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Introduction: Effective pain management is vital in orthopaedic care, impacting postoperative recovery and patient well-being. This study aimed to discern national and regional pain prescription trends among orthopaedic surgeons through Medicare claims data, using geospatial analysis to ascertain opioid and nonopioid usage patterns across the United States., Methods: Physician-level Medicare prescription databases from 2016 to 2020 were filtered to orthopaedic surgeons, and medications were categorized into opioids, muscle relaxants, anticonvulsants, and NSAIDs. Patient demographics were extracted from a Medicare provider demographic data set, while county-level socioeconomic metrics were obtained primarily from the American Community Survey. Geospatial analysis was conducted using Geoda software, using Moran I statistic for cluster analysis of pain medication metrics. Statistical trends were analyzed using linear regression, Mann-Whitney U test, and multivariate logistic regression, focusing on prescribing rates and hotspot/coldspot identification., Results: Analysis encompassed 16,505 orthopaedic surgeons, documenting more than 396 million days of pain medication prescriptions: 57.42% NSAIDs, 28.57% opioids, 9.84% anticonvulsants, and 4.17% muscle relaxants. Annually, opioid prescriptions declined by 4.43% ( P < 0.01), while NSAIDs rose by 3.29% ( P < 0.01). Opioid prescriptions dropped by 210.73 days yearly per surgeon ( P < 0.005), whereas NSAIDs increased by 148.86 days ( P < 0.005). Opioid prescriptions were most prevalent in the West Coast and Northern Midwest regions, and NSAID prescriptions were most prevalent in the Northeast and South regions. Regression pinpointed spine as the highest and hand as the lowest predictor for pain prescriptions., Discussion: On average, orthopaedic surgeons markedly decreased both the percentage of patients receiving opioids and the duration of prescription. Simultaneously, the fraction of patients receiving NSAIDs dramatically increased, without change in the average duration of prescription. Opioid hotspots were located in the West Coast, Utah, Colorado, Arizona, Idaho, the Northern Midwest, Vermont, New Hampshire, and Maine. Future directions could include similar examinations using non-Medicare databases., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Introduction:  Pectus excavatum (PE) is the most common deformity of the anterior chest wall and can be corrected surgically with different techniques. In the past years, medical literature suggests that the minimal invasive surgical correction of PE (MIRPE) has currently become the operation technique of choice in Europe, and the number of PE patients undergoing surgery has increased. The aim of this study was to evaluate trends in the number of patients operated on and the surgical techniques generally used in patients with PE in the Netherlands., Materials and Methods:  From the registration by Statistics Netherlands, the numbers of live births and gender were obtained for the period 1980 to 2017. Furthermore, from the Dutch hospital registration performed by Kiwa Prismant systems, the number of total surgical procedures of PE patients from the period 1998 to 2017, and the numbers of open and MIRPE surgery were obtained over the period 2005 to 2013., Results:  The birth rate in Netherlands has stayed more or less stable in the last two decades. The number of PE patients asking for correction, however, has increased. In addition, the percentage of thoracoscopic assisted correction has increased., Conclusion:  The increase in correction of PE is not due to an increased incidence but to an increase of patient wishes. The use of MIRPE is gaining popularity over time., Competing Interests: None declared., (Thieme. All rights reserved.)

Through a trainee research collaborative, we have studied the changes in practice of 12 T&O departments across the East of England over the first four weeks of the UK lockdown and COVID-19 pandemic, comparing to activity levels with the corresponding period in 2019. We focused on changes in T&O practice, training and redeployment of Trainees. Units differ considerably in several aspects of practice. We found a 97% reduction in elective operating, 64% reduction in elective outpatient activity and 37% reduction in operative trauma. 58% of trainees continued working in T&O clinics, with an average of 6 operative cases over this period. Our modelling suggests that the impact on training will persist; counter-measures must be incorporated into central recovery planning., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Lisfranc joint complex injury may be managed surgically by either an open reduction internal fixation (ORIF) or primary arthrodesis (PA). Published literature advocates PA for purely ligamentous injuries, but many surgeons in actuality refrain from performing PA. The purpose of the study is to assess surgeon practices and behavior in managing Lisfranc injuries due to the influence of peer reviewed literature with the help of the American Board of Orthopaedic Surgery (ABOS) database. Methods: Data were requested from the ABOS database of cases on Lisfranc joint injury requiring either an ORIF or PA from examination year 2004 to 2017 for both part II and maintenance of certification (MOC) examinees. Cases with ICD-9 code 838.03 only were considered as primarily ligamentous and all fracture codes classified under 825 with 838.03 were considered as fracture dislocation. The number of PA and ORIF were recorded for both types of examinees and specific type of Lisfranc joint injury (primarily ligamentous and fracture dislocation). Results: A total of 2010 cases of Lisfranc joint injuries managed surgically by 1230 board-eligible orthopaedic surgeons. Open fractures (93) and non-/malunion fractures were excluded. A total of 1016 primarily ligamentous and 474 fracture dislocation cases were performed by part II examinees. Overall, 288 primarily ligamentous and 139 fracture dislocation cases were performed by MOC examinees. A total of 27 PA were performed in the primarily ligamentous and 17 were performed on fracture dislocation cases. Conclusion: ORIF is commonly performed by newly trained and senior orthopaedic surgeons. There was no change in the number of PA performed on primarily ligamentous injuries in spite of the published literature. Levels of Evidence: Not applicable.

Background: In order to identify any changes in the utilization of new and old techniques, we investigated trends in the operative management of cervical stenosis by orthopaedic surgeons applying for board certification., Methods: We queried the American Board of Orthopaedic Surgery database from 1998 to 2013 to identify all of the cervical spine procedures for stenosis that had been performed by candidates taking Part II of the licensing examination. Longitudinal trends were determined for the utilized approach, the individual procedures that had been performed, and whether a motion-preserving technique had been employed., Results: There were 5,068 cervical spine procedures performed by 1,025 candidates. Procedure totals remained relatively constant until 2011, when a sudden increase of 280% (202 to 768 procedures) was noted. This trend continued, reaching a 460% increase (202 to 1,131 procedures) compared with 2010. The number of candidates only rose by 150% (42 to 105) over the entire study period. The proportion of procedures performed via an anterior approach saw a bimodal distribution; early on, this approach predominated over posterior procedures and was largely driven by the number of corpectomies that were performed. From 2004 to 2011, posterior procedures became more prevalent, but there was a sharp decline in 2011, driven by the large number of anterior cervical discectomies and fusions that were performed. This remained constant through 2013. Lastly, motion-preserving techniques, which included total disc replacement and laminoplasty, had modest increases in utilization from 2005 to 2007. This increased prevalence was short-lived, and it steadily declined through 2014 to <5% utilization., Conclusions: The number of candidates performing cervical spine procedures increased more than twofold over a 16-year period. This reflects a larger proportion of the orthopaedic graduates who subspecialize in spine surgery. While the number of surgeons performing spine surgery has increased, the sheer number of procedures that each surgeon performed greatly outpaced the increased number of surgeons. Motion-preserving techniques had their peak utilization in 2007, and have since decreased to <5%, in contrast to fusion techniques, which predominate, comprising >90% of the performed procedures.

We conducted a study to identify and contrast patterns in the treatment of common injuries that occur in National Football League (NFL) players and National Collegiate Athletic Association (NCAA) Division I football players. Orthopedic team physicians for all 32 NFL and 119 NCAA Division I football teams were asked to complete a survey regarding demographics and preferred treatment of a variety of injuries encountered in football players. Responses were received from 31 (97%) of the 32 NFL and 111 (93%) of the 119 NCAA team physicians. Although patellar tendon autograft was the preferred graft choice for both groups of team physicians, the percentage of NCAA physicians who allowed return to football 6 months or less after anterior cruciate ligament reconstruction was significantly (P = .03) higher than that of NFL physicians. Prophylactic knee bracing, which may prevent medial collateral ligament injuries, was used at a significantly (P < .0001) higher rate by NCAA teams (89%) than by NFL teams (28%). Ketorolac injections were given by a significantly (P < .01) higher percentage of NFL teams (93%) than of NCAA teams (62%). Understanding the current trends in the management of these injuries is beneficial in designing studies that may help improve the treatment and prevention of injuries in football players.

Background: The goal of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) is to improve patient safety. The database has been used by hospitals across the United States to decrease the rate of adverse events and improve surgical outcomes, including dramatic decreases in 30-day mortality, morbidity, and complication rates. However, only a few orthopaedic surgical studies have employed the ACS NSQIP database, all of which have limited their analysis to either single orthopaedic procedures or reported rates of adverse events without considering the effect of patient characteristics and comorbidities., Question/purposes: Our specific purposes included (1) investigating the most common orthopaedic procedures and 30-day adverse events, (2) analyzing the proportion of adverse events in the top 30 most frequently identified orthopaedic procedures, and (3) identifying patient characteristics and clinical risk factors for adverse events in patients undergoing hip fracture repair., Methods: We used data from the ACS NSQIP database to identify a large prospective cohort of patients undergoing orthopaedic surgery procedures from 2005 to 2011 in more than 400 hospitals around the world. Outcome variables were separated into the following three categories: any complication, minor complication, and major complication. The rate of adverse events for the top 30 orthopaedic procedures was calculated. Bivariate and multivariate analyses were used to determine risk factors for each of the outcome variables for hip fracture repair., Results: Of the 1,979,084 surgical patients identified in the database, 146,774 underwent orthopaedic procedures (7%). Of the 30 most common orthopaedic procedures, the top three were TKA, THA, and knee arthroscopy with meniscectomy, which together comprised 55% of patients (55,575 of 101,862). We identified 5368 complications within the top 30 orthopaedic procedures, representing a 5% complication rate. The minor and major complication rates were 3.1% (n = 3174) and 2.8% (n = 2880), respectively. The most common minor complication identified was urinary tract infection (n = 1534) and the most common major complication identified was death (n = 850). An American Society of Anesthesiologists class of 3 or higher was a consistent risk factor for all three categories of complications in patients undergoing hip fracture repair., Conclusions: The ACS NSQIP database allows for evaluating current trends of adverse events in selected surgical specialties. However, variables specific to orthopaedic surgery, such as open versus closed injury, are needed to improve the quality of the results.

Purpose: To investigate the current treatment patterns of carpal tunnel surgery by members of the American Society of Surgeons of the Hand today and to assess how several elements of practice vary by surgeon location and experience., Methods: An online survey consisting of 10 questions was sent electronically to members of the American Society of Surgeons of the Hand (N = 2,413). A brief description of the study and a link were sent to participants by the investigators. Results were anonymously uploaded to an online spreadsheet., Results: 716 hand surgeons (30%) responded to the survey. Surgeons were nearly equally represented by region. A wide variation in surgeon experience was observed. A majority (65%) performed most of their surgery at an outpatient surgical center. Preoperative electrodiagnostic testing was used, at least occasionally, by 90% of surgeons. Approximately one-half did not administer preoperative antibiotics at the time of surgery. Intravenous sedation with local anesthesia was the most common practice (43%), followed by Bier block (18%). A mini-open incision was most commonly used (50%). A minority reported using an orthosis postoperatively (29%), and they rarely prescribed a course of postoperative therapy (12%). Postoperative pain management was variable, with hydrocodone and derivatives given most commonly (61%). International practitioners were much less likely to operate in an outpatient surgical center (45%) or use antibiotics (13%). Younger surgeons were more likely to use electrodiagnostic testing (96%) compared with the mean (90%)., Conclusions: When compared with several previous similar studies, we noted a trend toward increased use of electrodiagnostic testing and decreased use of postoperative therapy and immobilization., Type of Study/level of Evidence: Economic and decision analysis V., (Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: An increased incidence rate of acromioplasty has been reported; we analyzed data from the Finnish National Hospital Discharge Register., Patients and Methods: During the 14-year study period (1998-2011), 68,877 acromioplasties without rotator cuff repair were performed on subjects aged 18 years or older., Results: The incidence of acromioplasty increased by 117% from 75 to 163 per 10(5) person years between 1998 and 2007. The highest incidence was observed in 2007, after which the incidence rate decreased by 20% to 131 per 10(5) person years in 2011. The incidence declined even more at non-profit public hospitals from 2007 to 2011. In contrast, it continued to rise at profit-based private orthopedic clinics., Interpretation: We propose that this change in clinical practice is due to accumulating high-quality scientific evidence that shows no difference in outcome between acromioplasty and non-surgical interventions for rotator cuff disease with subacromial impingement syndrome. However, the exact cause of the declining incidence cannot be defined based solely on a registry study. Interestingly, this change was not observed at private clinics, where the number of operations increased steadily from 2007 to 2011.

Objectives: To evaluate the influence of top fracture trials on the practice of orthopedic surgeons., Design: This is a cross-sectional study., Participants: We electronically administered the survey to all members of the Canadian Orthopedic Association. We received responses for 222 surveys, of which, 178 surveys were completed., Intervention: We distributed a survey that evaluated the influence of 7 important fracture studies (6 randomized controlled trials and 1 prospective cohort study) on practice, patient care and the overall advancement of knowledge in the field of orthopedics. This study was approved by our local ethics review board., Main Outcome Measure: The primary outcome measure was the perceived general influence and impact of important fracture studies on the perceptions and practice of orthopedic surgeons., Results: The Clavicular Fixation Trial (2007) and Tibial Fracture Trial (SPRINT, 2008) were perceived by surgeons to have the greatest influence on advancing overall knowledge in the field, improving personal practice, and the most influence on improving patient care. On the other hand, the Bone Stimulation in Fractures Trial (2011) and the recombinant human bone morphogenetic protein-2-BESST Trial (2002) had the lowest mean influence ranks. The probability of changing practice was significantly higher (Odds Ratio, 2.89; 95% confidence interval, 2.16-3.88; P < 0.00001) when studies had positive outcomes in comparison with negative outcomes., Conclusions: Despite the complexity and costs associated with clinical trials in orthopedic trauma, the results from this survey suggest that these studies result in a demonstrable perceived influence and impact on the practice of orthopedic surgeons.

Background: Advances in surgical technique for pectus excavatum repair continue to change practice patterns. The present study examines trends in operative age in a nationwide administrative database., Methods: A cross-sectional descriptive analysis was performed using the Nationwide Inpatient Sample (NIS) and Kids' Inpatient Database (KID) data from 1998 to 2009. Pediatric discharges involving surgical repair of pectus excavatum were selected. Patients were sub-grouped by age at operation and calendar year of repair for further comparison., Results: A total of 5830 elective admissions were identified that met inclusion criteria. Mean age at operation was 13.5 years, and this increased from 11.8 years to 14.4 years over the period studied and was accompanied by narrowing of the interquartile range. Examined over groups of four calendar years, patient age at the time of repair was significantly higher in more recent years in both unadjusted and multivariate analyses (P < .001)., Conclusions: The age at operation in this sample has steadily increased, with an accompanying decrease in variability. This is consistent with previous findings and with overall trends in patient selection reported in the literature. This selection pattern may reflect evolving consensus regarding optimal management of pectus excavatum and provide clinical guidance regarding appropriate referral and intervention., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Study Design: Retrospective cohort study., Objective: To evaluate the relationship between early physical therapy (PT) for acute low back pain and subsequent use of lumbosacral injections, lumbar surgery, and frequent physician office visits for low back pain., Summary of Background Data: Wide practice variations exist in the treatment of acute low back pain. PT has been advocated as an effective treatment in this setting although disagreement exists regarding its purported benefits., Methods: A national 20% sample of the Centers for Medicare and Medicaid Services physician outpatient billing claims was analyzed. Patients were selected who received treatment for low back pain between 2003 and 2004 (n = 439,195). To exclude chronic low back conditions, patients were excluded if they had a prior visit for back pain, lumbosacral injection, or lumbar surgery within the previous year. Main outcome measures were rates of lumbar surgery, lumbosacral injections, and frequent physician office visits for low back pain during the following year., Results: Based on logistic regression analysis, the adjusted odds ratio for undergoing surgery in the group of enrollees that received PT in the acute phase (<4 weeks) compared to those receiving PT in the chronic phase (>3 months) was 0.38 (95% confidence interval [CI], 0.360.41), adjusting for age, sex, diagnosis, treating physician specialty, and comorbidity. The adjusted odds ratio for receiving a lumbosacral injection in the group receiving PT in the acute phase was 0.46 (95% CI, 0.44-0.49), and the adjusted odds ratio for frequent physician office usage in the group receiving PT in the acute phase was 0.47 (95% CI, 0.44-0.50)., Conclusion: There was a lower risk of subsequent medical service usage among patients who received PT early after an episode of acute low back pain relative to those who received PT at later times. Medical specialty variations exist regarding early use of PT, with potential underutilization among generalist specialties.

Objectives: This study aims to determine the current approaches to surgical techniques and rehabilitation protocols used in anterior cruciate ligament (ACL) reconstruction performed by Turkish orthopedic surgeons and to compare their results with the data of "ACL Study Group"., Methods: A questionnaire consisting of 16 questions on surgical techniques, preoperative prerequisites, routine postoperative applications, rehabilitation approaches, and return to sport following ACL reconstruction was sent via e-mail to the 55 orthopedic surgeons performing annually 25 or more ACL reconstructions., Results: Response rate to questionnaire was 70.9% (n=39). Nineteen surgeons (48.7%) regularly performed only hamstring tendon (HT) graft, and four surgeons (10.3%) performed only patellar tendon (PT) graft, while 16 surgeons (41%) performed both HT and PT grafts. Three (18.8%) of the 16 surgeons who performed both HT and PT grafts had individual rehabilitation protocols for the two graft types. No statistically significant difference was found between the responses for two graft types in terms of the starting times for specific activities (p>0.05). Rehabilitation protocols were similar to the current data of "ACL Study Group". The use of a postoperative brace and continuous passive motion (CPM) was different between Turkish surgeons and "ACL Study Group". The CPM and postoperative brace use was more common in Turkey., Conclusion: There are only a few differences in the postoperative approach of ACL reconstruction with HT and PT grafts performed by Turkish orthopedic surgeons. The data obtained from the Turkish orthopedic surgeons showed similarities with the "ACL Study Group" current approaches.

This study reviewed surgical treatment methods in patients with type II odontoid fracture who were admitted to a level 1 spinal cord injury center during a 20-year period. Of the 186 patients who met inclusion criteria, 75 were treated operatively. The rate of surgical intervention increased during the study period. Length of hospital stay was not related to treatment. Estimated blood loss was significantly higher for posterior techniques. The Brooks technique and anterior odontoid screw fixation declined in frequency, whereas the Magerl technique has been used at a consistent rate since its introduction. The C1 lateral mass and C2 pedicle/isthmus screw technique has increased significantly since its description. Pneumonia, vocal cord, and swallowing problems occurred more often with anterior approaches.

Background: Although the word evidence-based medicine (EBM) has gained wide popularity, only a few studies have evaluated how EBM works in clinical practice., Methods: We have prospectively evaluated the feasibility of evidence-based trauma surgery. Orthopaedic trauma surgeons were asked to produce clinical questions related to the treatment of current patients. An informaticist searched the literature (Medline, Cochrane Library, practice guidelines and textbooks) and reported the findings on every following day. The study's main endpoints were the rate of questions for which relevant evidence (>level V) was available and the time necessary to find and critically appraise medical evidence., Results: In total, 44 EBM questions were formulated, mainly concerning treatment options. PubMed was searched for 39 questions, textbooks for 14, the Cochrane Library for 11, online guidelines for 9 and other sources were used for 4 questions. On average, 157 text items (three per questions) were identified as potentially relevant. Journal articles predominated (83%) over textbooks (10%). Sixty-eight percent of the questions (30 of 44) were answered, either on the basis level 1 (n=13 questions), level 2 (n=6), or level 4 evidence (n=14). Trying to answer a question required 53 min on average, split up between 39 min of database searches and 25 min of obtaining full text articles. In four cases, the evidence suggested a change in clinical management. The physicians were very appreciative of our project and found the provided evidence very helpful for their clinical decisions., Conclusions: Time will be the main barrier against the introduction of clinical EBM. It is likely that clinicians reduce EBM to those situations where evidence is likely to be found. Although the impact of EBM on patient-care was limited, the concept of EBM was successfully implemented.