Bingham, Joshua S

OBJECTIVES: This study seeks to evaluate the variability of Medicaid reimbursement and compare it with Medicare reimbursement using the 20 most commonly billed orthopaedic trauma Current Procedural Terminology (CPT) codes nationwide. The authors anticipate significant variability between states and hypothesize that Medicaid payment will be significantly less than Medicare payment. METHODS: The top 20 most common orthopaedic trauma surgery procedural codes were identified from a previous analysis performed by Haglin et al. The Centers for Medicare and Medicaid Services Physician Fee Schedule was used to determine reimbursement rates from Medicare, and state Medicaid fee schedules were used to determine reimbursement rates for Medicaid. State Medicaid rates were compared with their corresponding Medicare rates to determine a dollar difference. In addition, the dollar difference for each CPT code was divided by its respective physician relative value unit. This was used to acknowledge the possible variability in the complexity of orthopaedic procedures and the related physician effort. The Medicare Wage Index was used to adjust Medicaid rates based on the cost of living for the state as well. Coefficients of variation were calculated to represent overall variability in Medicaid and Medicare reimbursement rates. RESULTS: The mean reimbursement rates for Medicaid were lower for all 20 procedures compared with Medicare. On average, Medicaid reimbursed 16.0% less than Medicare and 29.6% less when adjusting for cost of living. MCD reimbursed at a higher rate than MCR for all procedures in only 9 states (Alaska, Arizona, Arkansas, Montana, Nebraska, New Jersey, New Mexico, North Dakota, and South Dakota) while 38 states reimbursed at a lower rate than MCR, on average. The coefficient of variation ranged from 0.24 to 0.34 for the Medicaid unadjusted group and from 0.35 to 0.46 for the Medicare Wage Index–adjusted group. By contrast, the Medicare group was consistent at 0.06 for all 20 procedures. The average dollar difference across the 20 CPT codes for Medicaid reimbursement compared with Medicare reimbursement ranged from −$76.89 to −$225.17, and the dollar difference per relative value unit ranged from −$5.96 to −$15.16. CONCLUSIONS: This study found a high amount of variation between state Medicaid reimbursement rates and average rates that were significantly lower than Medicare reimbursement rates for the top 20 most used orthopaedic trauma CPT codes as identified by Haglin et al. The discrepancy in reimbursement was increased when Medicaid rates were adjusted for state cost of living. LEVEL OF EVIDENCE: Prognostic, Level III. See Instructions for Authors for a complete description of levels of evidence.

ABSTRACT Introduction: Medical conferences are an integral aspect of medical education as they allow attendees to stay up to date with recent advancements in medicine, to develop presentation and communication skills, and to network and establish connections with professionals in their field of interest. But, when the coronavirus disease 2019 (COVID-19) pandemic was declared in March 2020, face-to-face medical conferences were suspended, and conference organizers began shifting their meetings to virtual platforms. These new virtual conferences afforded medical residents and fellows the unique opportunity to attend conferences from the comfort of their own home or workplace; however, the virtual meeting platforms did not provide attendees with the same networking experiences as in-person conferences. Since the end of the COVID-19 public health emergency, medical conferences are now faced with the question of whether they should remain virtual, shift back to in-person meetings, or develop a hybrid model of both options. Thus, the purpose of this study was to analyze medical resident and fellow sentiments and preferences by comparing virtual and in-person conference formats. Methods: A voluntary electronic survey was distributed to medical residents and fellows across the United States through their program coordinators and directors. Results: The main findings of this study suggest that medical residents and fellows largely prefer in-person conferences (85%) as compared to a virtual format because of the networking opportunities afforded to them along with the development of camaraderie with their peers. The findings in this study suggest that the largest benefit in attending a virtual conference is the flexibility to attend from any location (79% important or very important), which offered convenience, flexibility, and comfort to participants (n = 100). Conclusion: These results support our hypothesis that despite the convenience and portability afforded by attending conferences virtually, medical residents and fellows still ultimately prefer to attend conferences in person. Overall, the findings in this study are of relevance to conference organizers in understanding the driving forces behind attendance and should be considered in determining meeting format.

Background: While previously used in other specialties, the preference signaling program (PSP) was implemented in the 2022 to 2023 orthopaedic surgery residency application process for the first time. The PSP allowed for 30 signaling tokens to be sent by applicants to programs of their choice to indicate particular interest in a program. It remains unknown how the PSP affects applicants and programs in the orthopaedic surgery residency match. Thus, this study's purpose was to assess the utility of preference signaling within the orthopaedic surgery residency application process in its inaugural year of use. Methods: An anonymous electronic survey was emailed to all orthopaedic surgery residency applicants who applied to the authors' institution during the 2022 to 2023 application cycle. The survey was sent after match lists were submitted and closed before the release of match results. The survey collected information regarding applicant demographics, preference signaling habits, and attitude toward preference signaling. Results: The survey was completed by 101 applicants. Applicants applied to a mean of 90 programs (range: 10-197) and received an average of 12 interview invitations (range: 0-39). Applicants almost uniformly used all 30 signals, with nearly two-thirds signaling their home programs (65%, 49/76), and nearly all applicants sending signals to programs at which they performed away rotations (95.7%, 88/92). Applicants received a mean of 9 invitations from programs they signaled, compared with 2 invitations from programs they did not signal. Applicants were significantly more likely to receive an interview invite at a program they signaled than one they did not (p < 0.01). Overall, 57% of applicants (57/101) found the PSP to be helpful, whereas 28% (28/101) found it to be unhelpful, and 16% (16/101) had a neutral opinion. Conclusions: This study reports that the PSP in the 2022 to 2023 orthopaedic surgery match was an effective method of expressing interest in a program because applicants were significantly more likely to receive interview invites to signaled programs. More than half of respondents felt PSP to be helpful; however, the effect on application numbers is still unclear. Level of Evidence: III

In the setting of total hip arthroplasty (THA), pseudoaneurysms are extremely rare and can be difficult to diagnose, as clinical symptoms can mimic symptoms of other more common complications, such as periprosthetic joint infection, hematoma, and nerve damage. We present a case of a 69-year-old male with a history of slipped capital femoral epiphysis 56 years prior and subsequent right THA. The right hip primary arthroplasty was subsequently complicated by multiple dislocations and recurrent prosthetic joint infections. The most recent infection was treated with debridement, antibiotics, and implant retention (DAIR) in 2017. The patient later presented in 2019 with right thigh pain. Upon further analysis, he was diagnosed with Streptococcus bovis positive periprosthetic joint infection. The patient underwent a two-stage revision of the hip using an antibiotic spacer. Two weeks following the second stage, he presented with a sudden onset of uncontrolled atrial fibrillation with rapid ventricular response and a low hemoglobin. The computed tomography scan revealed a large hematoma involving both the anterior and posterior thigh compartments with lab markers that were questionable for infection. An operation to remove the hematoma revealed no purulence, and a large pulsatile pseudoaneurysm on the posterolateral aspect at the mid femur was found. A sharp bone fragment was noted next to the pseudoaneurysm. The pseudoaneurysm was repaired by a vascular surgeon, and the bone fragment was removed. Following this procedure, the patient developed a subsequent periprosthetic joint infection requiring a double DAIR procedure six weeks following the pseudoaneurysm repair and is now on chronic antibiotic suppression. Orthopedic surgeons should be aware of the potential for pseudoaneurysm in the setting of total joint arthroplasty when treating a postsurgical hematoma of sudden onset.

Purpose To evaluate the rates of lateral femoral cutaneous nerve (LFCN) injury in patients who underwent a direct anterior approach (DAA) total hip arthroplasty (THA) with and without previous hip arthroscopy. Methods We retrospectively investigated consecutive DAA THAs performed by a single surgeon. These cases were grouped into patients with and without a history of previous ipsilateral hip arthroscopy. LFCN sensation was assessed during the initial follow‐up (6 weeks) and 1‐year (or most recent) follow‐up visits. The incidence and character of LFCN injury was compared between the 2 groups. Results In total, 166 patients underwent a DAA THA with no previous hip arthroscopy, and 13 had a history of previous arthroscopy. Of the 179 total patients who underwent THA, 77 experienced some form of LFCN injury at initial follow‐up (43%). The rate of injury for the cohort with no previous arthroscopy was 39% (n = 65/166) on initial follow‐up, whereas the rate of injury for the cohort with a history of previous ipsilateral arthroscopy was 92% (n =12/13) on initial follow‐up ( P < .001). In addition, although the difference was not significant, 28% (n = 46/166) of the group without history of previous arthroscopy and 69% (n = 9/13) of the group with a history of previous arthroscopy had continued symptoms of LFCN injury at most recent follow‐up. Conclusions In this study, patients who underwent hip arthroscopy before an ipsilateral DAA THA were at increased risk of LFCN injury compared with patients who underwent a DAA THA without a previous hip arthroscopy. At final follow‐up of patients with initial LFCN injury, symptoms resolved in 29% (n = 19/65) of patients with no previous hip arthroscopy and 25% (n = 3/12) of patients with previous hip arthroscopy. Level of Evidence Level III, case–control study.

Introduction: Away rotations have become a critical factor for a successful orthopaedic surgery residency match. Away rotations significantly improve an applicant's chance of matching into an orthopaedic residency. Away rotations were limited during the 2020 to 2021 academic year because of the COVID-19 pandemic. During the 2021 to 2022 academic year, the American Association of Medical Colleges coalition recommended students only complete 1 rotation outside their home institution, whereas the American Orthopaedic Association Council of Residency Directors argued that multiple rotations should be allowed. We sought to quantify the impact of these restrictions on orthopaedic surgery applicants during the 2020 to 2021 residency application cycle. Methods: An online survey was sent to all applicants applying to the authors' home orthopaedic surgery program. The survey asked respondents to indicate how many away rotations they completed and how many they planned to complete but were unable to complete in the 2020 to 2021 application cycle. Historical match data were obtained from the National Resident Matching Program's publicly accessible Main Residency Match Data and Reports . Results: Survey responses were collected from 650 of 812 applicants (80%) to our program. Over a third of respondents (38.1%) reported completing 3 subinternship rotations during the 2020 to 2021 application cycle. Nearly a quarter of respondents (24.0%) reported completing 4 rotations. Most applicants (50.9%) were unable to complete 5 previously planned rotations because of pandemic-related restrictions, and 25.2% reported an inability to complete 4 rotations. Fewer applicants reported canceling 3 rotations (9.2%), 2 rotations (6.8%), or 1 (7.8%) rotation. Conclusions: Away rotations have been a traditional component of the orthopaedic surgery application process. Restrictions on away rotations in the 2020 to 2021 residency application cycle had affected the number of rotations that applicants were able to complete. However, despite those restrictions, over a third of applicants were able to complete at least 3 rotations. This suggests that the away rotation experience is variable for students and may be multifactorial; however, our study did not investigate the reasons for this. Accordingly, limiting away rotations may support an inequitable environment for medical students applying to orthopaedic surgery, and creating a consensus definition among medical schools, program directors, and orthopaedic chairs of away rotations, their duration, and the maximum number allowed would enhance fairness and reduce inconsistencies.

Background: Social media and online resources have been used in graduate medical education for years. In addition to an official residency program website, many orthopaedic surgery programs have an established social media presence to interact, educate, and engage with prospective applicants. The role of social media in orthopaedic surgery has significantly expanded in recent years. Despite its increasing use, the specific impact of social media on orthopaedic surgery residency applicants remains unknown. Methods: Applicants to the home institution's orthopaedic surgery residency program were sent an optional online survey during the 2020 to 2021 application cycle. No incentive was provided in exchange for participation. Results: Of 812 orthopaedic surgery applicants, 650 (80%) completed the survey. Program-based social media is widely accessed by applicants. Instagram is used by most applicants (61.9%), and nearly a third (28.7%) rely on it as their main resource when researching prospective residency programs. The majority (66.9%) agreed that social media can be successfully used to inform and interact with applicants. Most of the applicants (60.6%) also reported that social media had a positive impact on their perception of the associated program. Only 5.7% of respondents indicated that social media had a negative influence. The most effective uses of social media seem to be in allowing a program to display its culture and transparency. Conclusion: Social media plays a substantial role in the orthopaedic surgery residency application process, and its use continues to grow. Programs can use it to effectively engage with and inform prospective applicants. The impact of social media is positive on most of the applicants. Instagram is the preferred social media platform used by applicants, and nearly one-third rely on it as their main resource when researching programs. Investing time and resources into a social media presence seems to be a worthwhile pursuit for orthopaedic surgery programs as an important piece to a well-rounded recruitment effort of modern orthopaedic surgery applicants.

Introduction. This case report adds to current literature on management of a subdural hematoma following total knee arthroplasty and is particularly important as joint replacement moves into outpatient surgery centers where the orthopedic surgery team becomes the sole patient contact point. Case Presentation. A 66-year-old male presented to the emergency department five days after elective robotic-assisted left total knee arthroplasty performed with spinal epidural with the symptoms of a persistent nonpostural headache. CT of the head revealed a small bifrontal acute subdural hematoma. He was admitted for overnight monitoring as a precaution. No vascular abnormalities or underlying pathology was found on further advanced imaging. He was discharged the following morning after follow-up CT showed no focal changes. Magnetic resonance imaging (MRI) one month later confirmed resolution of the subdural hematoma. Conclusion. Orthopedic surgeons should be aware of the signs and symptoms, as well as the risk factors for subdural hematomas following lumbar puncture, as it is a rare, but potentially life-threatening complication of spinal epidural.

In the setting of below-knee amputation, compartment syndrome is a rare complication. Early clinical symptoms of an acute compartment syndrome following below-knee amputation can mimic or be masked by postoperative pain management. We present the case of a 38-year-old male with a significant past medical history of Proteus syndrome who underwent an elective transtibial below-knee amputation. Following surgery, the patient had extensive postoperative pain and high pain medication requirements and returned to the operating room for irrigation and debridement due to suspicion of an infection. Upon return to the operating room to manage the infection, the necrotic tissue was discovered and removed which had developed due to a suspected missed acute compartment syndrome. The necrotic tissue secondary to the compartment syndrome subsequently resulted in infection. Multiple irrigation and debridement procedures were performed to further manage the infection, and ultimately, the patient was deemed stable for discharge. Acute compartment syndrome (ACS) following below-knee amputation (BKA) is a rarely documented but critical complication. This case describes the unique setting in which a compartment syndrome can be masked due to postoperative pain management and infection. Orthopedic surgeons should be aware of the varying risk factors and presentations of an acute compartment syndrome (ACS) as it can occur and is a devastating complication.

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 .