularly in patients with accelerated progression. Clinically relevant and feasible prediction models and risk calculators may provide valuable decision-making support when caring for patients at risk of KOA progression, although standardization in modeling and variable identification does not yet exist.
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Affiliation(s)
- Peter Y Joo
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Alireza Borjali
- Harris Orthopaedics Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, GRJ-12-1223, Boston, MA, 02214, USA.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, USA
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Orhun K Muratoglu
- Harris Orthopaedics Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, GRJ-12-1223, Boston, MA, 02214, USA.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, USA
| | - Kartik M Varadarajan
- Harris Orthopaedics Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, GRJ-12-1223, Boston, MA, 02214, USA. .,Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, USA.
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Gillinov SM, Joo PY, Zhu JR, Moran J, Rubin LE, Grauer JN. Incidence, Timing, and Predictors of Hip Dislocation After Primary Total Hip Arthroplasty for Osteoarthritis. J Am Acad Orthop Surg 2022; 30:1047-1053. [PMID: 35947825 PMCID: PMC9588560 DOI: 10.5435/jaaos-d-22-00150] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 06/11/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Total hip arthroplasty (THA) may be complicated by dislocation. The incidence of and risk factors for dislocation are incompletely understood. This study aimed to determine the incidence and predictors of hip dislocation within 2 years of primary THA. METHODS The 2010 to 2020 PearlDiver MHip database was used to identify patients undergoing primary THA for osteoarthritis with a minimum of 2 years of postoperative data. Dislocation was identified by associated codes. Age, sex, body mass index, Elixhauser Comorbidity Index, fixation method, and bearing surface were compared for patients with dislocation versus control subjects by multivariate regression. Timing and cumulative incidence of dislocation were assessed. RESULTS Among 155,185 primary THAs, dislocation occurred within 2 years in 3,630 (2.3%). By multivariate analysis, dislocation was associated with younger age (<65 years), female sex, body mass index < 20, higher Elixhauser Comorbidity Index, cemented prosthesis, and use of metal-on-poly or metal-on-metal implants ( P< 0.05 for each). Among patients who experienced at least one dislocation, 52% of first-time dislocations occurred in the first 3 months; 57% had more than one and 11% experienced >5 postoperative dislocation events. Revision surgery was done within 2 years of index THA for 45.6% of those experiencing dislocation versus 1.8% of those who did not ( P < 0.001). CONCLUSION This study found that 2.3% of a large cohort of primary THA patients experienced dislocation within 2 years, identified risk factors for dislocation, and demonstrated that most patients experiencing dislocation had recurrent episodes of instability and were more likely to require revision surgery.
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Affiliation(s)
- Stephen M Gillinov
- From the Yale School of Medicine, New Haven, CT (Gillinov, Joo, Zhu, and Moran); Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT (Rubin and Grauer)
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Joo PY, Moran J, Wilhelm C, Ready J, Rubin LE, Grauer JN. Orthopaedic Program Reputation and Association With Social Media Utilization and Engagement. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202211000-00008. [PMID: 36733982 PMCID: PMC9649274 DOI: 10.5435/jaaosglobal-d-22-00095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 09/05/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND The associations of orthopaedic social media metrics with US News & World Report (USNWR) scores have not been well defined and are the focus of this study. METHODS Orthopaedic surgery departments and residency programs were matched to the USNWR overall orthopaedic score and professional opinion subscore. Corresponding Instagram and Twitter accounts were evaluated for the number of followers, number following, and posts. Correlations between these metrics and rank/reputation were assessed. Pearson correlations and Student t tests were used with significance set at P < 0.05. RESULTS Of the 192 departments associated with residency programs, there were social media accounts for 150 (78.1%) and USNWR rankings for 186 (96.9%), with an overlap of 147 (76.6%). Instagram accounts were identified for 138 (93.9%) and Twitter accounts for 85 (57.8%). Correlations were highest for the opinion subscore and number of followers (Instagram department R = 0.894, Instagram residency R = 0.338, Twitter department R = 0.808, and Twitter residency R = 0.878, P < 0.001 for each), less for the number of posts (Instagram department R = 0.590, Twitter department R = 0.521, and Twitter residency R = 0.696, P < 0.001 for each). CONCLUSION Social media metrics correlated with USNWR scores. Focusing on such social media platforms may help further the reputation, audience engagement, and ranking of orthopaedic departments and residencies.
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21
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Gouzoulis MJ, Joo PY, Kammien AJ, McLaughlin WM, Yoo B, Grauer JN. Risk factors for venous thromboembolism following fractures isolated to the foot and ankle fracture. PLoS One 2022; 17:e0276548. [PMID: 36264985 PMCID: PMC9584400 DOI: 10.1371/journal.pone.0276548] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 10/07/2022] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE Venous thromboembolism (VTE) is an uncommon, but potentially morbid, complication following foot and ankle fractures. Current standard is to not administer thromboprophylaxis to patients with such injuries. Nonetheless, patient and fracture factors might affect this risk/benefit consideration. The goal of this study was to determine what patients are most at risk. METHODS The M53Ortho Pearldiver database was used to identify patients with fractures isolated to the foot and ankle that were treated non-operatively or operatively. Patients with pilon, other appendicular fractures remote from the foot and ankle, and other traumatic injuries were excluded. The 90-day occurrence of VTE was identified based on codes for deep vein thrombosis or pulmonary embolism. Characteristics of those patients who did and did not have VTEs were compared using chi-square analyses. Multivariate logistical regression was then performed to determined factors independently associated with VTE. Finally, timing of VTE relative to fracture was analyzed. RESULTS A total of 298,886 patients with isolated foot or ankle fractures were identified, of which 1,661 (0.56%) had VTE in the 90 days following fracture. In terms of timing, 27.3% occurred in the first week, and 49.8% occurred in the first three weeks. Independent risk factors for VTE included (in decreasing order):prior VTE (odd ratio [OR] = 25.44), factor V Leiden (OR = 24.34), active cancer (OR = 1.84), specific fracture relative to metatarsal fracture (multiple fractures [OR: 1.51], ankle fracture [OR = 1.51], and calcaneus fracture [OR = 1.24]), surgical treatment (OR = 1.41), male sex (OR = 1.19), greater Elixhauser index (OR = 1.05), and increasing age (OR:1.05 per decade) (p<0.05 for each). CONCLUSIONS The present study found that, although only 0.56% of isolated foot and ankle fractures had a VTE within ninety days. Defined risk factors, such as Factor V Leiden, prior VTE, surgical treatment, active cancer, specific fracture patterns, and surgical treatment significantly affected the odds of their occurrence.
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Affiliation(s)
- Michael J. Gouzoulis
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, United States of America
| | - Peter Y. Joo
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, United States of America
| | - Alexander J. Kammien
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, United States of America
| | - William M. McLaughlin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, United States of America
| | - Brad Yoo
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, United States of America
| | - Jonathan N. Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, United States of America
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22
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Joo PY, Caruana DL, Gouzoulis MJ, Moore HG, Zhu JR, Ameri B, Grauer JN. Marfan syndrome and adolescent idiopathic scoliosis patients have similar 90-day postoperative outcomes and 5-year reoperation rates after spinal deformity surgery. Spine Deform 2022; 10:1169-1174. [PMID: 35362940 DOI: 10.1007/s43390-022-00501-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 10/23/2021] [Accepted: 03/19/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Outcomes after spinal deformity surgery in patients with Marfan syndrome (MFS) are poorly characterized given the rarity of the condition. Updated analyses from nationally representative samples, and comparison to outcomes after more commonly performed procedures for conditions such as adolescent idiopathic scoliosis (AIS) could help define the relative risks. METHODS Using the 2010-2020 PearlDiver administrative databases, patients who underwent posterior spinal fusion for > 7 segments were extracted. MFS patients were matched 1:4 to AIS patients based on age, sex, and Elixhauer comorbidity index (ECI). Ninety-day outcomes and 5-year reoperation rates were compared. Significance was set at p < 0.05. RESULTS In total, 206 MFS patients were matched to 825 AIS patients. After adjusting for age, sex, and ECI, multivariate odds ratios (OR) for 90-day any, serious, and minor adverse events, as well as readmissions, were not significantly different for those with MFS compared to those with AIS (p > 0.05 for each). Five-year reoperation rates were also not significantly different (13.1% for the MFS cohort and 13.0% for the AIS cohort (no difference by log-rank, p = 0.9). CONCLUSION While deformity surgery is much less commonly performed for MFS than AIS, it is not uncommonly considered for patients with this condition. Despite some known technical challenges for MFS deformity surgery, the current study leveraged a large, national database to find that 90-day adverse events and 5-year reoperations were not different for matched MFS and AIS patients undergoing deformity surgery. For select patients, these findings should be useful for surgical planning and patient counseling.
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Affiliation(s)
- Peter Y Joo
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06510, USA
| | - Dennis L Caruana
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06510, USA
| | - Michael J Gouzoulis
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06510, USA
| | - Harold G Moore
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06510, USA
| | - Justin R Zhu
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06510, USA
| | - Bijan Ameri
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06510, USA
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06510, USA.
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Joo PY, Chen AF, Richards J, Law TY, Taylor K, Marchand K, Clark G, Collopy D, Marchand RC, Roche M, Mont MA, Malkani AL. Clinical results and patient-reported outcomes following robotic-assisted primary total knee arthroplasty : a multicentre study. Bone Jt Open 2022; 3:589-595. [PMID: 35848995 PMCID: PMC9350694 DOI: 10.1302/2633-1462.37.bjo-2022-0076.r1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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] [Indexed: 12/02/2022] Open
Abstract
Aims The aim of this study was to report patient and clinical outcomes following robotic-assisted total knee arthroplasty (RA-TKA) at multiple institutions with a minimum two-year follow-up. Methods This was a multicentre registry study from October 2016 to June 2021 that included 861 primary RA-TKA patients who completed at least one pre- and postoperative patient-reported outcome measure (PROM) questionnaire, including Forgotten Joint Score (FJS), Knee Injury and Osteoarthritis Outcomes Score for Joint Replacement (KOOS JR), and pain out of 100 points. The mean age was 67 years (35 to 86), 452 were male (53%), mean BMI was 31.5 kg/m2 (19 to 58), and 553 (64%) cemented and 308 (36%) cementless implants. Results There were significant improvements in PROMs over time between preoperative, one- to two-year, and > two-year follow-up, with a mean FJS of 17.5 (SD 18.2), 70.2 (SD 27.8), and 76.7 (SD 25.8; p < 0.001); mean KOOS JR of 51.6 (SD 11.5), 85.1 (SD 13.8), and 87.9 (SD 13.0; p < 0.001); and mean pain scores of 65.7 (SD 20.4), 13.0 (SD 19.1), and 11.3 (SD 19.9; p < 0.001), respectively. There were eight superficial infections (0.9%) and four revisions (0.5%). Conclusion RA-TKA demonstrated consistent clinical results across multiple institutions with excellent PROMs that continued to improve over time. With the ability to achieve target alignment in the coronal, axial, and sagittal planes and provide intraoperative real-time data to obtain balanced gaps, RA-TKA demonstrated excellent clinical outcomes and PROMs in this patient population. Cite this article: Bone Jt Open 2022;3(7):589–595.
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Affiliation(s)
- Peter Y Joo
- University of Rochester Medical Center, Rochester, New York, USA
| | - Antonia F Chen
- Department of Orthopaedics, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jarod Richards
- Department of Orthopaedics, University of Louisville, Louisville, Kentucky, USA
| | - Tsun Y Law
- Department of Orthopaedics, Holy Cross Hospital, Fort Lauderdale, Florida, USA
| | - Kelly Taylor
- Orthopedics Rhode Island, Providence, Rhode Island, USA
| | - Kevin Marchand
- Department of Orthopaedics, Lenox Hill Hospital, New York, New York, USA
| | | | | | | | - Martin Roche
- Department of Orthopaedics, Holy Cross Hospital, Fort Lauderdale, Florida, USA
| | - Michael A Mont
- Rubin Institute for Advanced Orthopedic Surgery, Baltimore, Maryland, USA
| | - Arthur L Malkani
- Department of Orthopaedics, University of Louisville, Louisville, Kentucky, USA
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Joo PY, Jayaram RH, McLaughlin WM, Ameri B, Kammien AJ, Arnold PM, Grauer JN. Four-level anterior versus posterior cervical fusions: Perioperative outcomes and five-year reoperation rates: Outcomes after four-level anterior versus posterior cervical procedures. N Am Spine Soc J 2022; 10:100115. [PMID: 35392022 PMCID: PMC8980614 DOI: 10.1016/j.xnsj.2022.100115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 03/17/2022] [Indexed: 01/06/2023]
Abstract
Background Multilevel cervical pathology can often be addressed via anterior cervical discectomy and fusion (ACDF) or posterior cervical fusion (PCF). While posterior procedures may be technically easier for four-level pathology, there are advantages and disadvantages to both approaches that make it of interest to compare outcomes. The purpose was to compare perioperative adverse events and long-term cervical reoperation rates of four-level ACDF and PCF. Methods The 2010 to Q1 2020 PearlDiver MSpine database was queried. Patients undergoing isolated elective four-level ACDF or PCF were identified (excluding cases performed for trauma, neoplasm, and/or infections) and 1:1 matched based on age, sex, and comorbidities. Ninety-day adverse events were compared with univariate and multivariate analyses. Five-year incidences of subsequent cervical reoperations were also compared. Results A total of 3,714 patients 1:1 matched for four-level ACDF and PCF performed for degenerative pathologies were identified (1,857 for each of the study groups). On multivariate analysis controlling for age, sex, and comorbidities, PCF was found to have significantly greater odds ratios (OR) for any (OR 2.12), serious (OR 2.31), and minor (OR 1.95) adverse events, as well as for length of stay ≥3 days (OR 1.76), p<0.001 for each. However, PCF had nearly three times lower odds of dysphagia compared to ACDF (OR 0.36, p<0.001). At five years, four-level ACDF cases were found to have significantly higher reoperation rates compared to four-level PCF cases (26.3% vs 18.3%, p<0.001). Conclusion In evaluating four-level cervical cases, compared to anterior approach cases, posterior approach procedures were associated with approximately double the odds of any, serious, and minor adverse events, but around one third the rate of dysphagia and two thirds the rate of five-year reoperations. While the pathology may dictate surgical approach, this data suggests that the choice between four-level anterior versus posterior approach becomes a balance of risks/benefit considerations.
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Affiliation(s)
- Peter Y. Joo
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, United States
| | - Rahul H. Jayaram
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, United States
| | - William M. McLaughlin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, United States
| | - Bijan Ameri
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, United States
| | - Alexander J. Kammien
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, United States
| | - Paul M. Arnold
- Department of Neurosurgery, Carle Illinois College of Medicine, Champaign, IL, United States
| | - Jonathan N. Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, United States
- Corresponding author at: Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT 06510, United States.
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Joo PY, Zhu JR, Kammien AJ, Gouzoulis MJ, Arnold PM, Grauer JN. Clinical outcomes following one-, two-, three-, and four-level anterior cervical discectomy and fusion: a national database study. Spine J 2022; 22:542-548. [PMID: 34774751 DOI: 10.1016/j.spinee.2021.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 08/18/2021] [Revised: 10/15/2021] [Accepted: 11/01/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND CONTEXT Anterior cervical discectomy and fusion (ACDF) is a common surgical procedure. There is markedly less data on outcomes after three- and four-level cases than one- and two-level cases. PURPOSE To compare perioperative 90-day adverse events and 5-year reoperation rates between isolated one-, two-, three-, and four-level ACDF cases. STUDY DESIGN/SETTING Retrospective review of a large national database. PATIENT SAMPLE Overall, 97,081 patients undergoing ACDF were identified, of which one-level cases were 42,382 (43.7%), two-level cases were 24,055 (24.8%), three-level cases were 28,293 (29.1%), and four-level cases were 2,361 (2.4%). OUTCOME MEASURES Ninety-day adverse events and 5-year reoperation rates. METHODS The 2010 to Q1 2020 PearlDiver database was queried to identify patients who underwent elective ACDF for degenerative pathology without corpectomy or concomitant posterior procedures. Univariate and multivariate analyses were performed to compare outcomes of subcohorts with varying number of levels addressed by ACDF. RESULTS Of the 97,081 cases identified, patient characteristics and complication rates differed between the cohorts defined by levels treated. Univariate analyses revealed statistically different rates of 90-day any, serious, and minor adverse event rates between the groups, but the differences were all less than 2.5%. Readmission rates were statistically different by 2.9%, dysphagia by 3.2%, and prolonged length of stay by 6.3%.By multivariate analyses, three-level ACDF cases were not found to have greater 90-day adverse outcomes than two-level cases. Four-level ACDF cases were found to have significantly greater odds ratios of readmission, dysphagia, and prolonged length of stay (relative to one-level cases, OR 1.28, 1.63, and 1.97, respectively) but not other 90-day adverse events. Reoperation rates at five years for one-, two-, three-, and four-level cases were 13.0%, 13.5%, 15.0%, and 22.1%, respectively (log-rank p<.001). CONCLUSIONS The current study represents one of the largest comparative studies of patients undergoing one-, two-, three-, and four-level ACDF. While odds of 90-day adverse events were not greater for three- versus two-level cases, four-level cases had several that were higher odds than one-level cases. Reoperation and dysphagia rates were higher for four-level cases than lesser levels. While these outcomes were found to be acceptable, they should help guide hospital planning and patient counseling.
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Affiliation(s)
- Peter Y Joo
- Department of Orthopedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, USA
| | - Justin R Zhu
- Department of Orthopedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, USA
| | - Alexander J Kammien
- Department of Orthopedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, USA
| | - Michael J Gouzoulis
- Department of Orthopedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, USA
| | | | - Jonathan N Grauer
- Department of Orthopedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, USA.
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Moran J, Kahan JB, Morris J, Joo PY, O’Connor MI. Tranexamic Acid Administration at Hospital Admission Decreases Transfusion Rates in Geriatric Hip Fracture Patients Undergoing Surgery. Geriatr Orthop Surg Rehabil 2022; 13:21514593221124414. [PMID: 36081840 PMCID: PMC9445454 DOI: 10.1177/21514593221124414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 08/02/2022] [Accepted: 08/17/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction The timing of tranexamic acid (TXA) administration in fragility hip fracture patients is controversial. Prior studies have demonstrated reduction in transfusion requirements using the two-dose arthroplasty model. However, unlike arthroplasty patients whose bleeding starts at the time of surgical incision, hip fractures have an onset of bleeding at the time of the injury. The primary goal of this study was to evaluate the optimal timing of TXA administration and to determine its effect on red blood cell transfusions in fragility hip fracture patients. Methods All patients admitted to the fragility hip fracture service from April 1, 2019 to September 30, 2019 were prospectively screened for inclusion in the study. Eligible patients received 4 intravenous doses of TXA: Ineligible patients received no TXA. Patients with medical conditions precluding the use of TXA were deemed ineligible: allergy to TXA; creatinine clearance <30 mL/min; active malignancy; vascular event in the past year; anticoagulant use; fracture >48 hours prior to presentation. A subset of patients received only admission TXA dosing and a separate subset of patients received only incision and post op TXA dosing. Red blood cell transfusions, major adverse vascular events, and minor drug and infusion-related adverse events were recorded for all subgroups of patients. Results A total of 508 patients were eligible for analysis. In total, 180 patients received no TXA, 32 patients only received the admission doses of TXA, 112 patients received only the arthroplasty based (incision and post op) doses of TXA, and 183 patients received all 4 doses of TXA. The transfusion rate was significantly lower in patients who received all 4 doses of TXA (8.7%) and in those who only received one dose of TXA at admission (9.4%) compared to patients who received TXA at incision and recovery room (25.7%) or those patients who did not receive TXA prophylaxis (29.4%) (P = 0.001). Additionally, the transfusion rate for intramedullary nailing was higher compared to patients undergoing any other procedure (27% vs 13.8%, P < 0.001). Conclusions Patients with fragility hip fractures who received IV TXA at hospital admission have significantly lower transfusion rates compared to those who received no tranexamic acid or those who received two dose-TXA (at the operative incision and in the post-operative recovery room). These findings suggest that isolated dosing of TXA at hospital admission may be more effective at reducing post-operative bleeding than the traditional arthroplasty dosing (incision and post-op doses) and is equally as effective as the 4-dose TXA protocol in hip fracture patients undergoing surgery.
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Affiliation(s)
- Jay Moran
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Joseph B. Kahan
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Jensa Morris
- Center for Musculoskeletal Care and Yale New Haven Health, Yale School of Medicine, New Haven, CT, USA
- Hospitalist Service, Yale New Haven Hospital, New Haven, CT, USA
| | - Peter Y. Joo
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Mary I. O’Connor
- Department of Orthopaedic Surgery, Vori Health, San Francisco Bay Area, CA, USA
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Joo PY, Grauer JN. The posterior superior iliac rim screw as an adjunct to pelvic fixation in complex spinopelvic stabilization. N Am Spine Soc J 2021; 8:100094. [PMID: 35141658 PMCID: PMC8820036 DOI: 10.1016/j.xnsj.2021.100094] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/31/2021] [Accepted: 11/12/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Fixation to the ilium is a commonly used alternative or supplement to sacral fixation in complex spinopelvic reconstructions. This can be achieved with traditional posterior superior iliac spine or S2 alar-iliac screws. Posterior superior iliac rim screws may be considered to achieve or enhance pelvic fixation. The objective of this case series was to describe the use of and indications for posterior superior iliac rim screws. METHODS A retrospective review was performed of the medical records and radiographic data for three patients who underwent complex lumbosacral reconstructions involving the use of posterior superior iliac rim screws to enhance pelvic fixation. The cases included a 35-year-old with bilateral sacral fractures, a 43-year-old with extensive metastatic sarcoma to the sacrum, and a 48-year-old with multiple lumbar and pelvic fractures. An overview of the key surgical techniques is provided. RESULTS All three patients tolerated the procedure, without any unexpected post-operative complications or deficits. Radiographs at last follow-up showed stable fixation and no hardware issues. CONCLUSIONS The use of posterior superior iliac rim screws as an adjunct method of fixation in complex spinopelvic reconstructions is a feasible option that can be considered in the fixation armamentarium.
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Affiliation(s)
| | - Jonathan N. Grauer
- Corresponding author at: Yale University School of Medicine, Department of Orthopaedics and Rehabilitation, 47 College Street, New Haven, CT, 06510, USA.
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Joo PY, Baumhauer JF, Waldman O, Hoffman S, Houck J, Kohring JM, Flemister AS, Ketz JP, DiGiovanni BF, Oh I. Physical Function and Pain Interference Levels of Hallux Rigidus Patients Before and After Synthetic Cartilage Implant vs Arthrodesis Surgery. Foot Ankle Int 2021; 42:1277-1286. [PMID: 34024138 DOI: 10.1177/10711007211007843] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND Hallux rigidus is a common and painful degenerative condition of the great toe limiting a patient's physical function and quality of life. The purpose of this study was to investigate pre- and postoperative physical function (PF) and pain interference (PI) levels of patients undergoing synthetic cartilage implant hemiarthroplasty (SCI) vs arthrodesis (AD) for treatment of hallux rigidus using the Patient-Reported Outcomes Measurement Information System (PROMIS). METHODS PROMIS PF and PI t scores were analyzed for patients who underwent either SCI or AD. Postoperative final PROMIS t scores were obtained via phone survey. Linear mixed model analysis was used to assess differences in PF and PI at each follow-up point. Final follow-up scores were analyzed using independent sample t tests. RESULTS Total 181 (59 SCI, 122 AD) operatively managed patients were included for analysis of PROMIS scores. Final phone survey was performed at a minimum of 14 (mean 33, range, 14-59) months postoperatively, with 101 patients (40 SCI, 61 AD) successfully contacted. The mean final follow-up was significantly different for SCI and AD: 27 vs 38 months, respectively (P < .01). The mean age of the SCI cohort was lower than the AD cohort (57.5 vs 61.5 years old, P = .01). Average PF t scores were higher in the SCI cohort at baseline (47.1 and 43.9, respectively, P = .01) and at final follow-up (51.4 vs 45.9, respectively, P < .01). A main effect of superior improvement in PF was noted in the SCI group (+4.3) vs the AD group (+2) across time intervals (P < .01). PI t scores were similar between the 2 procedures across time points. CONCLUSION The SCI cohort reported slightly superior PF t scores preoperatively and at most follow-up time points compared with the arthrodesis group. No differences were found for PI or complication rates between the 2 treatment groups during this study time frame. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Peter Y Joo
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Judith F Baumhauer
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Olivia Waldman
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Samantha Hoffman
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Jeffrey Houck
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Jessica M Kohring
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - A Samuel Flemister
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - John P Ketz
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Benedict F DiGiovanni
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Irvin Oh
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
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