Publications by authors named "Neil Sheth"

95 Publications

Definitive surgical femur fracture fixation in Northern Tanzania: implications of cost, payment method and payment status.

Pan Afr Med J 2021 15;39:126. Epub 2021 Jun 15.

Department of Orthopaedics, University of Pennsylvania, Philadelphia, United States of America.

Introduction: Kilimanjaro Christian Medical Centre (KCMC) covers major orthopaedic trauma for a catchment population of 12.5 million people in northern Tanzania. Femur fractures, the most common traumatic orthopaedic injury at KCMC (39%), require open reduction and internal fixation (ORIF) for definitive treatment. It is unclear whether payment affects care. This study sought to explore associations of payment method with episodes of care for femur fracture ORIFs at KCMC.

Methods: we performed a retrospective review of orthopaedic records between February 2018 and July 2018. Patients with femur fracture ORIF were eligible; patients without charts were excluded. Ethical clearance was obtained from the KCMC ethics committee. Statistical analysis utilized descriptive statistics, Chi-squared and Fisher's exact Tests, and Student´s t-tests where appropriate.

Results: of 76 included patients, 17% (n=13) were insured, 83% (n=63) paid out-of-pocket, 11% (n=8) had unpaid balance, and 89% (n=68) fully paid. Average patient charge ($417) was 42% of per capita GDP ($998). Uninsured patients had higher bills ($429 vs $356; p=0.27) and were significantly more likely to pay an advance payment (95.2% vs 7.7%; p<0.001). Inpatient care was equivalent regardless of payment. Unpaid patients were less likely to receive follow-up (76.5% vs. 25%; p=0.006) and waited longer from injury to admission (31.5 vs 13.3 days; p<0.001), from admission to surgery (30.1 vs 11.1 days; p<0.001), and from surgery to discharge (18.4 vs 7.1 days; p<0.001).

Conclusion: equal standard of care is provided to all patients. However, future efforts may decrease disparities in advance payment, timeliness, and follow-up.
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http://dx.doi.org/10.11604/pamj.2021.39.126.25878DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8418167PMC
June 2021

Patient patronage and perspectives of traditional bone setting at an outpatient orthopaedic clinic in Northern Tanzania.

Afr Health Sci 2021 Mar;21(1):418-426

University of Pennsylvania, Department of Orthopaedic Surgery.

Background: Much of Sub-Saharan Africa meets the rising rates of musculoskeletal injury with traditional bone setting, especially given limitations in access to allopathic orthopaedic care. Concern for the safety of bone setter practices as well as recognition of their advantages have spurred research to understand the impact of these healers on public health.

Objectives: Our study investigates the role of bone setting in Tanzania through patient utilization and perspectives.

Methods: We surveyed 212 patients at the outpatient orthopaedic clinic at Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania. Surveys were either self-administered or physician-administered. Summary statistics were calculated using XLSTAT. Open responses were analyzed using a deductive framework method.

Results: Of all surveys, 6.3% (n=13) reported utilizing traditional bone setting for their injury prior to presenting to KCMC. Of the self-administered surveys, 13.6% (n=6) reported utilizing bone setting compared to 4.3% (n=7) of the physician-administered surveys (p=0.050). Negative perceptions of bone setting were more common than positive perceptions and the main reason patients did not utilize bone setting was concern for competency (35.8%, n=67).

Conclusion: Our study found lower bone setting utilization than expected considering the reliance of Tanzanians on traditional care reported in the literature. This suggests patients utilizing traditional care for musculoskeletal injury are not seeking allopathic care; therefore, collaboration with bone setters could expand allopathic access to these patients. Patients were less likely to report bone setter utilization to a physician revealing the stigma of seeking traditional care, which may present an obstacle for collaboration.
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http://dx.doi.org/10.4314/ahs.v21i1.52DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8356595PMC
March 2021

Anterolateral thigh osteomyocutaneous flap in head and neck: Lessons learned.

Microsurgery 2021 Jun 26. Epub 2021 Jun 26.

Departments of Oral and Maxillofacial Surgery and Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Background: Concerns regarding iatrogenic femur fracture may deter adoption of the anterolateral thigh osteomyocutaneous (ALTO) flap as an alternative reconstructive technique for large composite defects of the head and neck. We describe the evolution of our experience with this flap and the lessons learned in femur management.

Methods: Records from a prospective database (July 2009-January 2020) were reviewed to identify patients with composite osseous free tissue reconstructions. Venous thromboembolic events (VTE), femur fracture, estimated blood loss (EBL), procedure time, blood transfusions, and length of stay (days) were compared for ALTO flaps prior to and after the adoption of intramedullary fixation protocol.

Results: ALTO represented 10.5% (n = 23) of total osseus (n = 219) flaps. For large composite reconstructions with either ALTO flap, double flap (n = 2), or subscapular mega flaps (n = 14), ALTO flaps were most frequently used (59%, n = 23/59). There were no differences in operative time prior to and after implementation of prophylactic fixation [median (range): 5.4 (1.7-19.2) vs. 5.8 (1.7-15.0), p = .574]. Additionally, there were no differences in VTE, femur fracture, EBL, blood transfusion, or length of stay (p > .05) with adoption of prophylactic intramedullary fixation.

Conclusions: The ALTO flap represents a useful tool to consider in the armamentarium of reconstructive options for large through and through defects of the head and neck. In our experience, the ALTO flap is a reasonable alternative to subscapular or double flap reconstructions and especially in the setting of unusable fibular flaps or when bone need exceeds that available from the scapula.
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http://dx.doi.org/10.1002/micr.30779DOI Listing
June 2021

The Interconnected Ancestral Network of Hip Arthroplasty Device Approval.

J Am Acad Orthop Surg 2021 Jun 23. Epub 2021 Jun 23.

From the Department of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, (Premkumar, Cross, Gonzalez Della Valle), the Weill Cornell Medical College (Zhu, Ying), the Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY (Pean), and the Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA (Sheth).

Background: In the United States, the most overwhelming medical devices, including hip arthroplasty devices, are cleared for human use by demonstration of "substantial equivalence" to a predicate, previously approved marketed device. This study examined the predicate approval lineages of modern hip arthroplasty devices.

Methods: The FDA 510(k) and premarket approval databases were searched to identify all approved hip arthroplasty devices since the database's inception in May 28, 1976. Ancestral predicate lineages were created using approval documentation, and FDA recall data were used to identify recalled devices.

Results: Evaluating 2,118 hip arthroplasty devices approved from 1976 to 2020, we found that the number of descendant devices for each approved device varied from 0 to 242. Many descendant devices served as predicates for other devices, leading to frequent indirect connections of equivalency across a wide range of implants. Two hundred forty-six (11.6%) devices were recalled for various reasons, with 34 (1.6%) related to implant design. Evaluating the predicate lineage of 51 hip arthroplasty devices approved between May 1, 2019, and May 1, 2020, 32 of 51 (62.7%) devices were linked, directly or indirectly, to predicates which were recalled for design issues.

Conclusions: The lineage of hip arthroplasty device predicates reflects a complex ancestral web of equivalency across a wide range of implants, although their material and design properties may be different. Several currently approved devices were approved on substantial equivalence claims to products that were subsequently recalled from the market for implant design issues. These findings present several policy considerations for regulators, physicians, and the medical device industry.
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http://dx.doi.org/10.5435/JAAOS-D-21-00138DOI Listing
June 2021

Comparing the drivers of medical student emigration intention across two African nations.

Med Educ 2021 May 12. Epub 2021 May 12.

Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA.

Background: Sub-Saharan Africa faces the highest relative need for health care workers in the world and the emigration of physicians significantly contributes to this deficit. Few studies have explored development of these patterns during medical education. This study investigates career aspirations of medical students in two African nations with similar Human Development Indices, but distinct differences in training structure to better inform retention strategies.

Methods: A cross-sectional survey was administered in 2018 to medical students in Madagascar (University of Antananarivo, University of Mahajanga) and Tanzania (Kilimanjaro Christian Medical College, KCMC). Outcomes included emigration/career intentions, and factors influencing these decisions. Analysis utilised chi-square and Fisher's exact tests (α < 0.05, two-tailed) for statistical differences, logistic regression and qualitative content analysis of free text data.

Results: A total of 439 students responded to the survey with a response rate of 12.9% from Antananarivo (n = 142/1097), 11.6% from Mahajanga (n = 43/370), and 60.0% from KCMC (n = 254/423). Significantly more Malagasy (49.7%, n = 90/181) than Tanzanian (25.2%, n = 54/214) students expressed emigration intent (P < .001). Malagasy students indicating research, possibility of working abroad, or work intensity as influencing career choice more frequently expressed a desire to emigrate. Satisfaction with computer/internet access was inversely correlated with a desire to work abroad. In comparison, Tanzanian students reporting income potential as influential in their career choice or attending a private high school were more likely to express a desire to work abroad. Qualitative content analysis of free text data demonstrated deficits in faculty availability, diversity of training locations and a particular emphasis on infrastructure challenges within Madagascar.

Interpretation: A significant number of students desire to work abroad. Emigration interests are influenced by access to postgraduate training, infrastructure and opportunities in academia, which differ across countries. Efforts to retain physicians should consider these country and institution-specific factors that influence medical student desire to emigrate.
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http://dx.doi.org/10.1111/medu.14562DOI Listing
May 2021

Reduced postoperative morbidity in computer-navigated total knee arthroplasty: A retrospective comparison of 225,123 cases.

Knee 2021 Jun 27;30:148-156. Epub 2021 Apr 27.

University of Pennsylvania, Pennsylvania Hospital, Department of Orthopaedic Surgery, 800 Spruce Street, 8th Floor Preston Building, Philadelphia, PA 19107, USA.

Background: Total knee arthroplasty (TKA) is one of the most common elective surgical procedures in the United States, with more than 650,000 performed annually. Computer navigation technology has recently been introduced to assist surgeons with planning, performing, and assessing TKA bone cuts. The aim of this study is to assess postoperative complication rates after TKA performed using computer navigation assistance versus conventional methods.

Methods: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for unilateral TKA cases from 2008 to 2016. The presence of the CPT modifier for use of computer navigation was used to separate cases of computer-navigated TKA from conventional TKA. Multivariate and propensity-matched logistic regression analyses were performed to control for demographics and comorbidities.

Results: There were 225,123 TKA cases included; 219,880 were conventional TKA (97.7%) and 5,243 were navigated (2.3%). Propensity matching identified 4,811 case pairs. Analysis demonstrated no significant differences in operative time, length of stay, reoperation, or readmission, and no differences in rates of post-op mortality at 30 days postoperatively. Compared to conventional cases, navigated cases were at lower risk of serious medical morbidity (18% lower, p = 0.009) within the first 30 days postoperatively.

Conclusion: After controlling for multiple known risk factors, navigated TKA patients demonstrated lower risk for medical morbidity, predominantly driven by lower risk for blood transfusion. Given these findings, computer-navigation is a safe surgical technique in TKA.
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http://dx.doi.org/10.1016/j.knee.2020.12.015DOI Listing
June 2021

Soft-Tissue Balancing in Total Hip Arthroplasty.

JBJS Rev 2021 Feb 15;9(2):e20.00116. Epub 2021 Feb 15.

Department of Orthopaedic Surgery, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, Pennsylvania.

»: Appropriate total hip arthroplasty (THA) reconstruction must simultaneously address component position, restoration of biomechanics, and soft-tissue balance.

»: Preoperative planning for complex THA cases should include radiographic templating, a detailed case plan that contains backup implant options, and a thorough understanding of the patient's preoperative examination.

»: Using a systematic approach to soft-tissue balancing in THA enhances the ability to intraoperatively execute the preoperative plan.

»: In patients with preexisting deformities (e.g., dysplasia or prior surgery), increased attention to abductor function is necessary when assessing acetabular component placement and offset.
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http://dx.doi.org/10.2106/JBJS.RVW.20.00116DOI Listing
February 2021

The Dome Technique, an Option for Massive Anterosuperior Medial Acetabular Bone Loss: A Retrospective Case Series.

HSS J 2020 Dec 16;16(Suppl 2):521-526. Epub 2019 Dec 16.

Central DuPage Hospital-Northwestern Medicine, Winfield, IL USA.

Abstract:

Background: Acetabular bone loss in revision total hip arthroplasty can be very challenging even for fellowship-trained surgeons. Although it is uncommon, massive anterosuperior medial defects may be encountered, but treatment options have been limited and better ones are needed.

Questions/purposes: The primary purpose of this case series is to describe a novel surgical treatment, which we call the dome technique, that can be used to address these challenging defects. The dome technique allows for the systematic reconstruction of massive anterosuperior medial defects of the acetabulum. We sought to illustrate the utility of this procedure in three patients with failed acetabular components and massive anterosuperior medial defects.

Methods: We undertook a retrospective chart review of three patients who had had Paprosky 3B bone defects and undergone revision total hip arthroplasty by the senior author between 2013 and 2016 using the dome technique. The procedure involved the use of tantalum metal augments pieced together to fill the medial defect and recreate the column support needed for jumbo cup placement. The dome technique is unusual because it allows for intra-operative customization to obtain the proper fit.

Results: At a mean of 23.6 months' follow-up (range, 10 to 37 months), all patients had good functional outcomes; none was in need of further revision.

Conclusions: In three patients, the dome technique allowed for the anterosuperior column to be recreated by piecing together two porous metal augments to fill the medial bony void and create a stable column for a jumbo cup to be press fit. By recreating the deficient anterosuperior medial bone, the acetabulum can be downsized in a stepwise manner (with further surgery) and reconstructed in a stable fashion. This novel procedure is a unique option for the treatment of this challenging problem.
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http://dx.doi.org/10.1007/s11420-019-09730-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7749926PMC
December 2020

Future Demand for Total Joint Arthroplasty Drives Renewed Interest in Arthroplasty Fellowship.

HSS J 2020 Dec 9;16(Suppl 2):210-215. Epub 2019 Apr 9.

Department of Orthopaedic Surgery, Pennsylvania Hospital, 800 Spruce Street, 8th Floor Preston Building, Philadelphia, PA 19107 USA.

Background: Total joint arthroplasty (TJA) procedure volume has increased continuously in the USA, but prior reports have suggested that orthopedic surgeon supply may not meet future demand due to retirement and waning interest in arthroplasty fellowships.

Purposes: We sought to evaluate trends in growth in the number of orthopedic surgeons, orthopedic residents, and arthroplasty fellowships, in order to predict changes in future TJA procedure volume per surgeon.

Methods: We retrospectively reviewed data from 1995 to 2017 from the American Academy of Orthopaedic Surgeons, the National Residency Matching Program, American Osteopathic Association Residency Match, the San Francisco Match, and the National Inpatient Sample. Annual volume growth in the rate of TJA procedures and in orthopedic surgeons, residents, and fellows was determined.

Results: TJA procedure volume increased 129%, orthopedic surgeon volume increased 15.6%, and orthopedic resident volume increased 29.4%. The percentage of filled arthroplasty fellowship positions increased from 81.9 to 96.4%, and the number of arthroplasty fellowship positions increased 33.5%. Mean surgeon age increased from 50.9 to 56.5 years. By 2030, we estimate 90.1 TJA procedures per surgeon will be performed annually, a 57% increase from 2014. Over the same time period, we project mean orthopedic surgeon age to reach 62.4 years, if current growth rate persists.

Conclusion: During the study period, orthopedic surgeon, resident, and arthroplasty fellow volume have increased, although at a slower rate than TJA procedure growth. Renewed interest in arthroplasty fellowships has been demonstrated by an increase in the number and near complete filling of all available positions.
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http://dx.doi.org/10.1007/s11420-019-09678-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7749885PMC
December 2020

Technique and outcomes of Total Hip Arthroplasty with or without sub-trochanteric shortening osteotomy for neglected post-traumatic hip fracture-dislocations: A case-series.

J Clin Orthop Trauma 2020 Nov-Dec;11(6):1143-1150. Epub 2020 Oct 15.

Penn Orthopaedics at Pennsylvania Hospital, University of Pennsylvania, 1 Cathcart, 800 Spruce Street, 8 Preston Building, Philadelphia, PA 19107, United States of America.

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http://dx.doi.org/10.1016/j.jcot.2020.09.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7656479PMC
October 2020

Total Hip Arthroplasty for Developmental Dysplasia of Hip vs Osteoarthritis: A Propensity Matched Pair Analysis.

Arthroplast Today 2020 Sep 22;6(3):607-611.e1. Epub 2020 Jun 22.

Attending Orthopedic Surgeon, University of Pennsylvania, Department of Orthopedic Surgery, Pennsylvania Hospital, Philadelphia, PA, USA.

Background: The purpose of this study was to use the American College of Surgeons National Surgical Quality Improvement Program to compare the perioperative and postoperative outcomes after total hip arthroplasty (THA) for DDH and primary OA via a propensity-matched pair analysis and the valuation of THA between both groups.

Material And Methods: All patients who underwent THA between 2008 and 2016 were identified from National Surgical Quality Improvement Program database via the current procedural terminology (CPT) code. Patients were further identified and stratified based on International Statistical Classification of Diseases and Related Health Problems-9/International Statistical Classification of Diseases and Related Health Problems-10 diagnosis codes for primary OA (n = 115,166) and DDH (n = 603), which included codes for congenital hip dislocation, hip dysplasia, or juvenile osteochondrosis. Demographic variables were used to create 557 propensity-matched pairs.

Results: The DDH group was associated with a significantly longer operative time (120.3 vs 95.9 min), higher postoperative transfusion rate (12% vs 6.6%), and longer hospital length of stay (2.8 vs 2.5 days) compared with the primary OA group ( < .001, < .001, and  = .002, respectively). There were no statistically significant differences found between the two groups with respect to inpatient complications, discharge disposition ( = .123), readmissions ( = .615), or reoperations ( = .404).

Conclusions: Health policy makers should be cognizant of the higher complexity of THA for DDH when determining whether DDH and primary OA should be in the same bundle. Owing to the limitations of our data set, all the observed associations are likely an underestimate of the true risk posed to patients with severe DDH, as these patients were unable to be stratified in the present analysis.
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http://dx.doi.org/10.1016/j.artd.2020.02.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7502580PMC
September 2020

Letter to the Editor: How Accurate Are the Surgical Risk Preoperative Assessment System (SURPAS) Universal Calculators in Total Joint Arthroplasty?

Clin Orthop Relat Res 2020 12;478(12):2936-2937

N. P. Sheth, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA.

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http://dx.doi.org/10.1097/CORR.0000000000001490DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7899428PMC
December 2020

Merit-Based Incentive Payment System Scores in Ophthalmology and Optometry.

Ophthalmology 2021 May 12;128(5):793-795. Epub 2020 Sep 12.

Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, Illinois. Electronic address:

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http://dx.doi.org/10.1016/j.ophtha.2020.09.015DOI Listing
May 2021

Effect of operative time on complications following primary total hip arthroplasty: analysis of the NSQIP database.

Hip Int 2021 Mar 12;31(2):231-236. Epub 2020 Aug 12.

Perelman School of Medicine, University of Pennsylvania, PA, USA.

Background: Long operative times in total hip arthroplasty (THA) have been shown to be associated with increased risk of revision as well as perioperative morbidity. This study assesses the effect of extended operative times on complication rates following primary THA using the most recent national data.

Methods: The National Surgical Quality Improvement Program (NSQIP) database (2008-2016) was queried for primary THA. Groups were defined by operative time 1 standard deviation (1 SD) above the mean. Univariate, propensity score-matched, and multivariate logistic regression analyses were performed to evaluate outcomes.

Results: Data was available for 135,013 THA patients. Among these groups, mean operative time in the extended operative time group was 166 minutes (compared with 82 minutes). Patients undergoing longer operative times were 3.8 years younger, had a 1.5 kg/m higher body mass index and had a 0.5 day longer mean length of stay. Propensity matching identified 16,123 pairs for analysis in the 1 SD group. Longer operative time led to 173% increased risk of major medical morbidity, 140% increased likelihood of length of stay greater than 5 days, 59% increased risk of reoperation, 45% increased risk of readmission, and a 30% decreased likelihood of return to home postoperatively. There was no increased risk of death within 30 days.

Conclusion: Long operative times were associated with increases in multiple postoperative complications, but not mortality. Surgeons should be advised to take steps to minimise operative time by adequate preoperative planning and optimal team communication.
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http://dx.doi.org/10.1177/1120700020949701DOI Listing
March 2021

Mycobacterium fortuitum Prosthetic Joint Infection After Total Hip Arthroplasty: A Case Report.

JBJS Case Connect 2020 Apr-Jun;10(2):e0343

1Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 2Department of Orthopaedic Surgery, Adult Hip and Knee Reconstruction, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 3Section of Infectious Diseases, Pennsylvania Hospital, Philadelphia, Pennsylvania.

Case: A 57-year-old man presented with a Mycobacterium fortuitum prosthetic joint infection (PJI) after right total hip arthroplasty refractory to the initial revision surgery and cement spacer placement. The patient was subsequently treated with 2-stage total joint arthroplasty revision surgery using an antibiotic-laden spacer customized to include meropenem and delayed reimplantation to allow for prolonged, systemic antimicrobial treatment with multiple antimicrobials, including levofloxacin and linezolid.

Conclusions: There is little evidence to guide practitioners in the diagnosis and treatment of PJI caused by rare, rapidly growing mycobacteria (RGM) such as M. fortuitum. This case demonstrates a successful strategy for the treatment of RGM PJI.
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http://dx.doi.org/10.2106/JBJS.CC.18.00343DOI Listing
February 2021

Practices and Perspectives of Traditional Bone Setters in Northern Tanzania.

Ann Glob Health 2020 06 16;86(1):61. Epub 2020 Jun 16.

Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, US.

Background: Traditional health practitioners remain a critical source of care in Tanzania, more than 50% of Tanzanians frequently using their services. With a severe shortage of orthopaedic surgeons (1:3.3 million Tanzanians) traditional bone setters (TBSs) could potentially expand access to musculoskeletal care and improve outcomes for morbidity as a result of trauma.

Objective: We sought to identify the advantages and disadvantages of traditional bone setting in Tanzania and to assess potential for collaboration between TBSs and allopathic orthopaedic surgeons.

Methods: Between June and July 2017 we interviewed six TBSs identified as key informants in the regions of Kilimanjaro, Arusha, and Manyara. We conducted semi-structured interviews about practices and perspectives on allopathic healthcare, and analyzed the data using a deductive framework method.

Findings: The TBSs reported that their patients were primarily recruited from their local communities via word-of-mouth communication networks. Payment methods for services included bundling costs, livestock barter, and sliding scale pricing. Potentially unsafe practices included lack of radiographic imaging to confirm reduction; cutting and puncturing of skin with unsterile tools; and rebreaking healed fractures. The TBSs described past experience collaborating with allopathic healthcare providers, referring patients to hospitals, and utilizing allopathic techniques in their practice. All expressed enthusiasm in future collaboration with allopathic hospitals.

Conclusions: TBSs confer the advantages of word-of-mouth communication networks and greater financial and geographic accessibility. However, some of their practices raise concerns relating to infection, fracture malunion or nonunion, and iatrogenic trauma from manipulating previously healed fractures. A formal collaboration between TBSs and orthopaedic surgeons, based on respect and regular communication, could alleviate concerns through the development of care protocols and increase access to optimal orthopaedic care through a standardized triage and follow-up system.
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http://dx.doi.org/10.5334/aogh.2878DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7304448PMC
June 2020

Obesity and hypoalbuminaemia are independent risk factors for readmission and reoperation following primary total knee arthroplasty.

Bone Joint J 2020 Jun;102-B(6_Supple_A):31-35

Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Aims: Rates of readmission and reoperation following primary total knee arthroplasty (TKA) are under scrutiny due to new payment models, which penalize these negative outcomes. Some risk factors are more modifiable than others, and some conditions considered modifiable such as obesity may not be as modifiable in the setting of advanced arthritis as many propose. We sought to determine whether controlling for hypoalbuminaemia would mitigate the effect that prior authors had identified in patients with obesity.

Methods: We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for the period of January 2008 to December 2016 to evaluate the rates of reoperation and readmission within 30 days following primary TKA. Multivariate logistic regression modelling controlled for preoperative albumin, age, sex, and comorbidity status.

Results: Readmission rates only differed significantly between patients with Normal Weight and Obesity Class II, with a decreased rate of readmission in this group (odds ratio (OR) 0.82; 95% confidence interval (CI) 0.71 to 0.96; p = 0.010). The only group demonstrating association with increased risk of reoperation within 30 days was the Obesity Class III group (OR 1.38; 95% CI 1.05 to 1.82; p = 0.022). Hypoalbuminaemia (preoperative albumin < 35 g/L) was significantly associated with readmission (OR 1.62; 95% CI 1.41 to 1.86; p < 0.001) and reoperation (OR 1.52; 95% CI 1.18 to 1.96; p = 0.001) within 30 days.

Conclusion: In this study, hypoalbuminaemia appears to be a more significant risk factor for readmission and reoperation than even the highest obesity categories. Future studies may assess whether preoperative albumin restoration or weight loss may improve outcomes for patients with hypoalbuminaemia. The implications of this study may allow surgeons to discuss risk of surgery with obese patients planning to undergo primary TKA procedures if other comorbidities are adequately controlled. Cite this article: 2020;102-B(6 Supple A):31-35.
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http://dx.doi.org/10.1302/0301-620X.102B6.BJJ-2019-1509.R1DOI Listing
June 2020

The burden of prosthetic hip dislocations in the United States is projected to significantly increase by 2035.

Hip Int 2020 May 11:1120700020923619. Epub 2020 May 11.

Department of Orthopaedic Surgery University of Pennsylvania, Philadelphia, PA, USA.

Introduction: Prosthetic hip dislocation is a common, costly complication of total hip arthroplasty (THA). Despite this, the national burden of prosthetic hip dislocations remains uncharacterised in the United States, especially pertaining to injuries occurring years after the index procedure. This study examines historical and projected national estimates of prosthetic hip dislocations presenting to U.S. emergency departments between 2000 and 2035.

Methods: We conducted a cross-sectional, retrospective epidemiological study using narratives in the National Electronic Injury Surveillance System (NEISS) database (2000-2017) to identify an estimated 64,671 prosthetic hip implant dislocations presenting to U.S. emergency departments. Estimates for the prevalence of individuals living with a total hip implant were derived from the literature.

Results: The national estimate of prosthetic hip dislocations presenting to U.S. emergency departments rose significantly ( < 0.001) between 2000 ( = 2395; 95% CI, 1264-3526) and 2017 ( = 8094; 95% CI, 4276-11,912). These increases are likely driven by increased numbers of people living with THA overall, since between 2000 and 2017, the average incidence of prosthetic hip dislocation (0.14%; CI 0.08-0.21%) in patients living with hip implants has not changed significantly. Linear regression modeling (R = 0.7, < 0.01) projected an increasing number of dislocations through 2035, predicting 10,446 national cases per year by this date.

Conclusions: Driven by increases in THA, the annual volume of prosthetic hip dislocations presenting to U.S. emergency departments has increased significantly since 2000 and is projected to continue to rise sharply. Future advances in surgical technique, prosthesis design, and injury prevention policies aimed at decreasing the rate of THA dislocation would help alleviate this mounting national health burden.
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http://dx.doi.org/10.1177/1120700020923619DOI Listing
May 2020

Humanitarian Needs: The Arthroplasty Community and the COVID-19 Pandemic.

J Arthroplasty 2020 Jul 24;35(7S):S85-S88. Epub 2020 Apr 24.

Southern Joint Replacement Institute, Nashville, TN.

Background: As the world struggles with the COVID-19 pandemic, health care providers are on the front lines. We highlight the value of engaging in humanitarian medical work, contributions of the hip and knee arthroplasty community to date, and future needs after the resolution of the pandemic. We sought to understand how the arthroplasty community can contribute, based on historical lessons from prior pandemics and recessions, current needs, and projections of the COVID-19 impact.

Methods: We polled members of medical mission groups led by arthroplasty surgeons to understand their current efforts in humanitarian medical work. We also polled orthopedic colleagues to understand their role and response. Google Search and PubMed were used to find articles relevant to the current environment of the COVID-19 pandemic, humanitarian needs after previous epidemics, and the economic effects of prior recessions on elective surgery.

Results: Hip and knee arthroplasty surgeons are not at the center of the pandemic but are providing an invaluable supportive role through continued care of musculoskeletal patients and unloading of emergency rooms. Others have taken active roles assisting outside of orthopedics. Arthroplasty humanitarian organizations have donated personal protective equipment and helped to prepare their partners in other countries. Previous pandemics and epidemics highlight the need for sustained humanitarian support, particularly in poor countries or those with ongoing conflict and humanitarian crises.

Conclusion: There are opportunities now to make a difference in this health care crisis. In the aftermath, there will be a great need for humanitarian work both here and throughout the world.
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http://dx.doi.org/10.1016/j.arth.2020.04.054DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7195265PMC
July 2020

Reconstruction of Through-and-Through Composite Segmental Mandibulectomy Defect in a Patient With a Dominant Peroneal Artery Using an Anterior Lateral Thigh Osteomyocutaneous Free Flap: A Case Report and Description of Flap.

J Oral Maxillofac Surg 2020 Aug 15;78(8):1436.e1-1436.e7. Epub 2020 Mar 15.

Associate Professor, Department of Otorhinolaryngology/Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

The anterior lateral thigh osteomyocutaneous (ALTO) free flap represents a unique reconstructive option for patients who are otherwise not good candidates for traditional free flaps to repair a through-and-through defect of the head and neck. We report the case of a patient with squamous cell carcinoma of the oral cavity who had undergone composite segmental mandibulectomy with a resultant through-and-through defect. The patient was not a candidate for fibula free flap (FFF) reconstruction owing to the presence of bilaterally dominant peroneal arteries. The patient underwent reconstruction with a single free tissue ALTO flap, with a good viable flap postoperatively. The patient did not experience any major or minor surgical complications and has been living with no evidence of disease. The ALTO free flap could be an effective flap in the reconstruction of through-and-through defects of the mandible for patients who are not candidates for FFF-based reconstruction.
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http://dx.doi.org/10.1016/j.joms.2020.03.007DOI Listing
August 2020

Racial disparities in peri-operative complications following primary total hip arthroplasty.

J Orthop 2020 Sep-Oct;21:155-160. Epub 2020 Mar 26.

Division of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA.

Background: This study assesses if post-operative outcomes following THA vary by racial groups.

Methods: A review of the ACS-NSQIP database was performed to compare THA patient outcomes from 2008 to 2016 according to race.

Results: During the study period, 117,389 THA patients were identified. Blacks were at significantly increased risk of peri-operative complications in comparison to non-Hispanic Whites, including serious medical morbidity (+27%), and prolonged length of stay (+53%).

Conclusions: Despite multivariate control and propensity-matched analysis of important risk factors, race independently predicts longer operative times and higher rates of discharge to non-home facilities.
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http://dx.doi.org/10.1016/j.jor.2020.03.037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7114726PMC
March 2020

CORR Insights®: Which Preoperative Factors are Associated with Not Attaining Acceptable Levels of Pain and Function After TKA? Findings from an International Multicenter Study.

Authors:
Neil P Sheth

Clin Orthop Relat Res 2020 05;478(5):1029-1030

N. P. Sheth, Associate Professor, University of Pennsylvania, Department of Orthopaedic Surgery, Philadelphia, PA, USA.

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http://dx.doi.org/10.1097/CORR.0000000000001231DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7170681PMC
May 2020

Psychosocial health of patients receiving orthopaedic treatment in northern Tanzania: A cross-sectional study.

Ann Med Surg (Lond) 2020 Feb 2;50:49-55. Epub 2019 Nov 2.

Department of Orthopaedic Surgery, University of Pennsylvania, 800 Spruce Street, Philadelphia, PA, 19107, USA.

Background: Patients with musculoskeletal injuries in Sub-Saharan Africa often receive prolonged inpatient treatment due to limited access to surgical care. Little is known regarding the psychosocial impact of prolonged conservative treatment for orthopaedic injuries, which may add to disability and preclude rehabilitation.

Methods: A cross-sectional, questionnaire study was conducted to characterize the psychosocial health of orthopaedic inpatients at a tertiary hospital in Moshi, Tanzania. Three validated surveys assessing coping strategies, functional social support, and symptoms of depression were orally administered to all orthopaedic patients with a length of stay (LOS) ≥ 6 days by a Tanzanian orthopaedic specialist.

Results: Fifty-nine patient surveys were completed, and revealed 92% (54) of patients were more likely to utilize more adaptive than maladaptive coping strategies. Patients with chest or spinal column injuries were more likely to use maladaptive coping strategies (p = 0·027). Patients with head injuries had more social support compared to others (p = 0·009). Lack of insurance, limited education, and rural origins were associated with less functional social support, although this finding did not reach statistical significance. 23·7% (14) of patients had symptoms consistent with mild depression, 33·9% (20) with moderate depression, and 3·4% (2) with moderately-severe depression. LOS was the only significant predictor for depression severity.

Conclusions: 61% (36) of orthopaedic inpatients exhibited depressive symptoms, indicating that the psychosocial health in this population is sub-optimal. Mental health is a crucial element of successful orthopaedic care. Access to timely surgical care would greatly decrease LOS, the most prominent predictor of depressive symptom severity.
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http://dx.doi.org/10.1016/j.amsu.2019.10.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6994630PMC
February 2020

Acetabular Distraction Technique for Severe Acetabular Bone Loss and Chronic Pelvic Discontinuity: An Advanced Course.

Instr Course Lect 2020 ;69:35-42

Acetabular bone loss, and specifically when it is associated with a chronic pelvic discontinuity, presents a difficult clinical challenge at the time of revision total hip arthroplasty. Most centers have advocated the use of noncemented constructs in an effort to achieve biologic fixation. The authors prefer noncemented fixation with use of the acetabular distraction technique in conjunction with modular porous metal augments for the treatment of severe acetabular bone loss and an associated chronic pelvic discontinuity.
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February 2020

Safely Implementing the Direct Anterior Total Hip Arthroplasty: A Methodological Approach to Minimizing the Learning Curve.

J Am Acad Orthop Surg 2020 Nov;28(22):930-936

From the Perelman School of Medicine (Pirruccio), University of Pennsylvania, PA, the Department of Orthopaedic Surgery (Dr. Evangelista), University of Pennsylvania, PA, the Department of Orthopedics, South San Francisco Medical Center (Dr. Haw), San Francisco, CA, the Texas Orthopedics (Dr. Goldberg), LLC, Dell Medical School, Austin, TX, and the Department of Orthopaedic Surgery (Dr. Sheth), Pennsylvania Hospital, Orthopaedics University of Pennsylvania, PA.

Introduction: Orthopaedic surgeons often cite concern for a learning curve as a barrier to adopting the direct anterior approach (DAA) for total hip arthroplasty (THA) while transitioning from other approaches. Studies both assessing and describing a practical approach and strategy to safely accomplish this transition, as well as the effect on clinical outcomes, are not well described.

Methods: This prospective study compares a single surgeon's operative results and complications for the first consecutive 100 direct anterior THA to the last 100 consecutive posterior THA after 7 years in practice. The regimented and disciplined learning strategy used to implement the DAA is detailed in this study. The data were analyzed using univariate and multivariate regression models.

Results: Univariate analyses identified significant differences in sex, age, Asian race, and diagnostic cause for THA between the two cohorts. Multivariate analyses controlled for these differences and showed that relative to posterior THA, direct anterior THA cases were associated with 7-minute longer procedures (P = 0.002) and lengths of stay that were 0.7 days fewer (P = 0.013). No significant differences were present in the estimated blood loss, and importantly, no significant differences in death or surgical complication rates between cohorts.

Discussion: This study suggests that the DAA for THA can be safely implemented without the increased and adverse risk to the patient when a structured learning process is maintained and meticulously performed.
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http://dx.doi.org/10.5435/JAAOS-D-19-00752DOI Listing
November 2020

Acetabular reconstruction in revision total hip arthroplasty.

J Clin Orthop Trauma 2020 Jan-Feb;11(1):22-28. Epub 2019 Dec 2.

University of Pennsylvania, Chief of Orthopaedic Surgery - Pennsylvania Hospital, Assistant Professor of Orthopaedic Surgery, Department of Orthopaedic Surgery, 800 Spruce Street, 8th Floor Preston Building, Philadelphia, PA, 19107, USA.

The number of total hip arthroplasty (THA) procedures performed annually continues to rise. Specific challenges, including acetabular bone loss, are commonly encountered at the time of revision surgery, and orthopaedic surgeons must be prepared to address them. This review focuses on topics related to acetabular reconstruction, including pre-operative patient evaluation (clinical and radiographic), pre-operative planning, common causes of acetabular failure, classification of acetabular bone loss, methods of acetabular reconstruction, and clinical results based on reconstruction method. Pre-operative patient evaluation for revision THA begins with a thorough history and physical examination as well as laboratory workup to rule out infection. Detailed radiographic evaluation and pre-operative planning are also essential and will facilitate communication amongst all members of the operative team. Although there are several ways to describe acetabular bone loss, the Paprosky classification system - defined by anterosuperior and posteroinferior acetabular column integrity - is the system most commonly used today and will guide treatment strategy. Several treatment strategies have been developed and may be termed either "cemented" (e.g. impaction grafting, ring and cage construction, structural allograft) or "uncemented" (e.g. hemispheric shell ± porous metal augment, cup-cage, custom triflange acetabular component). Although each strategy has its advantages and disadvantages, the general principles remain the same. Successful treatment depends upon detailed pre-operative assessment, planning, and team-based plan execution. Uncemented techniques that allow for biologic fixation are preferred. In the special case of pelvic discontinuity, acetabular distraction is the authors' preferred technique. Longer term studies are still needed to evaluate the longevity of each of the various reconstruction methods presented.
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http://dx.doi.org/10.1016/j.jcot.2019.11.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6985018PMC
December 2019

Secondary Suture Fusion after Primary Correction of Nonsyndromic Craniosynostosis: Recognition of the Problem and Identification of Risk Factors.

Plast Reconstr Surg 2020 Feb;145(2):493-503

From the Division of Plastic and Reconstructive Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago.

Background: Secondary fusion of initially patent cranial sutures after primary correction of nonsyndromic craniosynostosis is rarely reported. This study's aim is to report the incidence and analyze whether there are variables that may predispose to such fusion.

Methods: A single-institution, retrospective, case-control study was conducted of all nonsyndromic patients who underwent operative treatment for craniosynostosis from April of 2008 to May of 2017. Patients with less than 1 year of follow-up and/or without a 1-year postoperative computed tomographic scan were excluded. Preoperative, intraoperative, and postoperative variables were analyzed using univariate and multivariate analyses.

Results: Sixty-six patients were included in the study, with a mean 2.57-year postoperative follow-up. Six patients (8.8 percent) were found to have secondary craniosynostosis, all of whom had fusion of sutures that were initially patent and refusion of the primary pathologic suture(s). Fifty percent of secondary fusions presented as pansynostosis. On univariate analysis, suturectomy with barrel staving (p < 0.01) was significantly associated with secondary suture fusion. On multivariate analysis, bilambdoid suture involvement (p = 0.03) and suturectomy with barrel staving (p = 0.01) were significantly associated with secondary suture fusion.

Conclusions: Secondary cranial suture fusion may be a relatively common complication after primary craniosynostosis correction. Suturectomy with barrel staving was independently associated with secondary craniosynostosis. Wide surgical separation of the dura from the cranium and osteotomies across patent sutures may predispose to secondary craniosynostosis.

Clinical Question/level Of Evidence: Risk, III.
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http://dx.doi.org/10.1097/PRS.0000000000006491DOI Listing
February 2020

Do spacer blocks accurately estimate deformity correction and gap balance in total knee arthroplasty? A prospective study with computer navigation.

Knee 2020 Jan 7;27(1):214-220. Epub 2020 Jan 7.

Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA.

Background: Spacer blocks are used commonly in knee arthroplasty to estimate gaps and ligament balance. Their use continues along with modern technology despite dearth of literature regarding their accuracy and reliability. This prospective study aims to determine the difference in values of gap and balance measurements between spacers and trials in computer assisted TKA.

Methods: 50 patients with moderate varus deformity of <20° undergoing primary TKA were recruited for this prospective study. After navigation assisted cuts and requisite ligament release, gaps and balance were recorded in extension and 90° flexion with spacer block followed by implant trials.

Results: There were 33 females and 17 males with average BMI of 28.2 ± 5kg/m. The average preoperative flexion deformity was 6.5° ± 4.4° and varus deformity was 8.2° ± 3.8°. Average difference of deformity in sagittal plane in extension between spacer and trial was 6.2° which was statistically significant (p = 0.001) implying that knee achieves more extension with spacer blocks as compared to trials because the blocks do not have posterior offset of the condyles. However, there was no difference between values of soft tissue balance and coronal plane correction between spacer blocks and trials in extension and 90° flexion (p > 0.05).

Conclusion: Spacer blocks do not estimate extension space accurately with knee achieving 6.2 more flexion with trials as compared to spacer blocks when assessed for sagittal plane correction in extension. Spacer blocks should pass in easily in extension to avoid any flexion deformity when the actual trials are inserted.
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http://dx.doi.org/10.1016/j.knee.2019.09.006DOI Listing
January 2020

What happens to global health research: analysis of the full-length publication rates of research abstracts presented at two major global health conferences.

Health Info Libr J 2019 Dec 30:49-60. Epub 2019 Dec 30.

Department of Orthopaedic Surgery, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, PA, USA.

Background: Global health research has been expanding rapidly. The Consortium of Universities for Global Health (CUGH) and Global Health and Innovation Conference (GHIC) are the two major conferences for global health research. It is unclear how much of the presented research goes on to full-length publication.

Objectives: This study sought to determine publication rates and journals of CUGH and GHIC research.

Methods: A total of 1449 abstracts from CUGH and GHIC from 2014 to 2015 were searched by title, author and keywords using Google Scholar and PubMed. Publications were categorised according to WHO Sustainable Development Goal (SDG) categories.

Results: Research was published in 293 journals at a rate of 34.0%, within an average of 15.1 months. The 15 MEDLINE indexed global health journals accounted for just 5.5% of publications.

Discussion: Despite growth in global health research, publication rates from the two major conferences are low. The majority of publications in journals are not MEDLINE indexed global health journals. Improved publication and consolidation of global health research is critical.

Conclusion: Global health conference publication rates are low. Effective dissemination is critical as the field grows. This may require increased publishing support, improved indexing and consolidation of global health research.
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http://dx.doi.org/10.1111/hir.12296DOI Listing
December 2019

The Association Between Newly Accredited Orthopedic Residency Programs and Teaching Hospital Complication Rates in Lower Extremity Total Joint Arthroplasty.

J Surg Educ 2020 May - Jun;77(3):690-697. Epub 2019 Nov 27.

Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.

Objective: The influence of residency programs on teaching hospital outcomes in total joint arthroplasty (TJA) has recently been debated. This study investigates how complication and readmission rates for primary elective total hip (THA) and total knee arthroplasty (TKA) changed before and after new orthopedic surgery residency programs meeting ACGME accreditation requirements were introduced at hospitals.

Design: We conducted a retrospective cohort study using the CMS Hospital Compare database, which contains hospital-level data on risk-standardized complication and readmission rates (2013-2018) for primary elective THA and TKA in Medicare beneficiaries. Orthopedic surgery residency programs that were newly accredited during this time were identified using ACGME publicly available data.

Setting: Eight primary adult teaching hospitals with complication and readmission data in the CMS database available prior to the first full year its affiliated residency program was implemented, and with subsequent program data also available.

Participants: Six ACGME accredited orthopedic surgery residency programs.

Results: Even after controlling for annual variation in surrounding hospital rates, the at-risk patient volume, and variation in starting rates for a given hospital in the first available year, multivariate linear regression demonstrated that complication rates for lower extremity TJA in Medicare beneficiaries decreased by 0.20 per year (R = 0.78, p = 0.005) after hospitals introduced new orthopedic surgery residency programs meeting ACGME accreditation requirements. There were no significant differences in readmission rates after the addition of newly accredited programs to these same hospitals (R = 0.51; p = 0.706).

Conclusions: Starting an orthopedic surgery residency program meeting ACGME accreditation requirements was associated with significantly reduced complication rates for primary elective lower extremity TJA in Medicare beneficiaries at teaching hospitals where these programs began rotating residents. These findings raise awareness regarding the potential for residency programs to contribute to improved patient care outside of the operating room as well as through direct resident involvement in procedures.
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http://dx.doi.org/10.1016/j.jsurg.2019.11.004DOI Listing
June 2021
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