Publications by authors named "David C Landy"

66 Publications

Impact of Level of Evidence on Citation of Orthopaedic Articles.

J Am Acad Orthop Surg 2021 Apr 7. Epub 2021 Apr 7.

From the Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL (Scott, Dirschl), and the Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY (Landy).

Introduction: Level of evidence grading has become widely used in orthopaedics. This study reviewed clinical research articles published in leading orthopaedic journals to describe the association between level of evidence and number of future citations, which is one measure of an article's impact in the field.

Methods: The first 100 clinical research articles published in 2014 by each of the Journal of Bone and Joint Surgery, Clinical Orthopaedics and Related Research, and the American Journal of Sports Medicine were reviewed for level of evidence and article characteristics. Web of Science was used to identify the number of citations of each article over the following 5 years. Univariable analyses and multivariable linear regression were used to describe the associations.

Results: Three hundred articles were evaluated. Univariable analysis revealed no association between level of evidence and number of citations, with a median number of citations for level 1 articles of 23 (interquartile range [IQR], 14-49), level 2 articles 24 (IQR, 13-47), level 3 articles 22 (IQR, 13-40), and level 4 or 5 articles 20 (IQR, 10-36). Univariable analyses showed weak associations between other article characteristics and citations. Even after adjusting for other variables, the standardized regression coefficient for level 1 versus level 4 or 5 was only 0.14 and the overall model had a poor fit with an R2 of 0.18.

Conclusions: Among clinical research articles published in leading orthopaedic journals, no notable association was found between level of evidence and future citations.

Clinical Relevance: Readers of the orthopaedic literature should understand that no association was found between level of evidence and future citations. Additional work is needed to better understand the effect level of evidence has on clinicians and researchers.
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http://dx.doi.org/10.5435/JAAOS-D-20-00733DOI Listing
April 2021

Gout in primary total knee arthroplasty: Prevalent but not independently associated with complications.

Knee 2021 Jan 6;28:45-50. Epub 2020 Dec 6.

University of Kentucky, Department of Orthopaedic Surgery, 740 S. Limestone, Lexington, KY, 40536, USA. Electronic address:

Background: Gout is a common synovial pathology, but its prevalence in patients undergoing total knee arthroplasty (TKA) and potential association with complications such as periprosthetic infection (PJI) and revision are unknown.

Methods: Medicare data from 2009 to 2013 was retrospectively reviewed using PearlDiver. All patients 65 years of age or older and undergoing primary TKA with at least 3 years of pre-TKA records were included. The prevalence of gout was based on ICD-9 codes. Univariable associations of gout with PJI and revision at 1 year were assessed using odds ratios with 95% confidence intrervals (C.I.). To control for potential confounding, patients with a history of gout were matched on age, gender, smoking history, and Elixhauser Comorbidity Index (ECI) to patients without gout and associations reassessed.

Results: The prevalence of gout in Medicare patients undergoing primary TKA was 5.7%. On univariable analysis, patients with a history of gout were more likely to develop PJI (O.R., 1.58; 95% C.I., 1.45-1.72) and undergo revision (O.R., 1.33; 95% C.I., 1.25-1.41) at 1 year. After matching for confounders, a history of gout was no longer associated with developing PJI (O.R., 0.98; 95% C.I., 0.90-1.06) or undergoing revision (O.R., 0.94; 95% C.I., 0.89-1.00) at 1 year.

Conclusions: Gout is a relatively common pathology in patients undergoing TKA. While gout is associated with increased complications, this appears to be driven by confounding through its association with other medical comorbidities. Gout does not appear to be an independent risk factor for complications following TKA.
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http://dx.doi.org/10.1016/j.knee.2020.11.007DOI Listing
January 2021

Periprosthetic Hip Fractures Outside the Initial Postoperative Period: Does Time from Diagnosis to Surgery Matter?

Arthroplast Today 2020 Sep 5;6(3):628-633.e0. Epub 2020 Aug 5.

Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA.

Background: Despite an increasing incidence and associated morbidity, the optimal timing for the surgical management of periprosthetic hip fractures remains unknown. This study sought to explore whether time to surgery was associated with medical or surgical complications.

Methods: A retrospective review of Medicare data from 2010 to 2014 was performed using PearlDiver. All patients with a periprosthetic hip fracture greater than 90 days from surgery and undergoing open reduction internal fixation (ORIF) or revision total hip arthroplasty (RTHA) were included. Time to surgery was measured from diagnosis and dichotomized at 48 hours.

Results: Of 342 patients undergoing ORIF, 269 (79%) had surgery within 48 hours. Of 255 patients undergoing RTHA, 142 (56%) had surgery within 48 hours. For ORIF, surgery more than 48 hours after diagnosis was associated with an increased rate of 30-day deep vein thrombosis or pulmonary embolism (15% vs 7%,  = .03), which remained after adjustment (odds ratio [OR]: 2.71, 95% confidence interval [CI]: 1.11-6.45). A similar association was seen for RTHA (12% vs 6%,  = .09 and OR: 2.61, 95% CI 1.01-7.24). For RTHA, surgery more than 48 hours after diagnosis was associated with an increased rate of 90-day periprosthetic joint infection (12% vs 4%,  = .007), which remained after adjustment (OR: 3.86, 95% CI: 1.36-12.72). A similar but not significant association was seen for ORIF (7% vs 3%,  = .18 and OR: 2.65, 95% CI: 0.73-8.91).

Conclusions: Among Medicare patients with a periprosthetic hip fracture, time to surgery greater than 48 hours was associated with increased medical and surgical complications.
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http://dx.doi.org/10.1016/j.artd.2020.06.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7502573PMC
September 2020

Public Interest in Knee Replacement Fell During the Onset of the COVID-19 Pandemic: A Google Trends Analysis.

HSS J 2020 Sep 15:1-5. Epub 2020 Sep 15.

Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA.

Background: The COVID-19 pandemic significantly altered medical practice and public behavior in the USA. In spring of 2020, elective surgery including most joint replacement was suspended and much of the public asked to stay at home. As elective surgery resumes, it is unknown how the public will respond.

Questions/purposes: We sought to describe public interest in knee replacement during the onset of the COVID-19 pandemic.

Methods: Google Trends was used to obtain the daily number of searches for "knee replacement," "coronavirus," and "knee pain" from December 19, 2019, to May 14, 2020. The number is on a term-specific scale weighted to the highest number of daily searches for that term. Seven-day weighted averages were used to smooth the data.

Results: The number of daily searches for "knee replacement" was stable until around March 8, 2020, after which it decreased through late March, plateauing at less than half the number of searches. At the same time, searches for "coronavirus" spiked. By early May, searches for "knee replacement" had not meaningfully increased, though at the end of the search period the slope turned positive and coronavirus searches decreased. Searches for "knee pain" initially followed a similar pattern to "knee replacement," though the decline was not as steep, and by late April searches for "knee pain" had meaningfully increased.

Conclusion: Public interest in knee replacement, assessed through internet search queries, decreased during the onset of the COVID-19 pandemic. While interest in pain has returned, the continued decreased level of interest in surgery may represent a fear of surgery among the general public in the setting of COVID-19. Surgeons may wish to focus outreach and education efforts on the safety and efficacy of knee replacement.
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http://dx.doi.org/10.1007/s11420-020-09794-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7490570PMC
September 2020

Distinguishing Periprosthetic Crystalline Arthropathy from Infection in Total Knee Arthroplasty: A Systematic Review.

J Knee Surg 2020 Sep 17. Epub 2020 Sep 17.

Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York.

Distinguishing periprosthetic crystalline arthropathy from periprosthetic joint infection (PJI) remains a diagnostic challenge as both symptom presentation and diagnostic tests overlap. Accurate differentiation is important as treatment plans vary significantly. We sought to systematically review all cases of total knee arthroplasty (TKA) periprosthetic crystalline arthropathy reported in the literature and summarize clinical, diagnostic, and operative findings in the context of guidelines for diagnosing PJI. The goal of this systematic review is to determine the amount of diagnostic overlap and to identify best practices for differentiating between these two diagnoses. MEDLINE and Google Scholar were searched to identify cases of crystalline arthropathy following TKA. Case reports were reviewed for patient characteristics, clinical symptoms, physical exam, laboratory results, and treatment outcomes. These findings were summarized across patients and dichotomized based on current thresholds for diagnosing PJI according to Musculoskeletal Infection Society criteria. Twenty-six articles were identified which included 42 cases of periprosthetic crystalline arthropathy (17 gout, 16 pseudogout, one both, and eight not specified). Of these cases, 25 presented over 1 year after their index arthroplasty and 15 had no prior history of crystalline arthropathy. Only six cases had a superimposed infection based on aspiration or intraoperative cultures. For cases without a culture-positive infection, several diagnostic tests overlap with PJI thresholds: 95% of patients had C-reactive protein greater than 1 mg/dL, 76% had an erythrocyte sedimentation rate greater than 30 mm/hour, 91% had a synovial white blood cell greater than 3,000 cells, and 76% had a synovial polymorphonuclear cells percent greater than 80%. Patients without co-infection were managed with non-steroidal anti-inflammatory drugs, colchicine, allopurinol, steroids, or a combination of these treatments and most had complete resolution of symptoms within 1 week. Commonly used markers of PJI fail to reliably distinguish periprosthetic crystalline arthropathy from infection. Though clinical judgement and consideration of the implications of delayed treatment for acute PJI remain paramount, in the setting of synovial crystals, surgeons may wish to consider this alternate etiology as the source of the patient's clinical symptoms.
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http://dx.doi.org/10.1055/s-0040-1716507DOI Listing
September 2020

The Association of Opioid Utilization and Patient Satisfaction Following Outpatient Orthopaedic Surgery: More May Not Be Better.

J Surg Orthop Adv 2020 ;29(2):88-93

University of Chicago Department of Orthopaedic Surgery and Rehabilitation Medicine, Chicago, Illinois.

Postoperative analgesia remains an important area of research in orthopaedics. There remains a lack of information on the complex interplay between opioid utilization postoperatively, pain and patient satisfaction. This study aims to describe the relationship between opioid utilization, postoperative pain, and patient satisfaction following outpatient orthopaedic surgery in a multispecialty orthopaedic practice. As a part of an ongoing quality control project at our institution patients were instructed to monitor utilization of postoperative opioids. The results of a convenience sample of 139 patients representing a 53% response rate among eligible patients that completed the survey following outpatient orthopaedic surgery are reported. Among patients undergoing outpatient orthopaedic surgery, there was no clinically significant association between opioid utilization and patient satisfaction. This association appeared largely independent of the patient's actual pain. While lower pain scores were associated with increasing patient satisfaction, this appeared to be independent of opioid utilization. (Journal of Surgical Orthopaedic Advances 29(2):88-93, 2020).
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November 2020

Healthy Behavior Adherence: The National Health and Nutrition Examination Survey, 2005-2016.

Am J Prev Med 2020 08 25;59(2):270-273. Epub 2020 Apr 25.

Hospital For Special Surgery, New York, New York.

Introduction: Leading public health institutions recommend participation in several evidence-based behaviors, including exercise, a healthy diet, and maintenance of a normal BMI while simultaneously avoiding cigarette smoking and excessive alcohol consumption. The investigators attempted to evaluate the collective adherence to these recommendations and population trends in these behaviors by evaluating nationally representative surveys over a period of 12 years.

Methods: In 2019, the data from 26,194 National Health and Examination Survey participants who provided answers to survey questions regarding diet, physical activity, and usage of cigarettes and alcohol were analyzed. BMI was obtained from the examination data. Adherence to each behavior and the constellation of all 5 behaviors was assessed and tracked over a 12-year timeframe.

Results: The smoking rates (p=0.01) and adherence to a healthy BMI declined over time (p=0.03). The total percentage of subjects who participated in all 5 behaviors ranged from 4.4% to 6.3%, whereas subjects who performed 2 or fewer behaviors ranged from 45.4% to 48.3%. Greater education (p<0.0001), higher SES (p<0.0001), and being a female participant (p<0.0001) predicted higher behavior scores.

Conclusions: Only 1 in 5 Americans engage in 4 or more healthy behaviors, whereas almost half of them participate in fewer than 3 healthy behaviors. Increased participation in numerous healthy behaviors can decrease premature mortality, decrease the burden of chronic diseases, improve life quality, and provide substantial economic benefits. A public health practice of targeting a constellation of behaviors as opposed to individual behaviors is needed.
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http://dx.doi.org/10.1016/j.amepre.2020.02.013DOI Listing
August 2020

Utilization of Debridement, Antibiotics, and Implant Retention for Infection After Total Joint Arthroplasty Over a Decade in the United States.

J Arthroplasty 2020 08 21;35(8):2210-2216. Epub 2020 Mar 21.

Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY.

Background: Reported clinical outcomes have varied for debridement, antibiotics, and implant retention (DAIR) and little is known regarding trends in utilization. We sought to evaluate the rate of DAIR utilization for total knee arthroplasty (TKA) and total hip arthroplasty (THA) periprosthetic joint infection (PJI) over a decade and clinical factors associated with these trends.

Methods: A retrospective study of primary TKAs and THAs was performed using Medicare data from 2005 to 2014 using the PearlDiver database platform. Current Procedural Technology and International Classification of Diseases Ninth Edition codes identified patients who underwent a surgical revision for PJI, whether revision was a DAIR, as well as associated clinical factors including timing from index arthroplasty.

Results: The proportion of revision TKAs and THAs performed using DAIR was 27% and 12% across all years, respectively. This proportion varied by year for TKAs and THAs with a linear trend toward increasing relative use of DAIR estimated at 1.4% and 0.9% per year (P < .001; P < .001). DAIR for TKA and THA performed within 90 days increased at a faster rate, 3.4% and 2.1% per year (P < .001; P < .001). Trends over time in TKA DAIRs showed an association with Elixhauser Comorbidity Index (ECI), 0-5 group increasing at 2.0% per year (P = .03) and patients >85 years (P = .04).

Conclusion: The proportion of revision arthroplasty cases for PJI managed with DAIR has been increasing over time in the United States, with the most substantial increase seen <90 days from index arthroplasty. Age, gender, and ECI had a minimal association with this trend, except in the TKA population >85 years and in those with a very low ECI score.
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http://dx.doi.org/10.1016/j.arth.2020.03.029DOI Listing
August 2020

Opioid Naive Surgeons and Opioid-Tolerant Patients: Can Education Alter Prescribing Patterns to Total Knee Arthroplasty Patients?

J Knee Surg 2020 Mar 4. Epub 2020 Mar 4.

Department of Orthopaedic Surgery, University of Chicago, Chicago, Illinois.

Patterns of opioid overprescribing following arthroplasty likely developed given that poor pain control can diminish patient satisfaction, delay disposition, and lead to complications. Recently, interventions promoting responsible pain management have been described, however, most of the existing literature focuses on opioid naive patients. The aim of this study was to describe the effect of an educational intervention on opioid prescribing for opioid-tolerant patients undergoing primary total knee arthroplasty (TKA). As the start to a quality improvement initiative to reduce opioid overprescribing, a departmental grand rounds was conducted. Prescribing data, for the year before and after this intervention, were retrospectively collected for all opioid-tolerant patients undergoing primary TKA. Opioid prescribing data were standardized to mean morphine milligram equivalents (MME). Segmented time series regression was utilized to estimate the change in opioid prescribing associated with the intervention. A total of 508 opioid-tolerant patients underwent TKA at our institution during the study period. The intervention was associated with a statistically significant decrease of 468 mean MME (23%) from 2,062 to 1,594 ( = 0.005) in TKA patients. This study demonstrates that an educational intervention is associated with decreased opioid prescribing among opioid-tolerant TKA patients. While the effective management of these patients is challenging, surgeon education should be a key focus to optimizing their care.
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http://dx.doi.org/10.1055/s-0040-1701449DOI Listing
March 2020

Stratifying Venous Thromboembolism Risk in Arthroplasty: Do High-Risk Patients Exist?

J Arthroplasty 2020 05 16;35(5):1390-1396. Epub 2020 Jan 16.

Northshore University HealthSystem, Skokie, IL.

Background: While there are many possible complications associated with total joint arthroplasty (TJA), venous thromboembolism (VTE) is both frequent and potentially severe. Despite this importance, there are inconsistent recommendations for prophylaxis based on patient risk factors.

Methods: A predictive model was constructed to compare low-molecular-weight heparin(LMWH) and aspirin (ASA) for prevention of VTE-associated complications following TJA.The model used risks from prior prophylaxis studies to estimate the risk of developing a symptomatic deep vein thrombosis, pulmonary embolism, thrombocytopenia, and operative or nonoperative site bleeding. We also evaluated the progression to 4 possible final health states: postphlebitis syndrome, intracranial hemorrhage, death, or baseline health. Within published ranges, we selected assumptions that were favorable to LMWH such that these analyses represent a best case scenario for LMWH or an alternative more aggressive low-molecular-weight heparin alternative (LMWHA). Events and outcomes were assigned quality-adjusted life-year (QALY) losses according to prior studies to determine the effect on patients' outcomes for ASA and LMWHA prophylaxis.

Results: Assessing VTE risk populations from 0.2% to 2% with life expectancies ranging from 5 to 40 years postoperatively, patients with a risk ratio less than 3.7 showed increased expected QALY with ASA compared to LMWHA. For patients with a baseline VTE risk of 1% and a 15 year life expectancy, a risk ratio of 13.4 was needed to identify patients that would benefit from LMWHA. With life expectancy increased to 30 years, the risk ratio needed to idetify these patients was 7.4.

Conclusion: Patients undergoing TJA should receive ASA chemoprophylaxis in nearly all situations, unless the patient has a significantly increased VTE risk compared to the baseline population and a long life expectancy.
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http://dx.doi.org/10.1016/j.arth.2020.01.013DOI Listing
May 2020

Olecranon Fracture through Persistent Olecranon Apophysis in a 21-Year-Old Male: A Case Report and Systematic Review of the Literature.

J Hand Surg Asian Pac Vol 2020 Mar;25(1):110-113

Department of Orthopaedic Surgery and Rehabilitation, University of Chicago Hospitals, Chicago, IL, USA.

Traumatic fractures involving an ununited olecranon apophysis in adults have been rarely documented in the literature. We present the case of a 21-year-old male wrestler with an elbow injury after a fall. Imaging revealed an acute fracture of the olecranon with sclerotic rounded edges indicating an injury through a persistent olecranon apophysis. Open reduction and internal fixation was performed with plate fixation and bone grafting with radiographic and clinical healing at 6 weeks. Review of the literature revealed 5 case reports showing high rates of non-union with tension band constructs while plate and screw fixation had no incidence of nonunion. Fractures through an ununited olecranon apophysis are successfully treated with plate and screw fixation with bone grafting.
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http://dx.doi.org/10.1142/S2424835520720017DOI Listing
March 2020

CORR Insights®: Is Switching from Oral Antidiabetic Therapy to Insulin Associated with an Increased Fracture Risk?

Authors:
David C Landy

Clin Orthop Relat Res 2020 05;478(5):1004-1006

D. C. Landy, Fellow, Hospital for Special Surgery, Department of Orthopaedic Surgery, New York, NY, USA.

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http://dx.doi.org/10.1097/CORR.0000000000001144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7170683PMC
May 2020

Varus-Valgus Constraint in Primary Total Knee Arthroplasty: A Short-Term Solution but Will It Last?

J Arthroplasty 2020 03 5;35(3):741-746.e2. Epub 2019 Oct 5.

Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL.

Background: Prostheses with varus-valgus constraint (VVC) are increasingly utilized in primary total knee arthroplasty (TKA) to address coronal malalignment and instability though little is known regarding the association between added constraint and aseptic loosening. We sought to systematically review the literature for reports of VVC in primary TKA and meta-analyze clinical results and implant survival.

Methods: PubMed was searched using broad terms to identify articles reporting VVC in primary TKA. Any article reporting clinical or survival outcomes was included. Clinical scores, close to 2 years postoperatively were converted to standardized mean differences, and the latest survival estimates were weighted using the inverse of their variance and meta-analyzed.

Results: Three hundred ninety-two search results were reviewed identifying 30 relevant articles reporting on 3620 knees in total. The estimate for the improvement in clinical scores postoperatively was 3.1 standard deviations (95% confidence interval 2.6-3.6). The estimate for implant revision slowly increased from 1% at 2 years to 2% at 6 years and then began to increase more rapidly beyond this point. The estimated revision rate was 9% by 12 years and 28% by 20 years. This revision rate estimate was stable with and without the inclusion of outlying studies.

Conclusion: VVC in primary TKA is associated with significant clinical improvement without significant risk of early failure. Meta-regression estimates raise concerns for significant revision risk with extended follow-up, especially beyond 5 years. In the absence of new data, VVC should continue to be used cautiously in the primary TKA.
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http://dx.doi.org/10.1016/j.arth.2019.09.048DOI Listing
March 2020

What Are the Implications of Alternative Alpha Thresholds for Hypothesis Testing in Orthopaedics?

Clin Orthop Relat Res 2019 Oct;477(10):2358-2363

D. C. Landy, T. J. Utset-Ward, M. J. Lee, University of Chicago, Chicago, IL, USA.

Background: Clinical research in orthopaedics typically reports the presence of an association after rejecting a null hypothesis of no association using an alpha threshold of 0.05 at which to evaluate a calculated p value. This arbitrary value is a factor that results in the current difficulties reproducing research findings. A proposal is gaining attention to lower the alpha threshold to 0.005. However, it is currently unknown how alpha thresholds are used in orthopaedics and the distribution of p values reported.

Questions/purposes: We sought to describe the use of alpha thresholds in two orthopaedic journals by asking (1) How frequently are alpha threshold values reported? (2) How frequently are power calculations reported? (3) How frequently are p values between 0.005 and 0.05 reported for the main hypothesis? (4) Are p values less than 0.005 associated with study characteristics such as design and reporting power calculations?

Methods: The 100 most recent original clinical research articles from two leading orthopaedic journals at the time of this proposal were reviewed. For studies without a specified primary hypothesis, a main hypothesis was selected that was most consistent with the title and abstract. The p value for the main hypothesis and lowest p value for each study were recorded. Study characteristics including details of alpha thresholds, beta, and p values were recorded. Associations between study characteristics and p values were described. Of the 200 articles (100 from each journal), 23 were randomized controlled trials, 141 were cohort studies or case series (defined as a study in which authors had access to original data collected for the study purpose), 31 were database studies, and five were classified as other.

Results: An alpha threshold was reported in 166 articles (83%) with all but two reporting a value 0.05. Forty-two articles (21%) reported performing a power calculation. The p value for the main hypothesis was less than 0.005 for 88 articles (44%), between 0.05 and 0.005 for 67 (34%), and greater than 0.05 for 29 (15%). The smallest p value was between 0.05 and 0.005 for 39 articles (20%), less than 0.005 for 143 (72%), and either not provided or greater than 0.05 for 18 (9%). Although 50% (65 of 130) cohort and database papers had a main hypothesis p value less than 0.005, only 26% (6 of 23) randomized controlled trials did. Only 36% (15 of 42) articles reporting a power calculation had a p value less than 0.005 compared with 51% (73 of 142) that did not report one.

Conclusions: Although a lower alpha threshold may theoretically increase the reproducibility of research findings across orthopaedics, this would preferentially select findings from lower-quality studies or increase the burden on higher quality ones. A more-nuanced approach could be to consider alpha thresholds specific to study characteristics. For example, randomized controlled trials with a prespecified primary hypothesis may still be best evaluated at 0.05 while database studies with an abundance of statistical tests may be best evaluated at a threshold even below 0.005.

Clinical Relevance: Surgeons and scientists in orthopaedics should understand that the default alpha threshold of 0.05 represents an arbitrary value that could be lowered to help reduce type-I errors; however, it must also be appreciated that such a change could increase type-II errors, increase resource utilization, and preferentially select findings from lower-quality studies.
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http://dx.doi.org/10.1097/CORR.0000000000000843DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6999932PMC
October 2019

General health measures in shoulder surgery: are we powered for success?

J Shoulder Elbow Surg 2019 Jul 26;28(7):1341-1346. Epub 2019 Mar 26.

Department of Orthopedic Surgery, University of Chicago, Chicago, IL, USA.

Background: Surgeons, policymakers, and payers increasingly use changes in general health to guide decision-making. It is unknown how such measures are incorporated into shoulder surgery research, how strongly they are associated with changes in shoulder-specific outcomes, and whether they are appropriately powered.

Methods: PubMed was searched for articles reporting shoulder-specific and general health measures after rotator cuff repair and total shoulder arthroplasty. Study characteristics, results at the study group level, reporting of power calculations, and statistical significance were recorded. Meta-regression was employed to describe the association of changes between shoulder-specific and general health measures.

Results: Of 360 identified abstracts, 21 articles with 28 patient groups were included. Only 1 article was published before 2000. There was a strong association of changes between shoulder-specific and general health measures (r = 0.66; P < .001). Power calculations were mentioned in 33% of studies and based on shoulder-specific measures. Of 20 studies conducting hypothesis tests, 75% reported agreement regarding the statistical significance of shoulder-specific and general health tests. Of 5 discordant studies, 4 found the shoulder-specific measure statistically significant and not the general health measure.

Conclusion: Shoulder surgery research increasingly reports changes in general health measures that are associated with changes in shoulder-specific measures, suggesting that improvements in shoulder symptoms increase quality of life. When disagreement exists, it usually results from the general health measure's not meeting statistical significance, which may simply reflect type II error. Research reporting general health measures should carefully report power considerations to avoid misinterpretation of findings failing to reach statistical significance.
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http://dx.doi.org/10.1016/j.jse.2018.12.012DOI Listing
July 2019

The Presence of a Psychiatric Condition is Associated With Undergoing Hip Arthroscopy for Femoroacetabular Impingement: A Matched Case-Controlled Study.

J Arthroplasty 2019 03 9;34(3):446-449. Epub 2018 Nov 9.

Department of Orthopaedic Surgery and Rehabilitation Medicine, The University of Chicago Medicine & Biological Sciences, Chicago, IL.

Background: We sought to examine the association between having a psychiatric condition and undergoing hip arthroscopy for femoroacetabular impingement (FAI).

Methods: A matched case-control study was performed to control for age and gender. All patients over 16 years of age with FAI treated with hip arthroscopy by a single surgeon were randomly matched to a patient of the same age and gender undergoing knee arthroscopy for any diagnosis other than infection by the same surgeon during the same period. Conditional logistic regression was used to compare the odds of having a psychiatric condition between groups.

Results: Fifty-one matched pairs of patients undergoing hip and knee arthroscopy were identified. Each group contained 35 females (69%) and had a mean age of 33.6 years. Of the 51 hip arthroscopy cases, 23 (45.1%) had a psychiatric condition. Of the 51 knee arthroscopy controls, 11 (21.6%) had a psychiatric condition. Patients undergoing hip arthroscopy were statistically significantly more likely to have a psychiatric condition compared to patients undergoing knee arthroscopy with an odds ratio of 3.4 (95% confidence interval 1.3-9.2, P < .01).

Conclusion: There was a strong association between having a psychiatric condition and undergoing hip arthroscopy for FAI. More research should be done investigating psychiatric conditions among patients with FAI and whether this association can identify strategies to optimize patient outcomes.
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http://dx.doi.org/10.1016/j.arth.2018.10.038DOI Listing
March 2019

Editorial Commentary: "Rotator-Metrics": Understanding Risk Factors for Rotator Cuff Repair Failure May Lead to Better Outcomes.

Arthroscopy 2018 11;34(11):2980-2982

University of Chicago.

Retear following rotator cuff repair is a significant risk and is associated with worse patient-reported outcomes. Tear size, fatty infiltration, age, and chronicity have all been reported as independent risk factors. Understanding risk factors for rotator cuff repair failure may allow surgeons to optimize outcomes by addressing certain tears, such as tears involving the anterior rotator cuff cable and subscapularis, more acutely and incorporating patch augmentation in tears that are at high risk for failure.
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http://dx.doi.org/10.1016/j.arthro.2018.08.002DOI Listing
November 2018

Time to Dislocation Analysis of Lumbar Spine Fusion Following Total Hip Arthroplasty: Breaking Up a Happy Home.

J Arthroplasty 2018 12 29;33(12):3768-3772. Epub 2018 Aug 29.

Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL.

Background: Although a history of lumbar spine fusion (LSF) is associated with increased dislocation risk following total hip arthroplasty (THA), the effect of LSF following THA is not well described. This study sought to describe the dislocation-free survival experience of patients with THA undergoing LSF, compare this to similar patients not undergoing LSF, and assess factors associated with dislocation risk following LSF.

Methods: Center for Medicare Service billing data from 2005 to 2014 was analyzed utilizing the PearlDiver platform. Patients without evidence of hip instability, defined as no dislocation event within at least 6 months following THA, were identified and stratified by having subsequent LSF. Kaplan-Meier curves were used to describe dislocation-free survival of these groups and assess factors associated with dislocation.

Results: Among 17,223 patients without history of hip instability following THA, there was no spike in dislocations following LSF with patients having a persistent and stable rate of dislocation of 0.7% per year. This experience was of similar shape but increased hazard when compared to that of 863,182 patients not undergoing LSF who had a dislocation rate of 0.4% per year (P < .001). Dislocations were not strongly associated with gender, age, comorbidities, or fusion length.

Conclusion: Patients without evidence of hip instability following THA subsequently undergoing LSF do not have a spike in dislocations in the perioperative period but do assume a persistently elevated risk of dislocation. Future research should identify factors responsible for this increased risk to determine whether they may be modifiable.
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http://dx.doi.org/10.1016/j.arth.2018.08.029DOI Listing
December 2018

Association of Injury Energy Level and Neurovascular Injury Following Knee Dislocation.

J Orthop Trauma 2018 11;32(11):579-584

Department of Orthopaedic Surgery and Rehabilitation Medicine, The University of Chicago, Chicago, IL.

Objective: To describe the associations between mechanism of injury energy level and neurovascular injury (NVI) following knee dislocation (KD) using a large representative sample of trauma patients and to examine risk factors within these groups.

Design: Retrospective cohort study.

Setting: Trauma centers participating in the American College of Surgeons National Trauma Data Bank.

Participants: Adult patients with KD without lower extremity fracture.

Intervention: Patients were grouped as ultra-low, low, or high-energy based on injury mechanism. Univariate/multivariate analyses assessed associations of energy level with NVI and of patient characteristics with NVI within energy-level groups.

Main Outcome Measurements: Rate of nerve and blood vessel injury.

Results: One hundred twenty-four patients with KD were identified; 181 sustained ultra-low-energy mechanisms, 275 low-energy, and 868 high-energy. Nerve injury occurred in 6% of ultra-low-energy injuries, 7% in low-energy, and 3% in high-energy (P = 0.03). Vessel injury occurred in 21% of ultra-low-energy injuries, 17% in low-energy, and 13% in high-energy (P = 0.01). On multivariate analyses, obesity was associated with nerve injury in the ultra-low-energy group (OR 4.9; 95% CI 1.0-24.0) but not with other energy levels. Obesity was also associated with vessel injury in the ultra-low-energy group (OR 4.0; 95% CI 1.6-9.7). Smoking, hypertension, and diabetes were not associated with NVI.

Conclusions: NVI following KD is more common after lower energy-level mechanisms. Obesity is associated with NVI in lower energy-level mechanisms. Physicians should be vigilant in screening for NVI in the setting of KD even with seemingly benign mechanisms of injury, especially in patients with obesity.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001277DOI Listing
November 2018

Thromboprophylaxis in Spinal Surgery.

Spine (Phila Pa 1976) 2018 04;43(8):E474-E481

Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago Medicine Division of Biological Sciences, Chicago, IL.

Study Design: Systematic review and meta-analysis.

Objective: Determine the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) in spinal surgery patients receiving no thromboprophylaxis, mechanoprophylaxis, and chemoprophylaxis.

Summary Of Background Data: The incidence of thromboembolic complications after spinal surgery is not well established. Although a variety of effective mechanical and chemical thromboprophylaxis interventions exist, their role in spinal surgery remains unclear. Spine surgeons are faced with the difficult decision of balancing the risk of death from a thromboembolic complication against the risk of permanent neurological damage from an epidural hematoma (EDH).

Methods: The Medline database was queried using combinations of the terms related to the aforementioned subject matter. Articles meeting our predetermined inclusion criteria were reviewed and relevant data extracted. Meta-analyses were created using a random-effects model for incidence of DVT and PE by type of thromboprophylaxis, method of screening, and study type.

Results: Twenty-eight articles were included in the final analyses. The higher mean incidence of DVT and PE in the mechanoprophylaxis group (DVT: 1%, PE: 0.81%) compared to the chemoprophylaxis group (DVT: 0.85%, PE: 0.58%) was not observed to be statistically significant. Six percent of PEs was fatal; the rate of EDHs was 0.3%. The incidence of DVT was higher in prospective studies (1.4%) compared to retrospective studies (0.61%); the incidence of DVT was not affected by whether the study screened only symptomatic patients.

Conclusion: Although the incidence of DVT and PE was relatively low regardless of prophylaxis type, the true incidence is difficult to determine given the heterogeneous nature of the small number of studies available in the literature. Our findings suggest there may be a role for chemoprophylaxis given the relatively high rate of fatal PE. Future studies are needed to determine which patient population would benefit most from chemoprophylaxis.

Level Of Evidence: 2.
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http://dx.doi.org/10.1097/BRS.0000000000002379DOI Listing
April 2018

A multicenter study of diet quality on birth weight and gestational age in infants of HIV-infected women.

Matern Child Nutr 2017 10 8;13(4). Epub 2016 Nov 8.

Division of Pediatric Clinical Research, Department of Pediatrics, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA.

We determined factors associated with diet quality and assessed the relationship between diet quality, birth weight, and gestational age in a prospective national multicenter cohort study. We evaluated diet quality with the Healthy Eating Index (HEI, scale 0-100) in the third trimester of pregnancy with three 24-hr multiple-pass dietary recalls in 266 HIV+ women enrolled in the Pediatric HIV/AIDS Cohort Study. Covariates included demographics, food security, pre-pregnancy body mass index, HIV disease severity, substance use, and antiretroviral exposures. A two-stage multivariate process using classification and regression trees (CART) followed by multiple regression described HEI tendencies, controlled possible confounding effects, and examined the association of HEI with birth weight and gestational age. To assess the stability of the CART solution, both the HEI 2005 and 2010 were evaluated. The mean HEI scores were 56.1 and 47.5 for the 2005 and 2010 HEI, respectively. The first-stage CART analysis examined the relationship between HEI and covariates. Non-US born versus US-born mothers had higher HEI scores (15-point difference, R  = 0.28). There was a secondary partition due to alcohol/cigarette/illicit drug usage (3.5-point difference, R  = 0.03) among US-born women. For the second-stage CART adjusted multiple regression, birth weight z-score was positively related to HEI 2005 and 2010 (partial r's > 0.13, P's ≤ 0.0398), but not gestational age (r = 0.00). We conclude that diet quality among HIV+ women is associated with higher birth weight. Despite the influence of a large cultural effect and poor prenatal behaviors, interventions to improve diet in HIV+ women may help to increase birth weight.
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http://dx.doi.org/10.1111/mcn.12378DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5575978PMC
October 2017

Unilateral Acute Angle-Closure Glaucoma After Lumbar Spine Surgery: A Case Report and Systematic Review of the Literature.

Spine (Phila Pa 1976) 2016 Mar;41(5):E297-9

Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL.

Study Design: A case report and literature review is presented of a patient that developed acute angle-closure glaucoma (AACG) after undergoing spine surgery in the prone position.

Objectives: To report a case of AACG after undergoing spine surgery in the prone position and describe potential causes and implications for future care.

Summary Of Background Data: Visual loss is a devastating complication after spine surgery and is most often due to ischemic optic neuropathy. Although far less common, three cases of AACG have previously been reported, all of which were bilateral. Mydriatric agents and prone positioning were hypothesized as precipitating factors as both are known to increase intraocular pressure. In contrast to other visual loss diseases after spine surgery, AACG is amenable to treatment if recognized and treated early; however, its diagnosis is often complicated by patients presenting days after surgery. We report the case of a 65-year-old male who underwent multilevel revision spine surgery in the prone position and developed unilateral AACG after discharge on postoperative day 5.

Methods: The case report is described. A literature review was performed using PubMed and keywords. The resulting articles were evaluated and references checked for additional cases.

Results: The case herein resulted in no vision loss after the AACG was treated with laser iridotomy. The patient had a history of ocular issues in the affected side, highlighting the potential role anatomy plays in the development of AACG following spine surgery. Three reports of AACG were found after the literature review was performed.

Conclusion: Although it is not practical to screen all patients through ophthalmologic referral, there may be a role for targeted preoperative screening of patients with risk factors for AACG.

Level Of Evidence: 5.
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http://dx.doi.org/10.1097/BRS.0000000000001224DOI Listing
March 2016

Ultrasound-guided aspiration of wrist ganglions: a follow-up survey of patient satisfaction and outcomes.

Acta Radiol 2016 Apr 7;57(4):481-6. Epub 2015 Aug 7.

Department of Radiology, University of Miami/Jackson Memorial Hospital, Miami, FL, USA.

Background: Ganglion cysts are one of the most frequently occurring masses of the wrist, often causing pain and interfering with daily activity. Ultrasound (US)-guided aspiration is a treatment for ganglion cysts of the wrist.

Purpose: To examine the results and patient satisfaction of US-guided aspiration of wrist ganglion cysts.

Material And Methods: Medical records from August 2009 through December 2013 were reviewed to identify all adult patients referred to a single musculoskeletal radiologist for US-guided aspiration of a painful wrist ganglion cyst. Records were reviewed for patient demographics, cyst size, location, and morphology. Outcomes and patient satisfaction were evaluated using a telephone questionnaire at a minimum of 9 months after the procedure.

Results: Of 56 consecutive patients identified, follow-up data were available for 39 patients (69%) at a minimum of 9 months. There were 21 volar and 18 dorsal ganglion cysts. The overall recurrence rate was 20% (8 of 39 patients) and only five patients reported a pain score of greater than 2 out of 10. The mean age of patients with recurrence of the cyst was greater than that of patients without recurrence (52 vs. 35 years, P = 0.03). Satisfaction with the outcome was high and varied by recurrence. There were no acute complications including infection, hemorrhage, or allergic reaction.

Conclusion: US-guided aspiration is a safe and potentially effective treatment for ganglion cysts of the wrist, with high patient satisfaction. US-guided aspiration may be particularly advantageous for volar ganglion cysts, and in patients who are poor surgical candidates.
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http://dx.doi.org/10.1177/0284185115597719DOI Listing
April 2016

Are Fire Policies Fair When They Mandate the Use of Chemical Flame Retardants Without Mandating Their Safety Testing?

JAMA Pediatr 2015 Sep;169(9):807-8

Department of Orthopedic Surgery, University of Chicago Medical Center, Chicago, Illinois.

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http://dx.doi.org/10.1001/jamapediatrics.2015.1067DOI Listing
September 2015

Commentary on "Race, socioeconomic status, health-related quality of life, and self-care of type 2 diabetes mellitus among adults in North Carolina".

South Med J 2015 Apr;108(4):217-8

From the Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, and the Department of Orthopaedic Surgery, University of Chicago Medical Center, Chicago, Illinois.

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http://dx.doi.org/10.14423/SMJ.0000000000000261DOI Listing
April 2015

Local administration of β-blockers for infantile hemangiomas: a systematic review and meta-analysis.

Ann Plast Surg 2015 Feb;74(2):256-62

From the *Division of Plastic, Aesthetic and Reconstructive Surgery, DeWitt-Daughtry Family Department of Surgery, University of Miami, Leonard Miller School of Medicine, Miami, FL; and †Department of Orthopaedic Surgery, University of Chicago Medical Center, Chicago, IL.

Background: Infantile hemangiomas (IHs) are a common pediatric lesion. Orally administered β-blockers have been reported as effective in treating these lesions. However, oral administration is also associated with systemic adverse effects. Treatment with locally administered β-blockers may provide acceptable efficacy with lower incidence of adverse effects. This may offer a better first-line treatment.

Methods: PubMed was searched through March 2014 for studies reporting patient-level response of 5 or more patients treated with intralesional propranolol, topical timolol, or topical propranolol for cutaneous IHs. Rates of response to treatment, defined as clinically significant regression, were combined using random-effects meta-analysis.

Results: Ninety-four articles were identified. Seventeen articles met the study criteria. These studies primarily focused on superficial IHs. Response rates for topical propranolol and topical timolol were not significantly different, 76% [95% confidence interval (CI), 62%-86%] and 83% (95% CI, 65%-93%), respectively (P=0.45). Prospectively conducted studies reported lower response rates compared to retrospective studies for both topical propranolol (P=0.06) and topical timolol (P<0.01). When only prospectively conducted studies were included, response rates for topical propranolol and topical timolol were not significantly different, 72% (95% CI, 57%-83%) and 72% (95% CI, 53%-86%), respectively (P=0.98). Significant adverse effects were rare. Only 1 case of sleep disturbance was reported across 554 patients from all studies.

Conclusions: Topically administered β-blockers are an effective treatment for superficial IHs that pose few adverse effects and should be considered for primary treatment.
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http://dx.doi.org/10.1097/SAP.0000000000000390DOI Listing
February 2015

Upper gastrointestinal symptoms in medical professionals: a higher burden?

South Med J 2015 Jan;108(1):39-45

From the Department of Medicine, Division of Gastroenterology, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida.

Objectives: Gastroesophageal reflux disease (GERD) and dyspepsia cause significant healthcare resource utilization and greatly affect quality of life; therefore, a tendency exists to self-treat in lieu of formal diagnosis. Although their prevalence is established in the general population, their prevalence in physicians remains unknown. Our aim was to estimate the prevalence of GERD and dyspepsia symptoms in a sample of medical professionals by level of training.

Methods: An anonymous, computer-based questionnaire was distributed to medical students, residents/fellows, and attending physicians at our institution. The survey included symptom-based questions for GERD (Reflux Disease Questionnaire); quality-of-life questionnaire for dyspepsia (Nepean Dyspepsia Index [NDI]), and the Gastroparesis Cardinal Symptom Index (GCSI). We calculated scores based on the validated system from each questionnaire and used appropriate statistical analysis to evaluate associations between symptomatology and training level (medical students, residents/fellows, and attending physicians).

Results: Overall, there were 327 respondents (155 medical students, 127 residents/fellows, 45 attending physicians), of whom 52% were women, 56% were white non-Hispanic, 19% were Hispanic, and 74% were born in the United States/Canada. A total of 21% reported previously diagnosed GERD/dyspepsia, and 42% reported previously or currently using a medication for GERD/dyspepsia, with significantly higher use of proton pump inhibitors in attending physicians than in medical students and residents/fellows (P < 0.01). Higher median total scores for the NDI (P = 0.01) and GCSI (P < 0.01) in medical students exist compared with residents/fellows and attending physicians, with no significant differences for the Reflux Disease Questionnaire among groups.

Conclusions: Although the prevalence of diagnosed GERD/dyspepsia in our sample was comparable to the general population, medication use was higher. Self-treatment with prescription medications increased with training. Median NDI and GCSI scores were inversely related to training level, which may reflect self-treatment in medical professionals with advanced training. Further study of GERD/dyspepsia in medical professionals is warranted.
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http://dx.doi.org/10.14423/SMJ.0000000000000213DOI Listing
January 2015

Prediction of postoperative pain after Mohs micrographic surgery with 2 validated pain anxiety scales.

Dermatol Surg 2015 Jan;41(1):40-7

*Department of Dermatology, The Rendon Center for Dermatology, Boca Raton, Florida; †School of Medicine, University of Miami, Miami, Florida; ‡Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, Florida; §Skin Institute of South Florida, Coral Springs, Florida.

Background: Anxiety toward pain has been shown in several studies to increase postoperative pain after surgical procedures. This anxiety can be measured by several validated questionnaires, the Pain Catastrophizing Scale (PCS) and the Pain Anxiety Symptoms Scale (PASS). Higher scores on these scales correlate with increased pain after surgery, but this has not yet been demonstrated in dermatologic surgery.

Objective: To assess whether pain anxiety will predict postoperative pain after Mohs micrographic surgery (MMS).

Materials And Methods: Patients at 2 private Mohs practices were recruited to fill out 2 pain questionnaires, the PCS and the PASS. Their postoperative pain was assessed after MMS.

Results: Three hundred fifty-six patients completed the study. Overall, most patients experienced little postoperative pain after Mohs surgery. However, for people with high anxiety toward pain, they also experienced statistically significant greater postoperative pain. Other factors that contributed to greater postoperative pain included female gender and lower extremity location. Second intention healing had lower pain than other repair types.

Conclusion: This study shows that postoperative pain is affected by pain anxiety, even in dermatologic surgery. However, most patients still had very little discomfort after surgery, further supporting MMS as an effective and safe procedure with relatively few postoperative problems.
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http://dx.doi.org/10.1097/DSS.0000000000000224DOI Listing
January 2015