James Ficke - Profile on Academia.edu (original) (raw)
Papers by James Ficke
Journal of Bone and Joint Surgery, 2017
Background: The 3-dimensional nature of adult acquired flatfoot deformity can be challenging to c... more Background: The 3-dimensional nature of adult acquired flatfoot deformity can be challenging to characterize using radiographs. We tested the hypothesis that measurements on weight-bearing (WB) cone-beam computed tomography (CT) images were more useful for demonstrating the severity of the deformity than non-weight-bearing (NWB) measurements. Methods: We prospectively enrolled 12 men and 8 women (mean age, 52 years; range, 20 to 88 years) with flexible adult acquired flatfoot deformity. The subjects underwent cone-beam CT while standing (WB) and seated (NWB), and images were assessed in the sagittal, coronal, and axial planes by 3 independent observers who performed multiple measurements. Intraobserver and interobserver reliabilities were assessed with the Pearson or Spearman correlation and the intraclass correlation coefficient (ICC), respectively. Measurements were compared using paired Student t tests or Wilcoxon rank-sum tests. P < 0.05 was considered significant. Results: W...
Adult acquired flatfoot deformity: Comparison of weightbearing and nonweightbearing CT examinations
Foot and Ankle Surgery, 2016
True Grit in Leadership
Journal of Bone and Joint Surgery, American Volume, May 15, 2019
: Grit is a positive noncognitive trait that is based on an individual’s passion for long-term go... more : Grit is a positive noncognitive trait that is based on an individual’s passion for long-term goals, coupled with a powerful motivation to achieve. Grit has been shown to be a greater predictor of success than intelligence. As the curriculum for orthopaedic trainees continues to evolve, deliberate practice for surgical skills, encouraging a growth mindset, and enhancing grit may be as important as preparation for board examinations. Although talent and skill play a role in achievement, the effort put forth in developing a skill can dramatically affect the ultimate achievement. Therefore, grit is a trait that can be developed. As educators, we can encourage hard work, reflection, and appropriate risk-taking. Implicit biases and microaggressions occur on a daily basis within orthopaedics, and grit will be an important trait to possess in order to combat these biases. However, we also will have to work as a community to create a more welcoming culture to underrepresented groups so that we can provide the highest level of musculoskeletal care and improve patient outcomes.
Associated Musculoskeletal Injuries
Severe central neurologic or axial skeletal trauma is commonly associated with high-energy extrem... more Severe central neurologic or axial skeletal trauma is commonly associated with high-energy extremity injuries. The most common injuries associated with spine trauma are head injuries (17 %), lower limb fractures (5.9 %), upper limb fractures (4.4 %), chest injuries (2.9 %), pelvic fractures (2.5 %), and abdominal injuries (1.5 %). The care of the multiply injured patient has improved substantially over the past several decades and led to higher survival rates. Damage-control orthopaedics, or temporizing treatment through rapid debridement of open wounds, restoration of tissue perfusion and limb circulation, stabilization of long bones, and, when possible, limb salvage using techniques has proven effective. Orthopaedic injuries including long bone fractures and vascular compromise due to compartment syndrome are important in initial stabilization and diagnosis and further complicate nursing care and mobilization. While timing of surgery for spine fractures is controversial, there is general consensus regarding several absolute indications for urgent surgical intervention. The most widely supported reason for early intervention is any progressive neurological deficit caused by spinal cord or root compression. Spinal dislocations associated with a neurological deficit or spinal kyphosis that compromises the overlying skin or patient positioning for non-spine procedures are also strong indications for urgent surgical intervention. Considerations for timing of decompression as well as stabilization are discussed and current evidence for outcomes in function and mortality are presented. Polytrauma in the setting of acute spinal injury is multifaceted and always interdisciplinary. It is most important for the general trauma surgeon, orthopaedic trauma surgeon, and spine surgeon to be in close communication to methodically coordinate each procedure so return to function can be optimized.
Journal of Foot & Ankle Surgery, Mar 1, 2020
Soft-tissue masses on the anterior ankle result from a broad range of underlying processes, often... more Soft-tissue masses on the anterior ankle result from a broad range of underlying processes, often presenting a diagnostic challenge. Appropriate treatment of these tumors can be determined by using a combination of patient history, interpretation of pathologic findings, physical examination, and radiographic appearance. We present a case of an exceptionally rare malignant cutaneous adnexal tumor, highlighting the importance of adherence to fundamental biopsy principles for diagnosing and managing musculoskeletal lesions.
Foot and Ankle Specialist, Aug 20, 2020
Background. Studies have shown conflicting results regarding associations of preoperative comorbi... more Background. Studies have shown conflicting results regarding associations of preoperative comorbidities with outcomes after total ankle arthroplasty (TAA). Our aim was to analyze preoperative risk factors for complications, longer hospital stay, and readmission within 30 days after TAA. Methods. We conducted a retrospective study using the American College of Surgeons National Surgical Quality Improvement Program database. We included 294 patients who underwent TAA from 2009 through 2012. We used multivariate logistic regression to identify risk factors for complications, longer hospital stay, and hospital readmission. Results. Surgical site infection was the most common complication. Diabetes was associated with greater odds of complications as was current smoker status. Notably, obesity was not associated with greater odds of complications. Age, chronic obstructive pulmonary disease, and diabetes mellitus were associated with longer hospital stays. Surgical site infection was the most common reason for hospital readmission. Conclusions. TAA has a low complication rate, with surgical site infection being the most common complication and the most common reason for hospital readmission. Patients with diabetes have greater odds of poor outcomes and prolonged hospital stays after TAA than patients without diabetes. Obesity was not associated with poor outcomes after TAA.
Journal of the American Academy of Orthopaedic Surgeons, Jun 1, 2020
Despite the use of digital technology in healthcare, telemedicine has not been readily adopted. D... more Despite the use of digital technology in healthcare, telemedicine has not been readily adopted. During the COVID-19 pandemic, healthcare systems have begun crisis management planning. To appropriately allocate resources and prevent virus exposure while maintaining effective patient care, our orthopaedic surgery department rapidly introduced a robust telemedicine program during a 5-day period. Implementation requires attention to patient triage, technological resources, credentialing, education of providers and patients, scheduling, and regulatory considerations. This article provides practical instruction based on our experience for physicians who wish to implement telemedicine during the COVID-19 pandemic. Between telemedicine encounters and necessary in-person visits, providers may be able to achieve 50% of their typical clinic volume within 2 weeks. When handling the massive disruption to the routine patient care workflow, it is critical to understand the key factors associated with an accelerated introduction of telemedicine for the safe and effective continuation of orthopaedic care during this pandemic.
Disability Associated with Musculoskeletal Injuries
Springer eBooks, Sep 10, 2015
Musculoskeletal-related injuries and disabling conditions represent the fastest-growing subset of... more Musculoskeletal-related injuries and disabling conditions represent the fastest-growing subset of military disability claims over the last 30 years. From 1981 to 2005, the number of disabling conditions related to the musculoskeletal system increased from 70/100,000 persons to 950/100,000 persons for those exiting the military (The changing profile of disability in the U.S. Army: 1981–2005. Disabil Health J 1(1):14–24, 2008). While there are many factors, such as an increase in combat missions or an increasing recognition of disabling conditions, that may account for this increase, recent analysis has shown that the almost 12-fold increase in musculoskeletal disability claims is coming largely from young, enlisted servicemen and servicewomen with lower levels of education (The changing profile of disability in the U.S. Army: 1981–2005. Disabil Health J 1(1):14–24, 2008). These disabling conditions require a disproportionately large amount of resources to care for (Knee adduction moment, serum hyaluronan level, and disease severity in medial tibiofemoral osteoarthritis. Arthritis Rheum 41(7):1233–40, 1998; Resource utilization and disability outcome assessment of combat casualties from Operation Iraqi Freedom and Operation Enduring Freedom. J Orthop Trauma 23(4):261–6, 2009; Evaluating the predictive value of osteoarthritis diagnoses in an administrative database. Arthritis Rheum 43(8):1881–5, 2000), and it is imperative to have a basic understanding of these ailments to develop and implement effective injury prevention strategies and to optimize the care provided to these patients (An update on the relationship between occupational factors and osteoarthritis of the hip and knee. Curr Opin Rheumatol 14(2):89–92, 2002). This chapter discusses the burden of disability associated with some of the more common musculoskeletal injuries and conditions seen within the military.
Reimbursement for Orthopaedic Surgeries in Commercial and Public Payors: A Race to the Bottom
Journal of the American Academy of Orthopaedic Surgeons, Mar 22, 2021
Introduction: The purpose of this study was to compare surgeon professional fee reimbursement and... more Introduction: The purpose of this study was to compare surgeon professional fee reimbursement and trends from Medicare versus commercial payors for inpatient orthopaedic surgeries: total knee arthroplasty (TKA), total hip arthroplasty (THA), total shoulder arthroplasty (TSA), anterior cervical diskectomy and fusion (ACDF), and posterior lumbar fusion (PLF). Methods: Patients undergoing TKA, THA, TSA, single-level ACDF, and single-level PLF from 2010 to 2018 were queried in a commercially insured claims database. Medicare reimbursements and the work relative value unit (wRVU) of each procedure were obtained from the Medicare Physician Fee Schedule. All costs were adjusted for inflation and reported in 2018 real dollars. Compound annual growth rates were calculated to assess the mean growth rate for each procedure. Linear regression was done to assess trends. Results: On average, payments from Medicare were 57% less than payments from commercial payors. From 2010 to 2018, both Medicare and commercial payments decreased significantly for each surgery (P < 0.05 for all). Compared with inflation-adjusted commercial payments, Medicare payments decreased 2.1 times faster for TKA (−2.1% versus −1.0%), 2.8 times faster for THA (−1.4% versus −0.5%), 1.3 times faster for TSA (−1.0% versus −0.8%), and 1.9 times faster for ACDF (−1.1% versus −0.6%). PLF was the only procedure for which Medicare payments declined slower than commercial payments (−0.6% versus −1.21%). Medicare payments per wRVU markedly declined for TKA (−0.83%), THA (−0.80%), TSA (−0.75%), and ACDF (−1.10%), whereas commercial payments per wRVU for those surgeries showed no notable change. For PLF, there was a notable decrease in both Medicare (−0.63%) and commercial (−1.21%) payments per wRVU. Conclusion: Over the past decade, both commercial and Medicare surgeon payments for commonly performed inpatient orthopaedic surgeries decreased markedly, with Medicare payments decreasing an average of 1.5 times faster than commercial payments. The impact of declining reimbursements on access and quality of care merits additional investigation.
What Proportion of East African Refugees Report Musculoskeletal Problems? A Cross-sectional Survey
Clinical Orthopaedics & Related Research
Background Musculoskeletal conditions are the leading cause of disability worldwide and dispropor... more Background Musculoskeletal conditions are the leading cause of disability worldwide and disproportionally affect individuals in low-income and middle-income countries. There is a dearth of evidence on musculoskeletal problems among refugees, 74% of whom reside in low-income and middle-income countries. Questions/purposes (1) What proportion of refugees in Nyarugusu Camp, Kigoma, western Tanzania, are affected by musculoskeletal problems and what are the characteristics of those individuals? (2) What are the characteristics of these musculoskeletal problems, including their causes, location, and duration? (3) What forms of healthcare do those with musculoskeletal problems seek, including those for both musculoskeletal and nonmusculoskeletal problems? Methods We conducted a cross-sectional study among refugees in Nyarugusu Camp, using the Surgeons OverSeas Assessment of Surgical Need tool. The Surgeons OverSeas Assessment of Surgical Need tool is a validated population-based survey to...
Trauma Surgery & Acute Care Open
ObjectiveUS trauma centers (TCs) must remain prepared for mass casualty incidents (MCIs). However... more ObjectiveUS trauma centers (TCs) must remain prepared for mass casualty incidents (MCIs). However, trauma surgeons may lack formal MCI training. The recent COVID-19 pandemic drove multiple patient surges, overloaded Emergency Medical Services (EMS) agencies, and stressed TCs. This survey assessed trauma surgeons’ MCI training, experience, and system and personal preparedness before the pandemic compared with the pandemic’s third year.MethodsSurvey invitations were emailed to all 1544 members of the American Association for the Surgery of Trauma in 2019, and then resent in 2022 to 1575 members with additional questions regarding the pandemic. Questions assessed practice type, TC characteristics, training, experience, beliefs about personal and hospital preparedness, likelihood of MCI scenarios, interventions desired from membership organizations, and pandemic experiences.ResultsThe response rate was 16.7% in 2019 and 12% in 2022. In 2022, surgeons felt better prepared than their hosp...
Anemia and Its Severity Is Associated With Worse Postoperative Outcomes Following Open Reduction Internal Fixation of Ankle Fractures
Foot & Ankle International
Background: Ankle fractures are often treated in a nonemergent fashion and therefore offer the ch... more Background: Ankle fractures are often treated in a nonemergent fashion and therefore offer the chance for treatment of preoperative anemia. Although preoperative anemia has been associated with postoperative morbidity following certain types of orthopaedic procedures, its effect on postoperative outcomes following open reduction internal fixation (ORIF) of ankle fractures has not been evaluated. The purpose of this study was to determine the influence of preoperative anemia on 30-day postoperative outcomes following ankle fracture ORIF. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ASC-NSQIP) registry was queried from 2005 to 2019 for patients undergoing ankle fracture ORIF. Patients were stratified into nonanemic, mildly anemic, and moderately to severely anemic. Univariate analyses were used to assess differences in patient characteristics between cohorts. Multivariate logistic regressions adjusting for these differences were performed to...
Orthopaedic Surgeon Distribution in the United States
Journal of the American Academy of Orthopaedic Surgeons
Background: There is limited research on the supply and distribution of orthopaedic surgeons in t... more Background: There is limited research on the supply and distribution of orthopaedic surgeons in the United States. The goal of this study was to analyze the association of orthopaedic surgeon distribution in the United States with geographic and sociodemographic factors. Methods: County-level data from the US Department of Health and Human Services Area Health Resources Files were used to determine the density of orthopaedic surgeons across the United States on a county level. Data were examined from 2000 to 2019 to analyze trends over time. Bivariate and multivariable negative binomial regression models were constructed to identify county-level sociodemographic factors associated with orthopaedic surgeon density. Results: In 2019, 51% of the counties in the United States did not have an orthopaedic surgeon. Metropolitan counties had a mean of 22 orthopaedic surgeons per 100,000 persons while nonmetropolitan and rural counties had a mean of 2 and 0.1 orthopaedic surgeons per 100,000...
Physical Therapy, 2021
Objective The purpose of this study was to characterize outpatient physical therapy (OPT) use fol... more Objective The purpose of this study was to characterize outpatient physical therapy (OPT) use following tibial fractures and examine the variability of OPT attendance, time of initiation, number of visits, and length of care by patient, injury, and treatment factors. In the absence of clinical guidelines, results will guide future efforts to optimize OPT following tibial fractures. Methods This study used 2016 to 2017 claims from the IBM MarketScan Commercial Claims Research Database. The cohort included 9079 patients with International Classification of Diseases: Tenth Revision (ICD-10) diagnosis codes for tibial fractures. Use in the year following initial fracture management was determined using Current Procedural Terminology codes. Differences in use were examined using χ2 tests, t tests, and Kruskal-Wallace tests. Results Sixty-seven percent of patients received OPT the year following fracture. OPT attendance was higher in female patients, in patients with 1 or no major comorbi...
JAAOS: Global Research and Reviews, 2020
Introduction: As healthcare costs continue to increase in the United States, it is important to u... more Introduction: As healthcare costs continue to increase in the United States, it is important to understand the trends in the allocation of healthcare spending for common orthopaedic surgical procedures. We investigated the recent trends in (1) total net payments (for episode of care), (2) payments to hospitals, (3) payments to physicians, (4) payments to physicians as a percentage of total net payments, and (5) regional variation in hospital and physician payments for four common orthopaedic procedures. Methods: Using a private insurance claims database, we analyzed the payments to US hospitals and physicians from 2010 to 2016 for primary total hip arthroplasty (THA) (n = 128,269), total knee arthroplasty (TKA) (n = 223,319), 1-level anterior cervical diskectomy and fusion (ACDF) (n = 51,477), and 1-level lumbarinstrumented posterior spinal fusion (PSF) (n = 45,680). Regional variations in payments were also assessed. Trends were analyzed using linear regression models adjusting for age, sex, comorbidities, duration of hospital stay, and inflation (alpha = 0.05). Results: Inflation-adjusted total net payments for the episode of care increased by the following percentages per year: 5.2% for ACDF, 3.2% for PSF, 2.9% for TKA, and 2.6% for THA. Annual inflation-adjusted hospital payments increased significantly for all 4 procedures, whereas annual inflation-adjusted physician payments decreased by 22.2%/year for PSF, 21.5%/year for TKA, 21.1%/year for THA, and 20.4%/year for ACDF (all, P , 0.001). As a percentage of total net payments, physician payments decreased markedly for ACDF (24.6%), PSF (23.1%), TKA (22.1%), and THA (21.8%). Hospital and physician payments varied significantly by region and were both highest in the West (P , 0.001). Conclusions: From 2010 to 2016, inflation-adjusted total net payments for 4 common orthopaedic surgical procedures increased markedly, as did payments to the US hospitals for these
Journal of the American Academy of Orthopaedic Surgeons, 2019
Long-distance running has become increasingly popular during the past decades. Many running patie... more Long-distance running has become increasingly popular during the past decades. Many running patients pose questions to their orthopaedic surgeons regarding risks, benefits, and running techniques. This article identifies 11 running-related questions that patients may ask and provides information to help answer those questions. This review discusses data on the health benefits of running, common running injuries, the relationship between running and osteoarthritis, recommendations regarding running after orthopaedic surgery, running shoes, and other questions that may arise when treating the running athlete.
Plastic & Reconstructive Surgery, 2018
Background: Soft-tissue complications often dictate the success of limb salvage and the overall o... more Background: Soft-tissue complications often dictate the success of limb salvage and the overall outcome of open fractures. Based on prior work at the R Adams Cowley Shock Trauma Center, the authors hypothesize that wounds larger than 200 cm2 are associated with a greater likelihood of both flap-related reoperation and wound complications among patients requiring soft-tissue reconstruction with a rotational flap or free tissue transfer. Methods: This study was a secondary analysis of Fluid Lavage in Open Wounds trial data that included all patients who received a rotational or free tissue flap transfer for an open fracture. The primary outcome was flap-related reoperation within 12 months of injury. The secondary outcome was wound complication, which included events treated operatively or nonoperatively. Multivariable logistic regression was used to assess the association between wound size and outcomes, adjusting for confounders. Results: Seventeen percent of the 112 patients requir...
Journal of orthopaedic trauma, May 1, 2018
Femoral neck fractures are associated with high rates of revision surgery after management with i... more Femoral neck fractures are associated with high rates of revision surgery after management with internal fixation. Using data from the Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trial evaluating methods of internal fixation in patients with femoral neck fractures, we investigated associations between baseline and surgical factors and the need for revision surgery to promote healing, relieve pain, treat infection or improve function over 24 months postsurgery. Additionally, we investigated factors associated with (1) hardware removal and (2) implant exchange from cancellous screws (CS) or sliding hip screw (SHS) to total hip arthroplasty, hemiarthroplasty, or another internal fixation device. We identified 15 potential factors a priori that may be associated with revision surgery, 7 with hardware removal, and 14 with implant exchange. We used multivariable Cox proportional hazards analyses in our investigation. Factors associated with increased ris...
Journal of patient safety, Jan 30, 2017
Teamwork training improves short-term teamwork behaviors. However, improvements are often not sus... more Teamwork training improves short-term teamwork behaviors. However, improvements are often not sustained. The purpose of this study was to explore the extent to which teamwork reinforcement activities for orthopedic surgery teams lead to sustained teamwork behaviors. Seven months after 104 staff from an orthopedic surgical unit were trained in Team Strategies and Tools to Enhance Performance and Patient Safety principles, 4 reinforcement activities were implemented regarding leadership and communication: lectures with videos on leadership skills for nursing staff; an online self-paced learning program on communication skills for nursing staff; a 1-page summary on leadership skills e-mailed to surgical staff; and a 1-hour perioperative grand rounds on Team Strategies and Tools to Enhance Performance and Patient Safety principles for anesthesia staff and new staff. Twenty-four orthopedic surgical teams were evaluated on teamwork behaviors during surgery by 2 observers before and after ...
Influence of reader experience on reliability of flatfoot measurements using weightbearing CT
Foot and Ankle Surgery, 2016
Journal of Bone and Joint Surgery, 2017
Background: The 3-dimensional nature of adult acquired flatfoot deformity can be challenging to c... more Background: The 3-dimensional nature of adult acquired flatfoot deformity can be challenging to characterize using radiographs. We tested the hypothesis that measurements on weight-bearing (WB) cone-beam computed tomography (CT) images were more useful for demonstrating the severity of the deformity than non-weight-bearing (NWB) measurements. Methods: We prospectively enrolled 12 men and 8 women (mean age, 52 years; range, 20 to 88 years) with flexible adult acquired flatfoot deformity. The subjects underwent cone-beam CT while standing (WB) and seated (NWB), and images were assessed in the sagittal, coronal, and axial planes by 3 independent observers who performed multiple measurements. Intraobserver and interobserver reliabilities were assessed with the Pearson or Spearman correlation and the intraclass correlation coefficient (ICC), respectively. Measurements were compared using paired Student t tests or Wilcoxon rank-sum tests. P < 0.05 was considered significant. Results: W...
Adult acquired flatfoot deformity: Comparison of weightbearing and nonweightbearing CT examinations
Foot and Ankle Surgery, 2016
True Grit in Leadership
Journal of Bone and Joint Surgery, American Volume, May 15, 2019
: Grit is a positive noncognitive trait that is based on an individual’s passion for long-term go... more : Grit is a positive noncognitive trait that is based on an individual’s passion for long-term goals, coupled with a powerful motivation to achieve. Grit has been shown to be a greater predictor of success than intelligence. As the curriculum for orthopaedic trainees continues to evolve, deliberate practice for surgical skills, encouraging a growth mindset, and enhancing grit may be as important as preparation for board examinations. Although talent and skill play a role in achievement, the effort put forth in developing a skill can dramatically affect the ultimate achievement. Therefore, grit is a trait that can be developed. As educators, we can encourage hard work, reflection, and appropriate risk-taking. Implicit biases and microaggressions occur on a daily basis within orthopaedics, and grit will be an important trait to possess in order to combat these biases. However, we also will have to work as a community to create a more welcoming culture to underrepresented groups so that we can provide the highest level of musculoskeletal care and improve patient outcomes.
Associated Musculoskeletal Injuries
Severe central neurologic or axial skeletal trauma is commonly associated with high-energy extrem... more Severe central neurologic or axial skeletal trauma is commonly associated with high-energy extremity injuries. The most common injuries associated with spine trauma are head injuries (17 %), lower limb fractures (5.9 %), upper limb fractures (4.4 %), chest injuries (2.9 %), pelvic fractures (2.5 %), and abdominal injuries (1.5 %). The care of the multiply injured patient has improved substantially over the past several decades and led to higher survival rates. Damage-control orthopaedics, or temporizing treatment through rapid debridement of open wounds, restoration of tissue perfusion and limb circulation, stabilization of long bones, and, when possible, limb salvage using techniques has proven effective. Orthopaedic injuries including long bone fractures and vascular compromise due to compartment syndrome are important in initial stabilization and diagnosis and further complicate nursing care and mobilization. While timing of surgery for spine fractures is controversial, there is general consensus regarding several absolute indications for urgent surgical intervention. The most widely supported reason for early intervention is any progressive neurological deficit caused by spinal cord or root compression. Spinal dislocations associated with a neurological deficit or spinal kyphosis that compromises the overlying skin or patient positioning for non-spine procedures are also strong indications for urgent surgical intervention. Considerations for timing of decompression as well as stabilization are discussed and current evidence for outcomes in function and mortality are presented. Polytrauma in the setting of acute spinal injury is multifaceted and always interdisciplinary. It is most important for the general trauma surgeon, orthopaedic trauma surgeon, and spine surgeon to be in close communication to methodically coordinate each procedure so return to function can be optimized.
Journal of Foot & Ankle Surgery, Mar 1, 2020
Soft-tissue masses on the anterior ankle result from a broad range of underlying processes, often... more Soft-tissue masses on the anterior ankle result from a broad range of underlying processes, often presenting a diagnostic challenge. Appropriate treatment of these tumors can be determined by using a combination of patient history, interpretation of pathologic findings, physical examination, and radiographic appearance. We present a case of an exceptionally rare malignant cutaneous adnexal tumor, highlighting the importance of adherence to fundamental biopsy principles for diagnosing and managing musculoskeletal lesions.
Foot and Ankle Specialist, Aug 20, 2020
Background. Studies have shown conflicting results regarding associations of preoperative comorbi... more Background. Studies have shown conflicting results regarding associations of preoperative comorbidities with outcomes after total ankle arthroplasty (TAA). Our aim was to analyze preoperative risk factors for complications, longer hospital stay, and readmission within 30 days after TAA. Methods. We conducted a retrospective study using the American College of Surgeons National Surgical Quality Improvement Program database. We included 294 patients who underwent TAA from 2009 through 2012. We used multivariate logistic regression to identify risk factors for complications, longer hospital stay, and hospital readmission. Results. Surgical site infection was the most common complication. Diabetes was associated with greater odds of complications as was current smoker status. Notably, obesity was not associated with greater odds of complications. Age, chronic obstructive pulmonary disease, and diabetes mellitus were associated with longer hospital stays. Surgical site infection was the most common reason for hospital readmission. Conclusions. TAA has a low complication rate, with surgical site infection being the most common complication and the most common reason for hospital readmission. Patients with diabetes have greater odds of poor outcomes and prolonged hospital stays after TAA than patients without diabetes. Obesity was not associated with poor outcomes after TAA.
Journal of the American Academy of Orthopaedic Surgeons, Jun 1, 2020
Despite the use of digital technology in healthcare, telemedicine has not been readily adopted. D... more Despite the use of digital technology in healthcare, telemedicine has not been readily adopted. During the COVID-19 pandemic, healthcare systems have begun crisis management planning. To appropriately allocate resources and prevent virus exposure while maintaining effective patient care, our orthopaedic surgery department rapidly introduced a robust telemedicine program during a 5-day period. Implementation requires attention to patient triage, technological resources, credentialing, education of providers and patients, scheduling, and regulatory considerations. This article provides practical instruction based on our experience for physicians who wish to implement telemedicine during the COVID-19 pandemic. Between telemedicine encounters and necessary in-person visits, providers may be able to achieve 50% of their typical clinic volume within 2 weeks. When handling the massive disruption to the routine patient care workflow, it is critical to understand the key factors associated with an accelerated introduction of telemedicine for the safe and effective continuation of orthopaedic care during this pandemic.
Disability Associated with Musculoskeletal Injuries
Springer eBooks, Sep 10, 2015
Musculoskeletal-related injuries and disabling conditions represent the fastest-growing subset of... more Musculoskeletal-related injuries and disabling conditions represent the fastest-growing subset of military disability claims over the last 30 years. From 1981 to 2005, the number of disabling conditions related to the musculoskeletal system increased from 70/100,000 persons to 950/100,000 persons for those exiting the military (The changing profile of disability in the U.S. Army: 1981–2005. Disabil Health J 1(1):14–24, 2008). While there are many factors, such as an increase in combat missions or an increasing recognition of disabling conditions, that may account for this increase, recent analysis has shown that the almost 12-fold increase in musculoskeletal disability claims is coming largely from young, enlisted servicemen and servicewomen with lower levels of education (The changing profile of disability in the U.S. Army: 1981–2005. Disabil Health J 1(1):14–24, 2008). These disabling conditions require a disproportionately large amount of resources to care for (Knee adduction moment, serum hyaluronan level, and disease severity in medial tibiofemoral osteoarthritis. Arthritis Rheum 41(7):1233–40, 1998; Resource utilization and disability outcome assessment of combat casualties from Operation Iraqi Freedom and Operation Enduring Freedom. J Orthop Trauma 23(4):261–6, 2009; Evaluating the predictive value of osteoarthritis diagnoses in an administrative database. Arthritis Rheum 43(8):1881–5, 2000), and it is imperative to have a basic understanding of these ailments to develop and implement effective injury prevention strategies and to optimize the care provided to these patients (An update on the relationship between occupational factors and osteoarthritis of the hip and knee. Curr Opin Rheumatol 14(2):89–92, 2002). This chapter discusses the burden of disability associated with some of the more common musculoskeletal injuries and conditions seen within the military.
Reimbursement for Orthopaedic Surgeries in Commercial and Public Payors: A Race to the Bottom
Journal of the American Academy of Orthopaedic Surgeons, Mar 22, 2021
Introduction: The purpose of this study was to compare surgeon professional fee reimbursement and... more Introduction: The purpose of this study was to compare surgeon professional fee reimbursement and trends from Medicare versus commercial payors for inpatient orthopaedic surgeries: total knee arthroplasty (TKA), total hip arthroplasty (THA), total shoulder arthroplasty (TSA), anterior cervical diskectomy and fusion (ACDF), and posterior lumbar fusion (PLF). Methods: Patients undergoing TKA, THA, TSA, single-level ACDF, and single-level PLF from 2010 to 2018 were queried in a commercially insured claims database. Medicare reimbursements and the work relative value unit (wRVU) of each procedure were obtained from the Medicare Physician Fee Schedule. All costs were adjusted for inflation and reported in 2018 real dollars. Compound annual growth rates were calculated to assess the mean growth rate for each procedure. Linear regression was done to assess trends. Results: On average, payments from Medicare were 57% less than payments from commercial payors. From 2010 to 2018, both Medicare and commercial payments decreased significantly for each surgery (P < 0.05 for all). Compared with inflation-adjusted commercial payments, Medicare payments decreased 2.1 times faster for TKA (−2.1% versus −1.0%), 2.8 times faster for THA (−1.4% versus −0.5%), 1.3 times faster for TSA (−1.0% versus −0.8%), and 1.9 times faster for ACDF (−1.1% versus −0.6%). PLF was the only procedure for which Medicare payments declined slower than commercial payments (−0.6% versus −1.21%). Medicare payments per wRVU markedly declined for TKA (−0.83%), THA (−0.80%), TSA (−0.75%), and ACDF (−1.10%), whereas commercial payments per wRVU for those surgeries showed no notable change. For PLF, there was a notable decrease in both Medicare (−0.63%) and commercial (−1.21%) payments per wRVU. Conclusion: Over the past decade, both commercial and Medicare surgeon payments for commonly performed inpatient orthopaedic surgeries decreased markedly, with Medicare payments decreasing an average of 1.5 times faster than commercial payments. The impact of declining reimbursements on access and quality of care merits additional investigation.
What Proportion of East African Refugees Report Musculoskeletal Problems? A Cross-sectional Survey
Clinical Orthopaedics & Related Research
Background Musculoskeletal conditions are the leading cause of disability worldwide and dispropor... more Background Musculoskeletal conditions are the leading cause of disability worldwide and disproportionally affect individuals in low-income and middle-income countries. There is a dearth of evidence on musculoskeletal problems among refugees, 74% of whom reside in low-income and middle-income countries. Questions/purposes (1) What proportion of refugees in Nyarugusu Camp, Kigoma, western Tanzania, are affected by musculoskeletal problems and what are the characteristics of those individuals? (2) What are the characteristics of these musculoskeletal problems, including their causes, location, and duration? (3) What forms of healthcare do those with musculoskeletal problems seek, including those for both musculoskeletal and nonmusculoskeletal problems? Methods We conducted a cross-sectional study among refugees in Nyarugusu Camp, using the Surgeons OverSeas Assessment of Surgical Need tool. The Surgeons OverSeas Assessment of Surgical Need tool is a validated population-based survey to...
Trauma Surgery & Acute Care Open
ObjectiveUS trauma centers (TCs) must remain prepared for mass casualty incidents (MCIs). However... more ObjectiveUS trauma centers (TCs) must remain prepared for mass casualty incidents (MCIs). However, trauma surgeons may lack formal MCI training. The recent COVID-19 pandemic drove multiple patient surges, overloaded Emergency Medical Services (EMS) agencies, and stressed TCs. This survey assessed trauma surgeons’ MCI training, experience, and system and personal preparedness before the pandemic compared with the pandemic’s third year.MethodsSurvey invitations were emailed to all 1544 members of the American Association for the Surgery of Trauma in 2019, and then resent in 2022 to 1575 members with additional questions regarding the pandemic. Questions assessed practice type, TC characteristics, training, experience, beliefs about personal and hospital preparedness, likelihood of MCI scenarios, interventions desired from membership organizations, and pandemic experiences.ResultsThe response rate was 16.7% in 2019 and 12% in 2022. In 2022, surgeons felt better prepared than their hosp...
Anemia and Its Severity Is Associated With Worse Postoperative Outcomes Following Open Reduction Internal Fixation of Ankle Fractures
Foot & Ankle International
Background: Ankle fractures are often treated in a nonemergent fashion and therefore offer the ch... more Background: Ankle fractures are often treated in a nonemergent fashion and therefore offer the chance for treatment of preoperative anemia. Although preoperative anemia has been associated with postoperative morbidity following certain types of orthopaedic procedures, its effect on postoperative outcomes following open reduction internal fixation (ORIF) of ankle fractures has not been evaluated. The purpose of this study was to determine the influence of preoperative anemia on 30-day postoperative outcomes following ankle fracture ORIF. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ASC-NSQIP) registry was queried from 2005 to 2019 for patients undergoing ankle fracture ORIF. Patients were stratified into nonanemic, mildly anemic, and moderately to severely anemic. Univariate analyses were used to assess differences in patient characteristics between cohorts. Multivariate logistic regressions adjusting for these differences were performed to...
Orthopaedic Surgeon Distribution in the United States
Journal of the American Academy of Orthopaedic Surgeons
Background: There is limited research on the supply and distribution of orthopaedic surgeons in t... more Background: There is limited research on the supply and distribution of orthopaedic surgeons in the United States. The goal of this study was to analyze the association of orthopaedic surgeon distribution in the United States with geographic and sociodemographic factors. Methods: County-level data from the US Department of Health and Human Services Area Health Resources Files were used to determine the density of orthopaedic surgeons across the United States on a county level. Data were examined from 2000 to 2019 to analyze trends over time. Bivariate and multivariable negative binomial regression models were constructed to identify county-level sociodemographic factors associated with orthopaedic surgeon density. Results: In 2019, 51% of the counties in the United States did not have an orthopaedic surgeon. Metropolitan counties had a mean of 22 orthopaedic surgeons per 100,000 persons while nonmetropolitan and rural counties had a mean of 2 and 0.1 orthopaedic surgeons per 100,000...
Physical Therapy, 2021
Objective The purpose of this study was to characterize outpatient physical therapy (OPT) use fol... more Objective The purpose of this study was to characterize outpatient physical therapy (OPT) use following tibial fractures and examine the variability of OPT attendance, time of initiation, number of visits, and length of care by patient, injury, and treatment factors. In the absence of clinical guidelines, results will guide future efforts to optimize OPT following tibial fractures. Methods This study used 2016 to 2017 claims from the IBM MarketScan Commercial Claims Research Database. The cohort included 9079 patients with International Classification of Diseases: Tenth Revision (ICD-10) diagnosis codes for tibial fractures. Use in the year following initial fracture management was determined using Current Procedural Terminology codes. Differences in use were examined using χ2 tests, t tests, and Kruskal-Wallace tests. Results Sixty-seven percent of patients received OPT the year following fracture. OPT attendance was higher in female patients, in patients with 1 or no major comorbi...
JAAOS: Global Research and Reviews, 2020
Introduction: As healthcare costs continue to increase in the United States, it is important to u... more Introduction: As healthcare costs continue to increase in the United States, it is important to understand the trends in the allocation of healthcare spending for common orthopaedic surgical procedures. We investigated the recent trends in (1) total net payments (for episode of care), (2) payments to hospitals, (3) payments to physicians, (4) payments to physicians as a percentage of total net payments, and (5) regional variation in hospital and physician payments for four common orthopaedic procedures. Methods: Using a private insurance claims database, we analyzed the payments to US hospitals and physicians from 2010 to 2016 for primary total hip arthroplasty (THA) (n = 128,269), total knee arthroplasty (TKA) (n = 223,319), 1-level anterior cervical diskectomy and fusion (ACDF) (n = 51,477), and 1-level lumbarinstrumented posterior spinal fusion (PSF) (n = 45,680). Regional variations in payments were also assessed. Trends were analyzed using linear regression models adjusting for age, sex, comorbidities, duration of hospital stay, and inflation (alpha = 0.05). Results: Inflation-adjusted total net payments for the episode of care increased by the following percentages per year: 5.2% for ACDF, 3.2% for PSF, 2.9% for TKA, and 2.6% for THA. Annual inflation-adjusted hospital payments increased significantly for all 4 procedures, whereas annual inflation-adjusted physician payments decreased by 22.2%/year for PSF, 21.5%/year for TKA, 21.1%/year for THA, and 20.4%/year for ACDF (all, P , 0.001). As a percentage of total net payments, physician payments decreased markedly for ACDF (24.6%), PSF (23.1%), TKA (22.1%), and THA (21.8%). Hospital and physician payments varied significantly by region and were both highest in the West (P , 0.001). Conclusions: From 2010 to 2016, inflation-adjusted total net payments for 4 common orthopaedic surgical procedures increased markedly, as did payments to the US hospitals for these
Journal of the American Academy of Orthopaedic Surgeons, 2019
Long-distance running has become increasingly popular during the past decades. Many running patie... more Long-distance running has become increasingly popular during the past decades. Many running patients pose questions to their orthopaedic surgeons regarding risks, benefits, and running techniques. This article identifies 11 running-related questions that patients may ask and provides information to help answer those questions. This review discusses data on the health benefits of running, common running injuries, the relationship between running and osteoarthritis, recommendations regarding running after orthopaedic surgery, running shoes, and other questions that may arise when treating the running athlete.
Plastic & Reconstructive Surgery, 2018
Background: Soft-tissue complications often dictate the success of limb salvage and the overall o... more Background: Soft-tissue complications often dictate the success of limb salvage and the overall outcome of open fractures. Based on prior work at the R Adams Cowley Shock Trauma Center, the authors hypothesize that wounds larger than 200 cm2 are associated with a greater likelihood of both flap-related reoperation and wound complications among patients requiring soft-tissue reconstruction with a rotational flap or free tissue transfer. Methods: This study was a secondary analysis of Fluid Lavage in Open Wounds trial data that included all patients who received a rotational or free tissue flap transfer for an open fracture. The primary outcome was flap-related reoperation within 12 months of injury. The secondary outcome was wound complication, which included events treated operatively or nonoperatively. Multivariable logistic regression was used to assess the association between wound size and outcomes, adjusting for confounders. Results: Seventeen percent of the 112 patients requir...
Journal of orthopaedic trauma, May 1, 2018
Femoral neck fractures are associated with high rates of revision surgery after management with i... more Femoral neck fractures are associated with high rates of revision surgery after management with internal fixation. Using data from the Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trial evaluating methods of internal fixation in patients with femoral neck fractures, we investigated associations between baseline and surgical factors and the need for revision surgery to promote healing, relieve pain, treat infection or improve function over 24 months postsurgery. Additionally, we investigated factors associated with (1) hardware removal and (2) implant exchange from cancellous screws (CS) or sliding hip screw (SHS) to total hip arthroplasty, hemiarthroplasty, or another internal fixation device. We identified 15 potential factors a priori that may be associated with revision surgery, 7 with hardware removal, and 14 with implant exchange. We used multivariable Cox proportional hazards analyses in our investigation. Factors associated with increased ris...
Journal of patient safety, Jan 30, 2017
Teamwork training improves short-term teamwork behaviors. However, improvements are often not sus... more Teamwork training improves short-term teamwork behaviors. However, improvements are often not sustained. The purpose of this study was to explore the extent to which teamwork reinforcement activities for orthopedic surgery teams lead to sustained teamwork behaviors. Seven months after 104 staff from an orthopedic surgical unit were trained in Team Strategies and Tools to Enhance Performance and Patient Safety principles, 4 reinforcement activities were implemented regarding leadership and communication: lectures with videos on leadership skills for nursing staff; an online self-paced learning program on communication skills for nursing staff; a 1-page summary on leadership skills e-mailed to surgical staff; and a 1-hour perioperative grand rounds on Team Strategies and Tools to Enhance Performance and Patient Safety principles for anesthesia staff and new staff. Twenty-four orthopedic surgical teams were evaluated on teamwork behaviors during surgery by 2 observers before and after ...
Influence of reader experience on reliability of flatfoot measurements using weightbearing CT
Foot and Ankle Surgery, 2016