Pollock, Jordan Riley

Background: Debridement and implant retention (DAIR) has variable success as a treatment for acute periprosthetic joint infection (PJI), with generally poor outcomes reported in the literature 1 . Because of the unacceptably high failure rate of DAIR, we implemented a 2-stage debridement protocol that includes the use of high-dose antibiotic beads between stages for the treatment of acute PJI. In 2 previous studies, with an average follow-up of 3.5 years in each study, we reported overall infection-control rates of 87% and 90% 2,3 . Description: Following exposure of the joint, cultures are obtained, and all modular components are removed, scrubbed, and soaked in an antiseptic solution. A thorough irrigation and debridement with complete synovectomy is performed, followed by temporary reinsertion of the original modular parts. High-dose antibiotic cement beads are inserted into the joint, and the joint is closed. Approximately 5 to 6 days later, a second debridement is performed, the beads are removed, and the new modular, sterile components are implanted. The patient is placed on a course of intravenous and, later, oral antibiotics, in addition to a standard postoperative rehabilitation protocol. Alternatives: Long-term suppressive antibiotic therapy. One-stage DAIR. One-stage exchange arthroplasty. Two-stage exchange arthroplasty. Resection arthroplasty. Amputation. Rationale: The treatment of acute PJI has historically consisted of a single irrigation and debridement, with exchange of modular parts and retention of the components, followed by intravenous antibiotic therapy. Despite having lower rates of patient morbidity compared with a 2-stage exchange arthroplasty, this more traditional procedure also has a higher rate of failure, with reported rates as high as 60% to 84% 4–12 . The utility of component retention continues to be a topic of debate 13 . Alternatives to component retention include both 1- and 2-stage exchange procedures. Although these modalities offer potentially higher rates of infection control, they are associated with substantial patient morbidity, particularly in patients with well-fixed implants 14–16 . Furthermore, exchange procedures may result in substantial iatrogenic bone loss, which can be problematic in revision total joint arthroplasty procedures, in which bone stock may already be limited. The double-DAIR protocol offers infection-control rates that are comparable with those of component-exchange procedures, but with the lower patient morbidity associated with component-retention procedures. Furthermore, the double-DAIR procedure provides the added benefit of retaining important bone stock. Expected Outcomes: The success rate for the double-DAIR procedure has been reproducible, with infection-control rates of 87% and 90% reported in 2 studies from a single cohort at our institution 2,3 . These rates represent a substantial improvement compared with a single irrigation and debridement 1 , and are on par with those reported for 2-stage exchange arthroplasty procedures 17–21 . The infection-control rates of the double-DAIR procedure did not significantly vary depending on whether infection occurred following a total knee or total hip arthroplasty. However, not surprisingly, patients who underwent debridement following a revision procedure had a lower rate of success (77.1% successful infection control) compared with patients debrided following a primary procedure (93.8% successful infection control). We could not demonstrate an association with organism and success or failure of treatment. Although not significant, there was a trend toward an association between the time from symptom onset to initial treatment and infection control (p = 0.07) 2 . Patients with successful infection control underwent the initial debridement an average of 6.2 days after symptom onset, compared with 10.7 days in patients in whom treatment had failed. Several other studies have demonstrated that successful infection control is associated with earlier initial irrigation and debridement 22–27 . We strongly support that, in the setting of confirmed acute PJI, prompt initiation of treatment optimizes the chances for successful infection control. Important Tips: Thorough debridement is key to successful infection control of infection. Antibiotic-loaded bone cement has repeatedly been demonstrated to be safe, and we recommend its use 28–31 . Extended oral antibiotics following debridement with component retention can increase infection-free survivorship 32 .

Purpose To determine the 50 most frequently cited studies in the orthopaedic shoulder arthroscopy literature and to conduct a bibliometric analysis of these studies. Methods The Clarivate Analytics Web of Knowledge database was used to gather data and metrics using Boolean queries to capture all possible iterations of shoulder arthroscopy research. The search list was sorted so that articles were organized in descending order based on the number of citations and included or excluded based on relevance to shoulder arthroscopy. The information extracted for each article included author name, publication year, country of origin, journal name, article type, and the level of evidence. Results For these 50 studies, the total number of citations was calculated to be 13,910, with an average of 278.2 citations per paper. The most‐cited article was cited 1134 times, whereas the second‐ and third‐most cited articles were cited 920 and 745 times, respectively. All 50 articles were published in English and came from 7 different orthopaedic journals. The United States was responsible for most of the included articles (31), followed by France (9) and Japan (3). Conclusions The majority of the most‐cited articles in shoulder arthroscopy are case series and descriptive studies originating from the United States. In addition, more than one half of the top 50 most‐cited studies were published after 2004, which suggests that article age may be less important in the accumulation of citations for a rapidly growing field like shoulder arthroscopy. Clinical Relevance The top 50 most‐cited studies list will provide researchers, medical students, residents, and fellows with a foundational list of the most important and influential academic contributions to shoulder arthroscopy.

Abstract BackgroundMost medical school applicants use the internet as a source of information when applying for medical school. Previous analyses have evaluated residency and fellowship websites, however, an in-depth analysis regarding medical school websites is lacking.MethodsWe evaluated 192 United States medical school websites for presence or absence of 39 items relevant to medical school applicants. Items fell into 7 general categories: curriculum, research, demographics of incoming class, admissions information, faculty, financial aid, and social.ResultsOf the 192 websites evaluated (152 allopathic and 40 osteopathic schools), websites contained a mean of 23 items (59%) with a standard deviation of 4.2 items. ConclusionOur study examining United States Medical School websites revealed a lack of online information for medical school applicants. As medical school interviews transition to being online during the COVID-19 pandemic, the importance of the medical school website to applicants becomes increasingly crucial. The information contained in our study could be used to improve accessibility and information on medical school websites, which could help both applicants and medical schools themselves.

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.

Objectives: In the field of orthopaedics, it has been evident that Medicare reimbursement rates have been relatively stagnant. Although, objective measures of how these financial trends have changed over the past couple of decades has been limited. If orthopaedic practitioners and hospital administrators wish to make progress and advance the degree of satisfactory reimbursement they can expect, a more thorough understanding of these trends is warranted. In this study, the field of orthopaedic shoulder, elbow, and upper arm surgery is being analyzed specifically. The objective of this analysis was to assess the monetary trends in Medicare reimbursement rates for the 10 most commonly utilized shoulder surgical procedures and the 10 most commonly utilized elbow and upper arm surgical procedures from 2000 to 2019. Methods: For this analysis, the current procedural terminology (CPT) code ranges that corresponded to “Surgical Procedures of the Shoulder” and “Surgical Procedures of the Humerus (Upper Arm) and Elbow” were determined. The Medicare Provider Utilization and Payment Data: Physician and Other Suppliers PUF CY 2017 document was then utilized to objectively determine the 10 most common CPT codes fororthopaedic shoulder surgical procedures and orthopaedic elbow and upper arm surgical procedures. The reimbursement data for each of these procedures was then compiled from The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services. All monetary data points were adjusted for inflation to 2019 US dollars utilizing changes to the United States consumer price index. The average annual and the total percentage change in reimbursement were based on the adjusted trends for the 10 included shoulder procedures and the 10 included elbow and upper arm procedures. Results: After adjustment for inflation, the average reimbursement for the top 10 orthopaedic shoulder surgery procedures decreased by 25.8% from 2000 to 2019. The greatest mean decrease was observed in the “Repair of ruptured musculotendinous cuff (e.g. rotator cuff) open; chronic (23412)” CPT code (-40.1%). No adjusted reimbursement rates were noted to be positive throughout the study period for surgical shoulder procedures. The procedure with the smallest mean decrease was the “Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulation (23600)” CPT code (-5.4%). From 2000 to 2019, the adjusted reimbursement rate for all included shoulder procedures decreased by an average of 1.6% per year. For the top 10 orthopaedic elbow and upper arm surgical procedures, the average reimbursement decreased by 19.5% from 2000 to 2019. The greatest mean decrease was observed in the “Osteoplasty,humerus (e.g., shortening or lengthening) (24420)” CPT code (-32.1%). The procedure with the only positive mean difference was “Closed treatment of humeral shaft fracture; without manipulation (24500)” CPT code (0.34%). From 2000 to 2019, the adjusted reimbursement rate for all included elbow and upper arm procedures decreased by an average of 1.2% per year. Conclusion: To our knowledge, this is the first study to evaluate the orthopaedic shoulder and elbow subspecialtyand its trends in Medicare reimbursement rates. When monetary data is corrected for inflation, Medicare reimbursement rates have shown a steady decline from 2000 to 2019. The 10 most common procedures of or relating to the shoulder have decreased by an average of 25.8% while the 10 most common procedures of or relating to the elbow or upper arm have decreased by an average of 19.5%. Additionally, only one procedure showed a positive increase in reimbursement rate (Closed treatment of humeral shaft fracture; without manipulation (24500)). If access to high quality and sustainable surgicalorthopaedic care is to persist in the United States, increased awareness of these trends is important for stakeholders to take note of.