Arthur, Jaymeson R.

Abstract Background Patients often turn to online reviews as a source of information to inform their decisions regarding care. Existing literature has analyzed factors associated with positive online patient ratings among hand and wrist surgeons. However, there is limited in-depth analysis of factors associated with low patient satisfaction for hand and wrist surgeons. The focus of this study is to examine and characterize extremely negative reviews of hand and wrist surgeons on Yelp.com. Methods A search was performed using the keywords “hand surgery” on Yelp.com for eight major metropolitan areas including Washington DC, Dallas, New York, Phoenix, Los Angeles, San Francisco, Boston, and Seattle. Only single-star reviews (out of a possible 5 stars) of hand and wrist surgeons were included. The complaints in the 1-star reviews were then categorized into clinical and nonclinical categories. Result A total of 233 single-star reviews were included for analysis, which resulted in 468 total complaints. Of these complaints, 81 (18.8%) were clinically related and 351 (81.3%) were nonclinical in nature. The most common clinical complaints were for complication (24 complaints, 6%), misdiagnosis (16 complaints, 4%), unclear treatment plan (16 complaints, 4%), and uncontrolled pain (15 complaints, 3%). The most common nonclinical complaints were for physician bedside manner (93 complaints, 22%), financially related (80 complaints, 19%), unprofessional nonclinical staff (61 complaints, 14%), and wait time (46 complaints, 11%). The difference in the number of complaints for surgical and nonsurgical patients was statistically significant (p < 0.05) for complication and uncontrolled pain. Clinical Relevance Patient satisfaction is dependent on a multitude of clinical and nonclinical factors. An awareness of online physician ratings is essential for hand and wrist surgeons to maintain and improve patient care and patient satisfaction. We believe the results of our study could be used to further improve the quality of care provided by hand and wrist surgeons.

Purpose To identify the 50 most highly cited research publications in the sport of basketball. Methods Using the Clarivate Analytics Web of Knowledge database and the search term “basketball”, we identified 2,704 articles. These articles were filtered by the total number of citations and the top 50 most cited articles with a central focus on basketball were selected for this analysis. For each article, we further identified and analyzed author name, publication year, country of origin, journal name, article type, main research topic area, competitive level, gender of study population, and the level of evidence. Results Medicine‐related topics, particularly those involving knee injuries, are more common than nonmedical topics (coaching, sports psychology etc.) among the highest cited articles. Articles originated from 13 different countries, with 48% originating in the United States. Only four authors had more than one article included in the top 50 most cited articles. Conclusion A majority of the top 50 research articles were from English‐speaking countries, published after 2000, primarily focused on medicine‐related topics, and were Level III evidence. Publications examining knee injuries were the most highly cited and appear to be of high interest to current investigators. The prestige of an author’s name appeared to be less influential to the number of citations. Clinical Relevance The top 50 most cited articles list will provide researchers, medical students, residents, and fellows with a foundational list of the most important and influential academic contributions to the basketball literature.

Purpose To examine and characterize extremely negative Yelp reviews of orthopedic sports surgeons in the United States. Methods A search for reviews was performed using the keywords “Orthopedic Sports Medicine” on Yelp.com for 8 major metropolitan areas. Single‐star reviews were isolated for analysis, and individual complaints were then categorized as clinical or nonclinical. The reviews were classified as surgical or nonsurgical. Results A total of 11,033 reviews were surveyed. Of these, 1,045 (9.5%) were identified as 1‐star, and 289 were ultimately included in the study. These reviews encompassed 566 total complaints, 133 (23%) of which were clinical, and 433 (77%) of which were nonclinical in nature. The most common clinical complaints concerned complications (32 complaints; 6%), misdiagnosis (29 complaints; 5%), and uncontrolled pain (21 complaints; 4%). The most common nonclinical complaints concerned physicians’ bedside manner (120 complaints; 21%), unprofessional staff (98 complaints; 17%), and finances (78 complaints; 14%). Patients who had undergone surgery wrote 47 reviews that resulted in 114 complaints (20.5% of total complaints), whereas nonsurgical patients were responsible for 242 reviews and a total of 452 complaints (81.3% of total complaints). The difference in the number of complaints by patients after surgery and patients without surgery was statistically significant ( P < 0.05) for all categories except for uncontrolled pain, delay in care, bedside manner of midlevel staff, and facilities. Conclusion Our study of extremely negative Yelp reviews found that 77% of negative complaints were nonclinical in nature. The most common clinical complaints were complications, misdiagnoses and uncontrolled pain. Only 16% of 1‐star reviews were from surgical patients. Clinical Relevance Patients use online review platforms when choosing surgeons. A comprehensive understanding of factors affecting patient satisfaction and dissatisfaction is needed. The results of our study could be used to guide future quality‐improvement measures and to assist surgeons in maintaining favorable online reputations.

Background: Periprosthetic joint infection (PJI) is a devastating complication following total knee arthroplasty (TKA), and perioperative antibiotics are commonly administered to try to mitigate the chance of infection. Intraosseous regional administration (IORA) of prophylactic antibiotics during TKA is a method of antibiotic delivery that has been shown to achieve markedly higher tissue concentrations at much lower doses. Other advantages include ease of administration, ability to time the antibiotic delivery with the surgical start time for maximal effectiveness, and less systemic side effects. The concept is similar to a Bier block, except that IORA involves the use of antibiotics instead of local anesthetic to perfuse the limb and is given via intraosseous rather than intravenous access. Description: After standard patient preparation and draping, the tourniquet is inflated and an intraosseous needle is inserted into the proximal medial face of the tibia, just medial and slightly above the level of the tubercle. A large syringe containing the desired antibiotic (typically 500 mg vancomycin suspended in normal saline solution) is connected to the needle and the solution is administered over 1 to 2 minutes. The intraosseous needle can then be removed and the surgical procedure proceeds as it normally would per surgeon preference and technique. Alternatives: Systemic administration of intravenous antibiotics, vancomycin powder, and antibiotic-impregnated cement are alternative options that can be utilized during TKA. Rationale: IORA has several distinct advantages over other methods of antibiotic delivery, including the ability to (1) deliver antibiotic directly to the surgical bed and avoid systemic delivery, (2) precisely time and quickly administer antibiotics to achieve highest concentrations at the start of and throughout the surgical procedure, and (3) avoid several common and potentially serious side effects, especially those associated with antibiotics such as vancomycin. Expected Outcomes: This technique for antibiotic delivery achieves markedly higher tissue concentrations compared with systemic administration, without prolonged preoperative infusion times. Intraosseous delivery optimizes timing and reduces the risk of systemic side effects while simultaneously providing equal or enhanced antibiotic prophylaxis in TKA. This delivery mechanism is especially useful in patients who are at high risk for infection and in the revision TKA setting. Further, there is little to no additional risk and the use of this method does not substantially prolong operative time. Important Tips: The proximal aspect of the tibia is the optimal injection site because the cortex is thinner in this region, making needle insertion easier. Additionally, the metaphyseal bone allows faster flow rates for the infusion. We have found that insertions made slightly more proximally are easier and have faster flow rates. Of note, although the antibiotic is infused into the tibia, as seen in the attached technique video, intraosseous administration achieves rapid uptake into the vascular tree. Therefore, all tissues distal to the tourniquet, including the femur and patella, will receive this optimal dose as well. We prefer the use of a power driver (EZ-IO; Teleflex); however, manual needles (Cook Medical) can also be utilized. Longer needles are available if needed for obese patients. Flow rates are variable and the infusion typically takes 1 to 2 minutes to complete. If the flow rate is slow, twisting and withdrawing the needle slightly (2 to 4 mm) may increase the rate. This contrasts with the 1 to 2-hour intravenous infusion time required when vancomycin is administered systemically. In our experience, intraosseous injection is still successful in the case of a previous high tibial osteotomy, although the flow rate may be slower. In complex revision cases with compromised proximal tibial bone, the medial malleolus is an alternative site for intraosseous administration. Choice of antibiotic: as vancomycin is difficult to adequately administer intravenously, it is ideally suited for IORA. We have studied and utilized a 500-mg dose of vancomycin suspended in a solution of 140 mL of normal saline solution (prepared by our pharmacy). Of note, we have not found rapid infusion of intraosseous vancomycin to cause red-man syndrome as it would with rapid systemic infusion. This is because of the lower dose of 500 mg and the use of the tourniquet, which keeps the antibiotic in the local tissues about the knee without allowing systemic exposure. All patients, regardless of weight or the size of their limb, receive the dose of 500 mg of vancomycin. As cefazolin does not have the same difficulties with intravenous administration, we continue to use standard intravenous prophylaxis with an appropriate weight-based dose of cefazolin prior to incision. Indications for IORA of vancomycin include clinical scenarios in which vancomycin would be administered intravenously. These indications include revision TKA, obesity (body mass index >40 kg/m 2 ), diabetes, beta-lactam allergy, known colonization with methicillin-resistant Staphylococcus aureus (MRSA) , patients coming from institutions with a high prevalence of MRSA , previous ligamentous surgical procedure or osteotomies, and current or recent smokers. IORA can be utilized even in the primary TKA setting if the patient is considered high-risk as defined by the criteria above. We also use IORA during reimplantation following 2-stage exchange for PJI and in patients undergoing irrigation and debridement for acute PJI when the organism has been identified preoperatively.

Purpose To analyze and objectively measure the trends in inflation‐adjusted Medicare reimbursement rates for the 20 most commonly performed orthopaedic arthroscopic surgical procedures from 2000 to 2019. Methods The Centers for Medicare & Medicaid Services website was used to find the top 20 most commonly performed arthroscopic procedures using the Public Use File data file for calendar year 2017. By use of the Physician Fee Schedule Look‐Up Tool, national reimbursement averages were calculated from 2000‐2019 and data were analyzed. Averages were adjusted for inflation using the Consumer Price Index. Current Procedural Terminology codes that did not exist in 2000 were unable to be analyzed in this study. Results When adjusted for inflation, Medicare reimbursement for the 20 most commonly performed arthroscopic procedures from 2000‐2019 has decreased substantially (–29.81%). The mean Medicare reimbursement to physicians was $906 in 2000 and $632 in 2019. During this same period, the annual change in the adjusted mean reimbursement rate for all included arthroscopic procedures was –1.8% whereas the average compound annual growth rate was –1.9%. Conclusions This study shows that when adjusted for inflation, Medicare reimbursement to physicians has decreased by nearly 30% during the past 20 years for the most common arthroscopic procedures. Clinical Relevance This analysis will give orthopaedic surgeons and hospital administrators a better understanding of the financial trends surrounding one of the fastest‐growing techniques in surgery. Additionally, these financial‐trend data will be increasingly important as the population in the United States continues to age and new payment models are introduced.

Background: Hip and groin injuries are common in competitive soccer players and have been shown to be significant sources of time loss. There are few studies describing the epidemiology of hip and groin injuries in female National Collegiate Athletic Association (NCAA) soccer players. Purpose: To describe the epidemiology of hip and groin injuries in women’s collegiate soccer players. Study Design: Descriptive epidemiology study. Methods: The NCAA Injury Surveillance System/Program (ISS/ISP) was analyzed from 2004 through 2014 for data related to hip and groin injuries in female collegiate soccer players. Injuries and athlete-exposures (AEs) were reported by athletic trainers. Data were stratified by time of season, event type, injury type, treatment outcome, time loss, and player field position. Results: Between 2004 and 2014, there were 439 recorded hip or groin injuries in female soccer players and an overall rate of injury of 0.57 per 1000 AEs. Injuries were 12.0 times more likely to occur during the preseason (4.41/1000 AEs) as opposed to during the regular season (0.37/1000 AEs) (injury rate ratio [IRR], 12.01; 95% confidence interval [CI], 9.92-14.55) or postseason (0.38/1000 AEs) (IRR, 11.55; 95% CI, 7.06-18.91). Rates of injury were similar during the regular season and postseason (IRR, 0.96; 95% CI, 0.59-1.58). Rates of injury were higher during competition (0.69/1000 AEs) than during practice (0.52/1000 AEs) (IRR, 1.33; 95% CI, 1.08-1.63). Most injuries were new (87.5%; n = 384) and unlikely to recur (12.5%; n = 55). Conclusion: Hip and groin injuries in female NCAA soccer players are uncommon, and fortunately, most players return to play quickly without recurrence. Future prospective studies should evaluate the effectiveness of strength and conditioning programs in preventing these injuries.

AbstractTourniquet use in total knee arthroplasty has become a controversial topic. There are several benefits of its use including improved visualization, decreased blood loss, shorter operative times, and improved antibiotic delivery. Conversely, there are several significant downsides associated with tourniquet use including postoperative pain, neuromuscular injuries, wound complications, reperfusion injury, increased risk of thrombosis, patellar tracking issues, delayed rehabilitation including decreased postoperative range of motion, and its negative effect on patients with vascular disease. However, objectively, the literature does not definitively push us toward or away from the use of a tourniquet. Furthermore, several alternatives have been developed to help mitigate some of the adverse effects associated with its use. This article summarizes the evidence for and against tourniquet use and provides an evidence-based approach to help guide surgeons in their own practice.