Publications by authors named "Elshaday S Belay"

10 Publications

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Physician burnout and professional satisfaction in orthopedic surgeons during the COVID-19 Pandemic.

Work 2021 ;69(1):15-22

Background: Burnout and professional satisfaction is an often an overlooked component for healthcare outcomes; the COVID-19 pandemic represents an unprecedented stressor that could contribute to higher levels of burnout.

Objectives: Our primary objective was to evaluate the association of a battery of fulfillment, job satisfaction change, COVID-19 concerns, and coping measures. Our secondary objective was to determine whether the fulfillment and coping measures differed by gender and by experience levels among a battery of physician specialties.

Methods: The study was a purposive sample of convenience. Study participants included all trainees and attending orthopedic surgeons from our academic institution; all participants were invited to complete a survey built around a validated measure of professional fulfillment aimed at assessing response to acute change and stressors. We performed univariate statistics and a matrix correlational analysis to correlate different survey domains with variables of interest.

Results: The survey was sent electronically to 138 individuals; 63 surveys were completed (response rate = 45.7%). Twenty-seven (42.8%) individuals met the threshold criteria for fulfillment whereas 10 (15.9%) met the threshold for burnout. We found that surgeon perspectives on COVID-19 were not associated with burnout or professional fulfillment. Burnout was inversely associated with professional fulfillment (R = -0.35). Support seeking was noted to be correlated with professional fulfillment (R = 0.37).

Conclusions: Stressors related to COVID-19 pandemic were not correlated with physician burnout and fulfillment. This held true even when stratifying by gender and by attending vs. trainee. Continued efforts should be implemented to protect against physician burnout and ensure professional fulfillment for Orthopedic surgeons.
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http://dx.doi.org/10.3233/WOR-205288DOI Listing
June 2021

Malnutrition in elective shoulder arthroplasty: a multi-institutional retrospective study of preoperative albumin and adverse outcomes.

J Shoulder Elbow Surg 2021 Apr 2. Epub 2021 Apr 2.

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA. Electronic address:

Background: Malnutrition is associated with poor postoperative outcomes after knee, hip, and spine surgery. However, whether albumin labs should be part of the routine preoperative workup for shoulder arthroplasty remains understudied. This study investigated the role of preoperative albumin levels in predicting common postoperative adverse outcomes in patients undergoing shoulder arthroplasty.

Methods: All shoulder arthroplasty cases performed at 2 tertiary referral centers between July 2013 and May 2019 (institution 1) and between June 2007 and Feb 2020 (institution 2) were reviewed. A total of 421 primary and 71 revision elective shoulder arthroplasty cases had preoperative albumin levels recorded. Common demographic variables and relevant Elixhauser comorbidities were pulled. Outcomes gathered included extended (>3 days) postoperative inpatient length of stay (eLOS), 90-day readmission, and discharge to rehab or skilled nursing facility (SNF).

Results: The prevalence of malnutrition (albumin <3.5 g/dL) was higher in the revision group compared with the primary group (36.6% vs. 19.5%, P = .001). Reverse shoulder arthroplasty (P = .013) and increasing American Society of Anesthesiologists score (P = .016) were identified as independent risk factors for malnutrition in the primary group. In the revision group, liver disease was associated with malnutrition (P = .046). Malnourished primary shoulder arthroplasty patients had an increased incidence of eLOS (26.8% vs. 13.6%, P = .003) and discharge to rehab/SNF (18.3% vs. 10.3%, P = .045). On univariable analysis, low albumin had an odds ratio (OR) of 2.34 for eLOS (P = .004), which retained significance in a multivariable model including age, American Society of Anesthesiologists score, sex, and body mass index (OR 2.11, P = .03). On univariable analysis, low albumin had an OR of 1.94 for discharge to SNF/rehab (P = .048), but this did not reach significance in the multivariable model. Among revisions, malnourished patients had an increased incidence of eLOS (30.8% vs. 6.7%, P = .014) and discharge to rehab/SNF (26.9% vs. 4.4%, P = .010). In both the primary and revision groups, there was no difference in 90-day readmission rate between patients with low or normal albumin.

Conclusion: Malnutrition is more prevalent among revision shoulder arthroplasty patients compared with those undergoing a primary procedure. Primary shoulder arthroplasty patients with low preoperative albumin levels have an increased risk of eLOS and may have an increased need for postacute care. Low albumin was not associated with a risk of 90-day readmissions. Albumin level merits further investigation in large, prospective cohorts to clearly define its role in preoperative risk stratification.
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http://dx.doi.org/10.1016/j.jse.2021.03.143DOI Listing
April 2021

Use of a 5-item modified Fragility Index for risk stratification in patients undergoing surgical management of proximal humerus fractures.

JSES Int 2021 Mar 16;5(2):212-219. Epub 2020 Dec 16.

Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA.

Hypothesis: We hypothesized that the modified Fragility Index (mFI) would predict complications in patients older than 50 years who underwent operative intervention for a proximal humerus fracture.

Methods: We retrospectively reviewed the American College of Surgeons National Surgery Quality Improvement Program database, including patients older than 50 years who underwent open reduction and internal fixation of a proximal humerus fracture. A 5-item mFI score was then calculated for each patient. Postoperative complications, readmission and reoperation rates as well as length of stay (LOS) were recorded. Univariate as well as multivariable statistical analyses were performed, controlling for age, sex, body mass index, LOS, and operative time.

Results: We identified 2,004 patients (median age, 66 years; interquartile range: 59-74), of which 76.2% were female. As mFI increased from 0 to 2 or greater, 30-day readmission rate increased from 2.8% to 6.7% (-value = .005), rate of discharge to rehabilitation facility increased from 7.1% to 25.3% (-value < .001), and rates of any complication increased from 6.5% to 13.9% (-value < .001). Specifically, the rates of renal and hematologic complications increased significantly in patients with mFI of 2 or greater (-value = .042 and -value < .001, respectively). Compared with patients with mFI of 0, patients with mFI of 2 or greater were 2 times more likely to be readmitted within 30 days (odds ratio = 2.2, -value .026). In addition, patients with mFI of 2 or greater had an increased odds of discharge to a rehabilitation center (odds ratio = 2.3, -value < .001). However, increased fragility was not significantly associated with an increased odds of 30-day reoperation or any complication after controlling for demographic data, LOS, and operative time.

Conclusion: An increasing level of fragility is predictive of readmission and discharge to a rehabilitation center after open reduction and internal fixation of proximal humerus fractures. Our data suggest that a simple fragility evaluation can help inform surgical decision-making and counseling in patients older than 50 years with proximal humerus fractures.
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http://dx.doi.org/10.1016/j.jseint.2020.10.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7910730PMC
March 2021

Utility of postoperative hemoglobin testing following total shoulder arthroplasty.

JSES Int 2021 Jan 8;5(1):149-153. Epub 2020 Sep 8.

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.

Background: Identifying areas of excess cost for shoulder arthroplasty patients can play a role in effective health care spending. The purpose of this study was to assess the utility of postoperative complete blood count (CBC) testing after total shoulder arthroplasty (TSA) and identify which patients benefit from routine CBC testing.

Methods: We performed a retrospective review of a cohort of patients who underwent primary TSA from January 2018 through January 2019. All patients in this cohort received tranexamic acid. Patient demographic characteristics and patient-specific risk factors such as American Society of Anesthesiologists score, Elixhauser index, body mass index, smoking status, and coagulopathy history were obtained. Perioperative values including length of surgery, preoperative and postoperative hemoglobin (Hgb) levels, and need for transfusion were also obtained.

Results: This study included 387 TSA patients in the final analysis. Comparison between the cohort requiring transfusion and the cohort undergoing no intervention revealed no statistically significant differences in age, sex, body mass index, American Society of Anesthesiologists score, or Elixhauser index. The group receiving transfusions was found to have significantly lower levels of preoperative Hgb (11.3 g/dL) and postoperative Hgb (8.1 g/dL) ( < .0001). Additionally, the percentages of patients with abnormal preoperative Hgb levels (<12 g/dL) (72.3%) and postoperative day 1 Hgb levels < 9 g/dL (81.8%) were significantly higher in the group receiving transfusions ( < .0001). A multivariate regression model identified an abnormal preoperative Hgb level (<12 g/dL), with an odds ratio of 3.8 (95% confidence interval, 1.5-6.2; < .001), and postoperative day 1 Hgb level < 9 g/dL, with an odds ratio of 3.3 (95% confidence interval, 0.4-6.1; < .03), as significant predictors of the risk of transfusion with a sensitivity of 64% and specificity of 96.2% with an area under the curve of 0.87.

Conclusion: Routine CBC testing may not be necessary for patients who receive tranexamic acid and have preoperative Hgb levels > 12 mg/dL and first postoperative Hgb levels > 9 mg/dL. This translates to potential health care cost savings and improves current evidence-based perioperative management in shoulder arthroplasty.
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http://dx.doi.org/10.1016/j.jseint.2020.07.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7846688PMC
January 2021

Are Weightbearing Restrictions Required After Microfracture for Isolated Chondral Lesions of the Knee? A Review of the Basic Science and Clinical Literature.

Sports Health 2021 Mar 28;13(2):111-115. Epub 2020 Jul 28.

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina.

Context: A strict rehabilitation protocol is traditionally followed after microfracture, including weightbearing restrictions for 2 to 6 weeks. However, such restrictions pose significant disability, especially in a patient population that is younger and more active.

Evidence Acquisition: An extensive literature review was performed through PubMed and Google Scholar of all studies through December 2018 related to microfracture, including biomechanical, basic science, and clinical studies. For inclusion, clinical studies had to report weightbearing status and outcomes with a minimum 12-month follow-up.

Study Design: Clinical review.

Level Of Evidence: Level 3.

Results: Review of biomechanical and biology studies suggest new forming repair tissue is protected from shear forces of knee joint loading by the cartilaginous margins of the defect. This margin acts as a shoulder to maintain axial height and allow for tissue remodeling up to at least 12 months after surgery, well beyond current weight bearing restriction trends. A retrospective case-control study showed that weightbearing status postoperatively had no effect on clinical outcomes in patients who underwent microfracture for small chondral (<2 mm) defects. In fact, 1 survey showed that many orthopaedic surgeons currently do not restrict weightbearing after microfracture.

Conclusion: This clinical literature review suggests that weightbearing restrictions may not be required after microfracture for isolated tibiofemoral chondral lesions of the knee.

Strength Of Recommendation Taxonomy: C.
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http://dx.doi.org/10.1177/1941738120938662DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8167347PMC
March 2021

Trends in reimbursement for primary and revision total elbow arthroplasty.

J Shoulder Elbow Surg 2021 Jan 28;30(1):146-150. Epub 2020 Jun 28.

Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC, USA.

Background: Relative value units (RVUs) are an essential component of reimbursement calculations from the Centers for Medicare & Medicaid Services. RVUs are calculated based on physician work, practice expense, and professional liability insurance. Procedures that are more complex, such as revision arthroplasty, require greater levels of physician work and should therefore be assigned a greater RVU. The purpose of this study is to compare RVUs assigned for primary and revision total elbow arthroplasty (TEA).

Methods: The National Surgical Quality Improvement Program database was used to collect all primary and revision total elbow arthroplasties performed between January 2015 and December 2017. Variables collected included age at time of surgery, RVUs assigned for the procedure, and operative time.

Results: A total of 359 cases (282 primary TEA, 77 revision TEA) were included in this study. Mean RVUs for primary TEA was 21.4 (2.0 standard deviation [SD]) vs. 24.4 (1.7 SD) for revision arthroplasty (P < .001). Mean operative time for primary TEA was 137.9 minutes (24.4 SD) vs. 185.5 minutes (99.7 SD) for revision TEA (P < .001). The RVU per minute for primary TEA was 0.16 and revision TEA was 0.13 (P < .001). This amounts to a yearly reimbursement difference of $71,024 in favor of primary TEA over revision TEA.

Conclusion: The current reimbursement model does not adequately account for increased operative time, technical demand, and pre- and postoperative care associated with revision elbow arthroplasty compared with primary TEA. This leads to a financial advantage on performing primary TEA.
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http://dx.doi.org/10.1016/j.jse.2020.06.004DOI Listing
January 2021

Intravenous tranexamic acid vs. topical thrombin in total shoulder arthroplasty: a comparative study.

J Shoulder Elbow Surg 2021 Feb 24;30(2):312-316. Epub 2020 Jun 24.

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.

Background: Blood loss and transfusions have been highlighted as a significant predictor of postoperative morbidity. Tranexamic acid (TXA) has been shown to decrease blood loss and transfusion in shoulder arthroplasty. However, the utility of topical thrombin in total shoulder arthroplasty (TSA) is unknown. The purpose of this study was to assess the utility of topical thrombin in TSA and compare the effectiveness of topical thrombin to intravenous (IV) TXA.

Methods: An institutional database was used to query shoulder arthroplasty patients from January 2017 to July 2019. Patients undergoing TSA were identified with CPT (Current Procedural Terminology) code (23742). After excluding reverse shoulder arthroplasty, arthroplasty for fracture or revision, the study groups were stratified based on intervention with IV TXA, topical thrombin, or neither. Patient demographics, American Society of Anesthesiologists (ASA) class, baseline coagulopathy, preoperative and postoperative hemoglobin levels, operative time, transfusion, length of stay, and 90-day readmission for each treatment group was obtained.

Results: A total of 283 TSA cases were included for final analysis. There was no statistically significant difference in the baseline characteristics with age, body mass index, or ASA class. The postoperative hemoglobin level (mg/dL) was higher in the group that received either IV TXA or thrombin compared with no hemostatic agents (P = .001). Calculated blood loss in TSA was significantly higher in the group without hemostatic agents, 369.8 mL (standard deviation [SD] 59.5), compared with IV TXA or topical thrombin, 344.3 mL (SD 67.1) and 342.9 mL (SD 65.6) (P = .03). Operative time was highest in the group that received no hemostatic agents, 2.3 hours (SD 0.6) (P = .01). The transfusion rate for TSA treated with IV TXA or topical thrombin was equivalent (2.2%) but significantly lower than the no intervention group (12%) (P = .01). The odds ratio for transfusion with IV TXA was 0.16 (95% confidence interval [CI] 0.07-0.40, P = .001) and for topical thrombin, 0.1 (95% CI 0.02-0.42, P = .02).

Conclusion: Topical thrombin is an effective adjunct to reduce blood loss and transfusion risk after TSA and a reasonable intraoperative alternative for TXA for patients with contraindication to IV TXA.
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http://dx.doi.org/10.1016/j.jse.2020.05.039DOI Listing
February 2021

Single-stage versus two-stage revision for shoulder periprosthetic joint infection: a systematic review and meta-analysis.

J Shoulder Elbow Surg 2020 Dec 18;29(12):2476-2486. Epub 2020 Jun 18.

Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA.

Background: Shoulder periprosthetic joint infection (PJI) is a significant complication after arthroplasty with high morbidity. An evidence-based algorithm for the treatment of shoulder PJI is lacking in current practice. The purpose of this systematic review and meta-analysis was to understand and compare the role of single- and 2-stage shoulder arthroplasty revision for PJI.

Methods: A comprehensive literature review was performed to identify all studies related to shoulder arthroplasty for PJI in PubMed, Scopus, and EMBASE. Inclusion criteria for this systematic review were studies that reported on single- or 2-stage revision, with infection eradication and a minimum follow-up of 12 months and a minimum of 5 patients for analysis. A random-effects meta-analysis was performed, and heterogeneity was assessed with Cochrane Q and I2.

Results: A total of 13 studies reporting on single-stage revision and 30 studies reporting on 2-stage revision were included in final analysis. The majority of positive cultures from single-stage revision for PJI resulted in Cutibacterium acnes with 113 of 232 (48.7%) reported cases compared with 190 of 566 (33.7%) reported cases for 2-stage revision. However, there was a lower percentage of methicillin-resistant Staphylococcus aureus positive cultures, with 2.5% for single-stage compared with 9.7% for 2-stage revision. The overall pooled random-effect reinfection incidence was 0.05 (95% confidence interval: 0.02-0.08), with moderate heterogeneity (I = 34%, P = .02). The reinfection rate was 6.3% for single-stage and 10.1% for 2-stage revision, but this was not significant (Q = 0.9 and P = .40).

Conclusion: Based on a systematic review with meta-analysis, single-stage revision for shoulder PJI is an effective treatment. Indeed, our analysis showed single-stage to be more effective than 2-stage, but this is likely confounded by a treatment bias given the higher propensity of virulent and drug-resistant bacteria treated with 2-stage in the published literature. This implies that shoulder surgeons treating PJI can be reassured of a low recurrence rate (6.3%) when using single-stage treatment for C acnes or other sensitive, low-virulence organisms.
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http://dx.doi.org/10.1016/j.jse.2020.05.034DOI Listing
December 2020

Biceps tenotomy has earlier pain relief compared to biceps tenodesis: a randomized prospective study.

Knee Surg Sports Traumatol Arthrosc 2019 Dec 5;27(12):4032-4037. Epub 2019 Sep 5.

Department of Orthopaedic Surgery, Durham Veterans Affairs Medical Center, Duke University Medical Center, Box 3000, Durham, NC, 27710, UK.

Purpose:  Surgical management for long head of the biceps (LHB) tendinopathy with either biceps tenotomy or tenodesis is a reliable, but debated treatment option. The aim of this prospective, randomized, single-blinded study is to evaluate differences in pain relief and subjective outcomes between biceps tenotomy versus tenodesis for LHB tendinopathy.

Methods:  Subjects were randomized and blinded to biceps tenotomy versus arthroscopic tenodesis intra-operatively. Outcomes evaluated included subjective patient outcome scores, pain, and cosmetic deformity. Subjective outcomes scores and pain were analyzed using a two-way ANOVA, controlling for concomitant rotator cuff repair. Binary outcomes were compared using Chi-square tests.

Results:  Thirty-four subjects (31 male, 3 female) with a median age of 56 (range 30-77) were enrolled. Twenty subjects were randomized to tenotomy and 14 to tenodesis. Fifty-six percent had concomitant rotator cuff repairs. The mean VAS pain score at 3 months was lower with tenotomy versus tenodesis. 2-year follow-up demonstrated no statistically significant differences for VAS, ASES, or SANE. 15/20 (75%) subjects with biceps tenotomy reported no pain medication use at the 2-week postoperative visit versus 5/14 (33%) for biceps tenodesis. Popeye deformity was found in 5/20 (25%) of tenotomy subjects versus 1/14 (7%) in tenodesis subjects.

Conclusion: Outcomes appear similar between biceps tenotomy versus tenodesis; however, the tenotomy group demonstrated greater incidence of cosmetic deformity but an earlier improvement in postoperative pain.

Level Of Evidence: Treatment Studies, Level II.
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http://dx.doi.org/10.1007/s00167-019-05682-1DOI Listing
December 2019

Perioperative Selective Serotonin Reuptake Inhibitor Use Is Associated With an Increased Risk of Transfusion in Total Hip and Knee Arthroplasty.

J Arthroplasty 2019 Dec 22;34(12):2898-2902. Epub 2019 Jun 22.

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC.

Background: Selective serotonin reuptake inhibitors (SSRIs) have been shown in both orthopedic and general surgery literature to be associated with an increased risk of blood loss, and this is thought to occur via diminished platelet serotonin reuptake and subsequent decline in platelet aggregation potential. In this study, we aim at quantifying the effect of treatment with SSRIs on blood loss and transfusion rates following total hip (THA) or total knee arthroplasty (TKA).

Methods: THA (4485) and TKA (5584) cases from January 2013 to December 2017 at the investigating institution were queried and analyzed separately from an institutional database. Patients were stratified by utilization of an SSRI at the time of surgery. Patient demographics, baseline coagulopathy, preoperative and postoperative hemoglobin, transfusion, and length of stay were obtained to compare the 2 cohorts.

Results: The transfusion rate for SSRI users was 3.9% in the TKA group and 8.5% in the THA group. After controlling for age, gender, body mass index, presence of coagulopathy, procedure (THA vs TKA), and SSRI status, SSRI utilization was significantly associated with increased blood loss (P < .004), and logistic regression controlling for the same variables showed SSRI utilization to be predictive of transfusion (odds ratio, 1.476; P < .001).

Conclusion: SSRI utilization was associated with increased perioperative blood loss and predictive of transfusion risk, particularly with THA. This represents an important factor that may be modified in the setting of total joint arthroplasty but further work will be necessary to study potential alternative medications for depression in the perioperative phase.
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http://dx.doi.org/10.1016/j.arth.2019.04.057DOI Listing
December 2019
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