Preface: Sports-Related Injuries Jennifer Flynn-Briggs

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1 Sports-Related Injuries ix CONTENTS Preface: Sports-Related Injuries Jennifer Flynn-Briggs xv The Future of Arthroplasty Patrick C. Toy Health Care Reform: Impact on Total Joint Replacement 645 Monique C. Chambers, Mouhanad M. El-Othmani, The US health care system has been fragmented for more than 40 years; this model created a need for modification. Sociopoliticomedical system-related factors led to the Affordable Care Act (ACA) and a restructuring of health care provision/delivery. The ACA increases access to high-quality affordable care under cost-effective measures. This article provides a comprehensive review of health reform and the motivating factors that drive policy to empower arthroplasty providers to effectively advocate for the field of orthopedics as a whole, and the patients served. Reducing Length of Stay in Total Joint Arthroplasty Care 653 Megan Walters, Monique C. Chambers, Zain Sayeed, Afshin A. Anoushiravani, Mouhanad M. El-Othmani, As health care reforms continue to improve quality of care, significant emphasis will be placed on evaluation of orthopedic patient outcomes. Total joint arthroplasty (TJA) has a proven track record of enhancing patient quality of life and are easily replicable. The outcomes of these procedures serve as a measure of health care initiative success. Specifically, length of stay, will be targeted as a marker of quality of surgical care delivered to TJA patients. Within this review, we will discuss preoperative and postoperative methods by which orthopedic surgeons may enhance TJA outcomes and effectively reduce length of stay. Approach to Decrease Infection Following Total Joint Arthroplasty 661 Daniel Hatz, Afshin A. Anoushiravani, Monique C. Chambers, Mouhanad M. El-Othmani, Surgical site infection in total joint arthroplasty is a challenging complication that warrants discussion with regard to prevention and management. Limiting postoperative infection rate is a paramount quest in the orthopedic community. Several preoperative risk factors have been identified in orthopedic literature with regards to likelihood of developing postoperative infection. This article evaluates several factors that predispose total joint arthroplasty patients to infection. Methods of patient surgical preparation designed to decrease postoperative infection, decreasing intraoperative traffic during procedural settings, and elaborate intraoperative prophylactic advancements are assessed. Approaches to decrease postoperative infection by discussing means of lowering rates of postoperative transfusion, wound drainage, and hematoma formation are analyzed.

2 x Contents Reducing 30-day Readmission After Joint Replacement 673 Monique C. Chambers, Mouhanad M. El-Othmani, Afshin A. Anoushiravani, Zain Sayeed, Hospital readmission is a focus of quality measures used by the Center for Medicare and Medicaid (CMS) to evaluate quality of care. Policy changes provide incentives and enforce penalties to decrease 30-day hospital readmissions. CMS implemented the Readmission Penalty Program. Readmission rates are being used to determine reimbursement rates for physicians. The need for readmission is deemed an indication for inadequate quality of care subjected to financial penalties. This reviews identifies risk factors that have been significantly associated with higher readmission rates, addresses approaches to minimize 30-day readmission, and discusses the potential future direction within this area as regulations evolve. Planning, Building, and Maintaining a Successful Musculoskeletal Service Line 681 Zain Sayeed, Mouhanad M. El-Othmani, Afshin A. Anoushiravani, Monique C. Chambers, Within the past 3 decades, a recent trend in the growth of musculoskeletal service lines has been seen nationally. Orthopedics offers an appealing concourse for implementation of service-line care. Within this review, the authors address the components involved in planning and building a musculoskeletal service line. The authors also address methods by which orthopedic surgeons can maintain the efficacy of their service lines by examining how orthopedic surgeons can navigate their service line through recent advents in health care reform. Finally, the authors review successful examples of musculoskeletal service lines currently in practice within the orthopedic community. High Reliability of Care in Orthopedic Surgery: Are We There Yet? 689 Afshin A. Anoushiravani, Zain Sayeed, Mouhanad M. El-Othmani, Peter K. Wong, As health care reimbursement models shift from volume-based to value-based models, orthopedic surgeons must provide patients with highly reliable care, while consciously minimizing cost, maintaining quality, and providing timely interventions. An established means of achieving these goals is by implementing a highly reliable care model; however, before such a model can be initiated, a safety culture, robust improvement strategies, and committed leadership are needed. This article discusses interdependent and critical changes required to implement a highly reliable care system. Specific operative protocols now mandated are discussed as they pertain to high reliability of orthopedic care and elimination of wrong-site procedures. Patient Centeredness in Total Joint Replacement: Beyond the Slogan 697 Hussein A. Zeineddine, Mouhanad M. El-Othmani, Zain Sayeed, Monique C. Chambers, Patient-centered care (PCC) is gaining considerable momentum among health care professionals and policy-making authorities. The need for PCC stems from the innumerable benefits of adopting such a system. The practice of PCC in orthopedic surgery in general, and in total joint replacement in particular, is still in its youth. However, present literature already establishes the need for applying PCC in total joint replacement. Extensive research and effort should be invested to better grasp and define the dimensions of PCC as they relate to total joint replacement.

3 Contents xi Affordable Care Organizations and Bundled Pricing: A New Philosophy of Care 707 Gonzalo Barinaga, Monique C. Chambers, Mouhanad M. El-Othmani, Richard B. Siegrist, Under the Patient Protection and Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services Innovation was chartered to develop new models of health care delivery. The changes meant a drastic need to restructure the health care system. To minimize costs and optimize quality, new laws encourage continuity in health care delivery within an integrated system. Affordable care organizations provided a model of high-quality care while reducing costs. Bundled payments can have a substantial effect on the national expenditures. This article examines new developments in bundle payments, affordable care organizations, and gainsharing agreements as they pertain to arthroplasty. Big Data, Big Research: Implementing Population Health-Based Research Models and Integrating Care to Reduce Cost and Improve Outcomes Afshin A. Anoushiravani, Jason Patton, Zain Sayeed, Mouhanad M. El-Othmani, Recent trends in clinical research have moved attention toward reporting clinical outcomes and resource consumption associated with various care processes. This change is the result of technological advancement and a national effort to critically assess health care delivery. As orthopedic surgeons traverse an unchartered health care environment, a more complete understanding of how clinical research is conducted using large data sets is necessary. The purpose of this article is to review various advantages and disadvantages of large data sets available for orthopaedic use, examine their ideal use, and report how they are being implemented nationwide. Big Data, Big Problems: Incorporating Mission, Values, and Culture in Provider Affiliations Steven H. Shaha, Zain Sayeed, Afshin A. Anoushiravani, Mouhanad M. El-Othmani, This article explores how integration of data from clinical registries and electronic health records produces a quality impact within orthopedic practices. Data are differentiated from information, and several types of data that are collected and used in orthopedic outcome measurement are defined. Furthermore, the concept of comparative effectiveness and its impact on orthopedic clinical research are assessed. This article places emphasis on how the concept of big data produces health care challenges balanced with benefits that may be faced by patients and orthopedic surgeons. Finally, essential characteristics of an electronic health record that interlinks musculoskeletal care and big data initiatives are reviewed Trauma John C. Weinlein Tibial Stress Fractures in Athletes 733 John J. Feldman, Eric N. Bowman, Barry B. Phillips, and John C. Weinlein Tibial stress fractures are common in the athlete. There are various causes of these fractures, the most common being a sudden increase in training intensity. Most of these injuries are treated conservatively; however, some may require operative intervention. Intervention is mostly dictated by location of the fracture and failure of conservative treatment. There are several surgical options available to the treating surgeon, each with advantages and disadvantages. The physician must understand the nature of the fracture and the likelihood for it to heal in a timely manner in order to best treat these fractures in this patient subset.

4 xii Contents Pediatrics Jeffrey R. Sawyer Pediatric Elbow and Wrist Pathology Related to Sports Participation 743 Matthew D. Ellington and Eric W. Edmonds Pediatric overuse injuries are becoming more prevalent in today s society with more children competitively playing year-round sports at a younger age. The importance of prompt diagnosis and treatment is paramount to the treatment for these injuries, second only to rest and activity modification. This article will focus on overuse injuries of the upper extremity, specifically: little league elbow, elbow osteochondritis dissecans, and gymnast wrist. It will also discuss the pathophysiology, diagnosis, imaging, and treatment of each of these entities. Shoulder Injuries in Pediatric Athletes 749 James E. Moyer and Jennifer M. Brey Shoulder injuries in pediatric athletes are typically caused by acute or overuse injuries. The developing structures of the shoulder lead to injury patterns that are distinct from those of adult athletes. Overuse injuries often affect the physeal structures of the proximal humerus and can lead to pain and loss of sports participation. Shoulder instability is common in pediatric athletes, and recurrence is also a concern in this population. Fractures of the proximal humerus and clavicle are typically treated with conservative management, but there is a trend toward surgical intervention. Pediatric Knee Osteochondritis Dissecans Lesions 763 Aristides I. Cruz Jr, Kevin G. Shea, and Theodore J. Ganley Osteochondritis dissecans (OCD) can cause knee pain and dysfunction in children. The etiology of OCD remains unclear; theories on causes include inflammation, ischemia, ossification abnormalities, genetic factors, and repetitive microtrauma. Most OCD lesions in skeletally immature patients will heal with nonoperative treatment. The success of nonoperative treatment decreases once patients reach skeletal maturity. The goals of surgical treatment include maintenance of articular cartilage congruity, rigid fixation of unstable fragments, and repair of osteochondral defects with cells or tissues that can adequately replace lost or deficient cartilage. Unsalvageable OCD lesions can be treated with various surgical techniques. Anterior Cruciate Ligament Injuries in Children and Adolescents 777 Peter D. Fabricant and Mininder S. Kocher Dramatic increases in youth competitive athletic activity, early sport specialization, and year-round training and competition, along with increased awareness of anterior cruciate ligament (ACL) injuries in children, have led to a commensurate increase in the frequency of ACL tears in the skeletally immature. Recent understanding of the risks of nonoperative treatment and surgical delay have supported a trend toward early operative treatment. This article discusses treatment strategies for ACL injuries in children and adolescents, and offers our preferred treatment strategy for skeletally immature youth athletes with ACL tears.

5 Contents xiii Upper Extremity Benjamin M. Mauck and James H. Calandruccio Ulnar-Sided Wrist Pain in the Athlete 789 Chance J. Henderson and Ky M. Kobayashi Ulnar-sided wrist pain can be a challenging entity for the hand surgeon and even more so in the athletic population. The authors present 8 causes of ulnar-sided wrist pain in an athlete (hook of hamate fracture, pisiform fracture, hypothenar hammer syndrome, triangular fibrocartilage complex injuries, ulnocarpal impaction syndrome, lunotriquetral ligament tears, extensor carpi ulnaris tendinitis, subluxation of extensor carpi ulnaris) and their associated imaging and treatment options. Thumb Ligament Injuries in the Athlete 799 F. Patterson Owings, James H. Calandruccio, and Benjamin M. Mauck Hand injuries account for up to 15% of sports injuries and are common in contact sports and in sports with a high risk of falling. Appropriate management requires knowledge of the type of injury, demands of the sport and position, competitive level of the athlete, future athletic demands and expectations, and the role of rehabilitation and protective splints for return to play. Management of the athlete requires aggressive and expedient diagnostic intervention and treatment. This article describes ligamentous injuries to the thumb, including thumb carpometacarpal dislocations, thumb metacarpophalangeal dislocations, collateral ligament injuries and interphalangeal dislocations, their evaluation, treatment and outcomes. Foot and Ankle Benjamin J. Grear Foot and Ankle Stress Fractures in Athletes 809 Michael C. Greaser The incidence of stress fractures in the general athletic population is less than 1%, but may be as high as 15% in runners. Stress fractures of the foot and ankle account for almost half of bone stress injuries in athletes. These injuries occur because of repetitive submaximal stresses on the bone resulting in microfractures, which may coalesce to form complete fractures. Advanced imaging such as MRI and triple-phase bone scans is used to evaluate patients with suspected stress fracture. Low-risk stress fractures are typically treated with rest and protected weight bearing. High-stress fractures more often require surgical treatment. Index 823