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1.  Work Satisfaction and Retirement Plans of Orthopaedic Surgeons 50 Years of Age and Older 
Retirement age and practice patterns before retirement are important for making accurate workforce predictions for orthopaedic surgeons. A survey of orthopaedic surgeons 50 years of age and older therefore was conducted by the American Academy of Orthopaedic Surgeons in cooperation with the Association of American Medical Colleges Center for Workforce Studies. The survey focused on three questions: (1) At what age do orthopaedic surgeons retire? (2) Do they stop working abruptly or do they work part time before retirement? (3) What are the major factors that determine when an orthopaedic surgeon retires? According to the survey, the median retirement age for orthopaedic surgeons was 65 years. Nineteen percent of orthopaedic surgeons worked part time before retirement. Decreasing reimbursement and increasing malpractice costs were consistently cited as factors that strongly influenced retirement plans. Career satisfaction was high and was the strongest factor that kept the respondents in the workforce. The option to work part time would have the most impact on keeping orthopaedic surgeons working past the age of 65 years.
Level of Evidence: Level IV Economic and Decision Analyses. See the Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC2505310  PMID: 18196399
2.  The Evolution of Advocacy and Orthopaedic Surgery 
The future direction of American health care has become increasingly controversial during the last decade. As healthcare costs, quality, and delivery have come under intense scrutiny, physicians play evolving roles as “advocates” for both their profession and patients via healthcare policy. Hospital-physician alignment is critical to the future success of advocacy among orthopaedic surgeons, as both hospitals and physicians are key stakeholders in health care and can work together to influence major health policy decisions.
We (1) define the role of advocacy in medicine, specifically within orthopaedic surgery; (2) explore the history of physician advocacy and its evolution; (3) examine the various avenues of involvement for orthopaedic surgeons interested in advocacy; and (4) reflect on the impact of such activities on the future of orthopaedic surgery as it relates to hospital-physician alignment.
We performed a comprehensive review of the literature through a bibliographic search of MEDLINE® and Google Scholar databases from January 2000 to December 2010 to identify articles related to advocacy and orthopaedic surgery.
Advocacy among orthopaedic surgeons is critical in guiding the future of the American healthcare system. In today’s world, advocacy necessitates a wider effort to improve healthcare access, quality, and delivery for patients on a larger scale. The nature of physician advocacy among orthopaedic surgeons is grounded in the desire to serve patients and alleviate their suffering. Participation in medical societies and political campaigns are two avenues of involvement.
The increasing role of government in American health care will require a renewed commitment to advocacy efforts from orthopaedic surgeons. The role of advocacy is rapidly redefining the continuum of care to a trinity of clinical excellence, innovative research, and effective advocacy. Failure to recognize this growing role of advocacy limits the impact we can have for our patients.
PMCID: PMC3706663  PMID: 23479232
3.  Smartphone Apps for Orthopaedic Surgeons 
The use of smartphones and their associated applications (apps) provides new opportunities for physicians, and specifically orthopaedic surgeons, to integrate technology into clinical practice.
The purpose of this study was twofold: to review all apps specifically created for orthopaedic surgeons and to survey orthopaedic residents and surgeons in the United States to characterize the need for novel apps.
The five most popular smartphone app stores were searched for orthopaedic-related apps: Blackberry, iPhone, Android, Palm, and Windows. An Internet survey was sent to ACGME-accredited orthopaedic surgery departments to assess the level of smartphone use, app use, and desire for orthopaedic-related apps.
The database search revealed that iPhone and Android platforms had apps specifically created for orthopaedic surgery with a total of 61 and 13 apps, respectively. Among the apps reviewed, only one had greater than 100 reviews (mean, 27), and the majority of apps had very few reviews, including AAOS Now and AO Surgery Reference, apps published by the American Academy of Orthopaedic Surgeons and AO Foundation, respectively. The national survey revealed that 84% of respondents (n = 476) have a smartphone, the majority (55%) have an iPhone, and that 53% of people with smartphones already use apps in clinical practice. Ninety-six percent of respondents who use apps reported they would like more orthopaedic apps and would pay an average of nearly $30 for useful apps. The four most requested categories of apps were textbook/reference, techniques/guides, OITE/board review, and billing/coding.
The use of smartphones and apps is prevalent among orthopaedic care providers in academic centers. However, few highly ranked apps specifically related to orthopaedic surgery are available, and the types of apps available do not appear to be the categories most desired by residents and surgeons.
PMCID: PMC3111786  PMID: 21547414
4.  Shared Decision-making in Orthopaedic Surgery 
The process of clinical decision-making and the patient-physician relationship continue to evolve. Increasing patient involvement in clinical decision-making is embodied in the concept of “shared decision-making” (SDM), in which the patient and physician share responsibility in the clinical decision-making process. Various patients’ decision aid tools have been developed to enhance this process.
We therefore (1) describe decision-making models; (2) discuss the different types of patients’ decision aids available to practice SDM; and (3) describe the practice and early impact of SDM on clinical orthopaedic surgery.
We performed a search of the literature using PubMed/MEDLINE and Cochrane Library. We identified studies related to shared decision-making and the use of patients’ decision aids in orthopaedics. The search resulted in 113 titles, of which 21 were included with seven studies on patients’ decision aid use specifically in orthopaedics.
Although limited studies suggest the use of patients’ decision aids may enhance decision-making, conclusions about the use of these aids in orthopaedic clinical practice cannot be made and further research examining the best type, timing, and content of patients’ decision aids that will lead to maximum patient involvement and knowledge gains with minimal clinical workflow interruption are needed.
In clinical practice today, patients are increasingly involved in clinical decision-making. Further research on SDM in orthopaedic surgery examining the feasibility and impact on practice, on patients’ willingness and ability to actively participate in shared decision-making, and the timing and type of patients’ decision aids appropriate for use is still needed.
PMCID: PMC3293980  PMID: 22057819
5.  Patient Decision Aids in Joint Replacement Surgery: A Literature Review and An Opinion Survey of Consultant Orthopaedic Surgeons 
Patient decision aids could facilitate shared decision-making in joint replacement surgery. However, patient decision aids are not routinely used in this setting.
With a view to developing a patient decision aid for UK hip/knee joint replacement practice, we undertook a systematic search of the literature for evidence on the use of shared decision-making and patient decision aids in orthopaedics, and a national survey of consultant orthopaedic surgeons on the potential acceptability and feasibility of patient decision aids.
We found little published evidence regarding shared decision-making or patient decision aids in orthopaedics. In the survey, 362 of 639 (57%) randomly selected consultant orthopaedic surgeons responded. Respondents appear representative of consultant orthopaedic surgeons in the UK. Of 272 valid responses, 79% (95% CI, 73–85%) thought patient decision aids a good or excellent idea. There was consensus on the potential helpfulness of patient decision aids and core content. A booklet to take home was the preferred medium/practice model.
Despite the increased emphasis on patient involvement in decision-making, there is little evidence in the medical literature relating to shared decision-making or the use of patient decision aids in orthopaedic surgery. Further research in this area of clinical practice is required. Our survey shows that consultant orthopaedic surgeons in the UK are generally positive about the use of patient decision aids for joint replacement surgery. Survey results could inform future development of patient decision aids for joint replacement practice in the UK.
PMCID: PMC2430464  PMID: 18430333
Decision support techniques; Arthroplasty; Attitude of health personnel; Questionnaire
6.  The Impact of Disruptive Innovations in Orthopaedics 
The US healthcare system is currently facing daunting demographic and economic challenges. Because musculoskeletal disorders and disease represent a substantial and growing portion of this healthcare burden, novel approaches will be needed to continue to provide high-quality, affordable, and accessible orthopaedic care to our population. The concept of “disruptive innovations,” which has been studied and popularized by Harvard Business School Professor Clayton Christensen, may offer a potential framework for developing strategies to improve quality and control costs associated with musculoskeletal care. The introduction of mobile fluoroscopic imaging systems, the development of the Surgical Implant Generation Network intramedullary nail for treatment of long bone fractures in the developing world, the expanding role and contributions of physician assistants and nurse practitioners to the orthopaedic team, and the rise of ambulatory surgery centers are all examples of disruptive innovations in the field of orthopaedics. Although numerous cultural and regulatory barriers have limited the widespread adoption of these “disruptive innovations,” we believe they represent an opportunity for clinicians to regain leadership in health care while at the same time improving quality and access to care for patients with musculoskeletal disease.
PMCID: PMC2745460  PMID: 19415405
7.  The Impact of Disruptive Innovations in Orthopaedics 
The US healthcare system is currently facing daunting demographic and economic challenges. Because musculoskeletal disorders and disease represent a substantial and growing portion of this healthcare burden, novel approaches will be needed to continue to provide high-quality, affordable, and accessible orthopaedic care to our population. The concept of “disruptive innovations,” which has been studied and popularized by Harvard Business School Professor Clayton Christensen, may offer a potential framework for developing strategies to improve quality and control costs associated with musculoskeletal care. The introduction of mobile fluoroscopic imaging systems, the development of the Surgical Implant Generation Network intramedullary nail for treatment of long bone fractures in the developing world, the expanding role and contributions of physician assistants and nurse practitioners to the orthopaedic team, and the rise of ambulatory surgery centers are all examples of disruptive innovations in the field of orthopaedics. Although numerous cultural and regulatory barriers have limited the widespread adoption of these “disruptive innovations,” we believe they represent an opportunity for clinicians to regain leadership in health care while at the same time improving quality and access to care for patients with musculoskeletal disease.
PMCID: PMC2745460  PMID: 19415405
8.  Disclosure of Financial Conflicts of Interest: An Evaluation of Orthopaedic Surgery Patients’ Understanding 
Industry and orthopaedic surgeons often partner to develop new technology, which can lead to orthopaedic surgeons having financial conflicts of interest (FCOI). It is essential these FCOI be conveyed clearly to patients. It is unclear, however, whether and to what degree patients understand the ramifications of physician FCOI.
We evaluated (1) patients’ concerns regarding their surgeon having FCOI or the presence of institutional FCOI, (2) the effect of surgeon FCOI on patients’ willingness to have surgery, and (3) patients’ understanding of FCOI.
We asked 101 patients (66% female) receiving total joint arthroplasty from the orthopaedic practices of two surgeons at an academic health center to complete a descriptive, correlational designed survey at their 6-week followup appointment. The data collected included patient demographics, knowledge of FCOI, and the influence of FCOI on patient attitudes toward surgery and their surgeon.
A minority of patients (13%) reported discussing FCOI with prior physicians and only 55% agreed or strongly agreed a surgeon should disclose FCOI. Only 15% of patients believed such conflicts would make them less likely to have their surgeon operate on them. Level of education was weakly correlated (Spearman’s rho = 0.29) with patient understanding of FCOI.
Overall, patients had a poor understanding of FCOI. Both level of education and previous discussions of FCOI predicted better understanding. This study emphasizes communication of FCOI with patients needs to be enhanced.
Electronic supplementary material
The online version of this article (doi:10.1007/s11999-012-2525-y) contains supplementary material, which is available to authorized users.
PMCID: PMC3549175  PMID: 22948521
9.  Public Reporting of Cost and Quality Information in Orthopaedics 
Public reporting of patient health outcomes offers the potential to incentivize quality improvement by fostering increased accountability among providers. Voluntary reporting of risk-adjusted outcomes in cardiac surgery, for example, is viewed as a “watershed event” in healthcare accountability. However, public reporting of outcomes, cost, and quality information in orthopaedic surgery remains limited by comparison, attributable in part to the lack of standard assessment methods and metrics, provider fear of inadequate adjustment of health outcomes for patient characteristics (risk adjustment), and historically weak market demand for this type of information.
We review the origins of public reporting of outcomes in surgical care, identify existing initiatives specific to orthopaedics, outline the challenges and opportunities, and propose recommendations for public reporting of orthopaedic outcomes.
We performed a comprehensive review of the literature through a bibliographic search of MEDLINE and Google Scholar databases from January 1990 to December 2010 to identify articles related to public reporting of surgical outcomes.
Orthopaedic-specific quality reporting efforts include the early FDA adverse event reporting MedWatch program and the involvement of surgeons in the Physician Quality Reporting Initiative. Issues that require more work include balancing different stakeholder perspectives on quality reporting measures and methods, defining accountability and attribution for outcomes, and appropriately risk-adjusting outcomes.
Given the current limitations associated with public reporting of quality and cost in orthopaedic surgery, valuable contributions can be made in developing specialty-specific evidence-based performance measures. We believe through leadership and involvement in policy formulation and development, orthopaedic surgeons are best equipped to accurately and comprehensively inform the quality reporting process and its application to improve the delivery and outcomes of orthopaedic care.
PMCID: PMC3293971  PMID: 21952744
10.  Internet use by orthopaedic outpatients – current trends and practices 
The Australasian Medical Journal  2012;5(12):633-638.
The e-patient revolution increasingly enables patients to self diagnose and self educate, influencing decisions affecting their health. This poses a challenge for both patients and health care professionals due to the highly variable and often poor quality information available on the internet.
This study aims to measure the current internet usage in patients attending outpatient clinics, in both a public and private setting. All patients were recruited whilst consulting orthopaedic surgeons.
We developed a 29 question survey which asked questions related to patient demographics, general internet usage and internet usage related to the patient’s orthopaedic condition. Patients were recruited for the public cohort during Western Health outpatient clinics and for the private cohort during private surgical consults in the waiting rooms of eight surgeons’ clinics.
A total of 400 surveys were completed; 200 in both the private and public cohorts of the study. Of all surveyed participants, 79% (n = 316) had access to the internet. Of people who had access to the internet 65.2% (n = 206) used the internet to investigate their orthopaedic condition. 29.6% (n = 61) of participants asked their surgeon questions related to information they had read on the internet. Of patients that had access to the internet 36.1% (n = 114) used the internet to research their surgeon.
Patients are commonly using the internet as an information resource, in spite of the highly variable quality of this information. This highlights the need for patient information websites which reflect the current standards of clinical practice.
PMCID: PMC3561591  PMID: 23382767
Online medical information; Internet use; Patient’s awareness; orthopaedics
11.  Breakout Session: Diversity, Cultural Competence, and Patient Trust 
The patient population served by orthopaedic surgeons is becoming increasingly more diverse, but this is not yet reflected in our workforce. As the cultural diversity of our patient population grows, we must be adept at communicating with patients of all backgrounds.
Where Are We Now?
Efforts to improve the diversity of our workforce have been successful in increasing the number of female residents, but there has been no improvement in the number of African American and Hispanic residents. There is currently no centralized effort to recruit minority and female students to the specialty of orthopaedic surgery. The American Academy of Orthopaedic Surgeons has been leading workshops to train residents and practicing surgeons in communication skills and cultural competency.
Where Do We Need to Go?
We must train the current generation of orthopaedic surgeons to become adept at interacting with patients of all backgrounds. While initiatives for crosscultural communication in orthopaedic surgery have been established, they have not yet been universally incorporated into residency training and Continuing Medical Education programs.
How Do We Get There?
We must continue to recruit the brightest students of all backgrounds, with a concerted effort to provide equal opportunities for early guidance to all trainees. Opportunities to improve diversity among orthopaedic surgeons exist at many stages in a future physician’s career path, including “shadowing” in high school and college and continuing with mentorship in medical school. Additional resources should be dedicated to teaching residents about the immediate relevancy of cultural competency, and faculty should model these proficiencies during their patient interactions.
PMCID: PMC3111788  PMID: 21264554
12.  Sources of information influencing decision-making in orthopaedic surgery - an international online survey of 1147 orthopaedic surgeons 
Manufacturers of implants and materials in the field of orthopaedics use significant amounts of funding to produce informational material to influence the decision-making process of orthopaedic surgeons with regards to choice between novel implants and techniques. It remains unclear how far orthopaedic surgeons are really influenced by the materials supplied by companies or whether other, evidence-based publications have a higher impact on their decision-making. The objective was to evaluate the subjective usefulness and usage of different sources of information upon which orthopaedic surgeons base their decisions when acquiring new implants or techniques.
We undertook an online survey of 1174 orthopaedic surgeons worldwide (of whom n = 305 were head of their department). The questionnaire included 34 items. Sequences were randomized to reduce possible bias. Questions were closed or semi-open with single or multiple answers. The usage and relevance of different sources of information when learning about and selecting orthopaedic treatments were evaluated. Orthopaedic surgeons and trainees were targeted, and were only allowed to respond once over a period of two weeks. Baseline information included country of workplace, level of experience and orthopaedic subspecialisation. The results were statistically evaluated.
Independent scientific proof had the highest influence on decisions for treatment while OEM (Original Equipment Manufacturer) driven activities like newsletters, white papers or workshops had the least impact. Comparison of answers from the three best-represented countries in this study (Germany, UK and USA) showed some significant differences: Scientific literature and congresses are significantly more important in the US than in the UK or Germany, although they are very important in all countries.
Independent and peer-reviewed sources of information are preferred by surgeons when choosing between methods and implants. Manufacturers of medical devices in orthopaedics employ a considerable workforce to inform or influence hospital managers and leading doctors with marketing activities. Our results indicate that it might be far more effective to channel at least some of these funds into peer-reviewed research projects, thereby assuring significantly higher acceptance of the related products.
PMCID: PMC3600018  PMID: 23496954
Orthopaedics; Survey; Decision-making process; Evidence-based medicine; Online evaluation; Opinion; Internet-based
13.  The Current Practice of Orthopaedic Oncology in North America 
The field of orthopaedic oncology in North America has been formalized over the past 30 years with the development of the Musculoskeletal Tumor Society (MSTS) and fellowship education opportunities.
To characterize current practices we assessed the fellowship education, practice setting, constitution of clinical practice, bone and soft tissue sarcoma treatment volume, perceived challenges and rewards of the career, and the nonclinical activities of orthopaedic oncologists.
Members of the MSTS and attendees of the 2009 AAOS–MSTS Specialty Day meeting were invited to participate in a twenty-three question online survey. One hundred and four surgeons including 99 of the 192 (52%) MSTS members completed the online survey.
Sixty-nine of the 104 (66%) responding surgeons completed a 1-year musculoskeletal oncology fellowship. Thirty-eight (37%) completed an additional orthopaedic subspecialty fellowship. Seventy-four (79%) work in an academic practice and 70 (+/− 16) % of clinical time is spent practicing musculoskeletal oncology. An average of 20 (+/− 16) bone and 40 (+/− 36) soft tissue sarcomas were treated annually. Insufficient institutional support, reimbursement, and emotional stresses were perceived as the most important challenges in a musculoskeletal oncology practice. Sixty-seven (64%) of the surgeons reported serving in a leadership position at the departmental or national level.
Professional time distribution is similar to other academic orthopaedists. The members of the MSTS are responsible for the treatment of more than two-thirds of bone and soft tissue sarcomas in the United States.
Clinical Relevance
This information can assist the fellowship directors and related professional societies in tailoring their educational programs and the interested orthopaedic resident to make a more informed career choice.
PMCID: PMC2947687  PMID: 20532714
14.  Presidential address 1998. In search of daylight 
Canadian Journal of Surgery  1999;42(4):269-273.
Practising medicine in Canada has become increasingly bureaucratic, confrontational and stressful. The Canadian Orthopaedic Association must take a far more proactive role in the development of orthopedic surgeons as professionals and in the political environment in which they practise.
Living in a “knowledge-rich workplace” orthopedic surgeons must support continuous professional development and provide leadership and incentive to maintain competence in their profession.
The “baby boomers” are coming. Their numbers will have a profound effect on the practice of orthopedic surgery, not 20 or 30 years from now but within the next 10 years. Therefore it is imperative that orthopedic surgeons assess and accept the impact that the “boomers” will have on surgeons, hospital beds and operating-room time.
Orthopedic surgeons and the Canadian Orthopaedic Association are challenged by a new role as vendors of information in a new “information age” economy, whose fundamental sources of wealth are knowledge and communication.
PMCID: PMC3788996  PMID: 10459326
15.  Aligning Incentives in Orthopaedics: Opportunities and Challenges—the Case Medical Center Experience 
For 30 years, the orthopaedic faculty at Case Western Reserve University worked as an independent private corporation within University Hospitals Case Medical Center (Hospital). However, by 2002, it became progressively obvious to our orthopaedic practice that we needed to modify our business model to better manage the healthcare regulatory changes and decreased reimbursement if we were to continue to attract and retain the best and brightest orthopaedic surgeons to our practice. In 2002, our surgeons created a new entity wholly owned by the parent corporation at the Hospital. As part of this transaction, the parties negotiated a balanced employment model designed to fully integrate the orthopaedic surgeons into the integrated delivery system that included the Hospital. This new faculty practice plan adopted a RVU-based compensation model for the physicians, with components that created incentives both for clinical practice and for academic and administrative service contributions. Over the past 5 years, aligning incentives with the Hospital has substantially increased the clinical productivity of the surgeons and has also benefited the Hospital and our patients. Furthermore, aligned incentives between surgeons and hospitals could be of substantial financial benefit to both, as Medicare moves forward with its bundled project initiative.
PMCID: PMC2745473  PMID: 19585178
16.  Healthcare Technology: Physician Collaboration in Reducing the Surgical Cost 
The increasing cost of providing health care is a national concern. Healthcare spending related to providing hospital care is one of the primary drivers of healthcare spending in the United States. Adoption of advanced medical technologies accounts for the largest percentage of growth in healthcare spending in the United States when compared with other developed countries. Within the specialty of orthopaedic surgery, a variety of implants can result in similar outcomes for patients in several areas of clinical care. However, surgeons often do not know the cost of implants used in a specific procedure or how the use of an implant or technology affects the overall cost of the episode of care.
The purposes of this study were (1) to describe physician-led processes for introduction of new surgical products and technologies; and (2) to inform physicians of potential cost savings of physician-led product contract negotiations and approval of new technology.
We performed a detailed review of the steps taken by two centers that have implemented surgeon-led programs to demonstrate responsibility in technology acquisition and product procurement decision-making.
Each program has developed a physician peer review process in technology and new product acquisition that has resulted in a substantial reduction in spending for the respective hospitals in regard to surgical implants. Implant costs have decreased between 3% and 38% using different negotiating strategies. At the same time, new product requests by physicians have been approved in greater than 90% of instances.
Hospitals need physicians to be engaged and informed in discussions concerning current and new technology and products. Surgeons can provide leadership for these efforts to reduce the cost of high-quality care.
PMCID: PMC3706644  PMID: 23404417
17.  Interprofessional Relationships between Orthopaedic and Podiatric Surgeons in the UK 
The first comprehensive report on the interprofessional relationships between foot and ankle surgeons in the UK is presented.
A questionnaire was sent to orthopaedic surgeons with membership of the British Foot and Ankle Surgery Society (BOFAS), orthopaedic surgeons not affiliated to the specialist BOFAS and podiatrists specialising in foot surgery. The questionnaire was returned by 77 (49%) of the BOFAS orthopaedic consultant surgeons, 66 (26%) of non-foot and ankle orthopaedic consultant surgeons and 99 (73%) of the podiatric surgeons.
While most respondents have experience of surgeons working in the other specialty in close geographical proximity, the majority do not believe that this has adversely affected their referral base. The experience of podiatrists of the outcomes of orthopaedic surgery has been more positive than orthopaedic surgeons of podiatric interventions. Podiatrists are more welcoming of future orthopaedic involvement in future foot and ankle services than in reverse. However, there are a sizeable number of surgeons in both professions who would like to see closer professional liaisons. The study has identified clear divisions between the professions but has highlighted areas where there is a desire from many clinicians to work more harmoniously together, such as in education, training and research.
While major concerns exist over issues such as surgery by non-registered medical practitioners and the suitable spectrum of surgery for each profession, many surgeons, in both professions, are willing to provide training for juniors in both specialties and there is a wish to have closer working relationships and common educational and research opportunities than exists at present.
PMCID: PMC2727809  PMID: 18796189
Foot and ankle surgery; Orthopaedic surgeon; Podiatric surgeon
18.  Factors That Influence Provider Selection for Elective Total Joint Arthroplasty 
The growth of consumer-directed health plans has sparked increased demand for information regarding the cost and quality of healthcare services, including total joint arthroplasty (TJA). However, the factors that influence patients’ choice of provider when pursuing elective orthopaedic care, such as TJA, are poorly understood.
We evaluated the factors patients consider when selecting an orthopaedic surgeon and hospital for TJA.
Two hundred fifty-one patients who sought treatment from either an academic or community-based orthopaedic practice for primary TJA completed a 37-item survey using a 5-point Likert scale rating (“unimportant” to “very important”) regarding seven established clinical and nonclinical dimensions of care patients considered when selecting a provider and hospital.
Patients rated physician manner (average Likert, 4.7) and physician quality (eg, outcomes) (average Likert, 4.6) as most important in their selection of surgeon and hospital for TJA. Despite the expressed importance of surgeon and hospital quality, only 46% of patients were able to find useful information to compare outcomes among surgeons, and 47% for hospitals that perform TJA.
Our findings suggest physician manner and surgical outcomes are the most important considerations for patients when choosing a provider for elective TJA. Cost sharing is the least important criterion patients considered. Patients expressed high motivation to seek out provider quality information but indicated accessible and actionable sources of information are lacking. Future efforts should be directed at developing clinically relevant, easily interpretable, objective, risk-adjusted measures of physician and hospital quality.
PMCID: PMC3706672  PMID: 23065331
19.  Current state of computer-assisted trauma surgery 
Computer assisted surgery (CAS) was first used in neurosurgery. Currently, CAS has gained popularity in several surgical disciplines including urology and abdominal surgery. In trauma and orthopaedic surgery, computer assisted systems are used for fracture reduction, planning and positioning of implants as well as the accurate implantation of hip and knee prostheses. The patient’s anatomy is virtualized and the surgical instruments integrated into the digitized image background, thus allowing the surgeon to navigate the surgical instruments and the bone in an improved, virtual visual environment. CAS improves overall accuracy, reducing intraoperative radiation exposure and minimizing unnecessary surgical dissection combined with increased patient and surgeon safety. However, limitations include prolonged surgical time, technical errors and cost implications. This article will outline the current state of computer assisted trauma surgery including its implications and specific challenges in orthopaedic trauma surgery.
PMCID: PMC3535088  PMID: 22832946
Computer assisted surgery; Navigation; Trauma; SI-screw; Femur; Femoral malrotation
20.  Isolated specialist or system integrated physician – different views on sickness certification among orthopaedic surgeons: an interview study 
Sickness certification is a frequent and sometimes problematic task for orthopaedic surgeons.
Our aim was to explore how orthopaedic surgeons view their sick-listing commission and sick-listing practice.
Semi-structured interviews with seventeen orthopaedic surgeons from five orthopaedic clinics in four Swedish counties. The focus was on the experiences of these physicians in relation to handling of sickness certification. Phenomenographic analysis was performed to reveal differences in existing views.
The orthopaedic surgeons' views on sick-listing seemed mainly to be a consequence of how they perceived their role in the healthcare system. Three categories were found: The "isolated specialists", whose work and responsibilities were confined to the orthopaedic clinic, and did not really include sickness certification; the "orthopaedic advisers", who saw themselves mainly as advice-givers in the general health care system and perceived sickness certification as part of their job; the "system-integrated physicians", who perceived the orthopaedic clinic as one part of the healthcare system and whose ultimate goal was to get the patient well functioning in her life again with regained work ability, seeing sick-listing as one of the instruments to achieve this. Some informants described difficulties in handling conflicting opinions with patients in relation to the need for sick-leave.
Orthopaedic surgeons certify a large proportion of total sickness benefits. Some orthopaedic surgeons may certify sickness benefits sub-optimally for patients and society due to a narrow view of their role in the health care system or due to poor skills in handling discordant opinions with the patient. This problem can be addressed at the level of the individual physician and at the system level.
PMCID: PMC2651137  PMID: 19105821
21.  Orthopaedic audit: one year's experience in a district general hospital. 
In 1982 a prospective Audit of complications and mortality and a quarterly retrospective analysis of work done were undertaken on the orthopaedic unit of Southmead Hospital, Bristol. Since no account has been presented of Orthopaedic Audit it was felt that a discussion of the method, results and whether the aims had been achieved and at what cost would be of interest to other surgeons, and to orthopaedic surgeons in particular. Two orthopaedic surgeons treated 1811 inpatients during the year; 73.7% of the patients undergoing surgery at Southmead Hospital were emergencies. Mortality, excluding fractures of the neck of femur, was 0.22% and total mortality 1.8%; 16.7% of patients had a recorded complication of which the largest group was technical failure (2.7%) followed by wound infection (2.4%).
PMCID: PMC2494445  PMID: 6508166
22.  Surgeon Demographics and Medical Malpractice in Adult Reconstruction 
Orthopaedic adult reconstruction subspecialists are sued for alleged medical malpractice at a rate over twice that of the physician population as a whole, and the rate appears disproportionately high in the first decade of practice. The overall risk of a malpractice claim is related to years spent in practice. After 30 years in an adult reconstruction practice, the cumulative rate of being sued at least once is over 90%. Previous investigations suggest factors such as practice setting and size, fellowship training, years in practice, volume, and location of practice correlate with malpractice risk. In contrast, we were unable to identify any relationship between the type, size, or location of practice, fellowship training, or surgery volume and the risk of an adult reconstruction surgeon being named as a defendant in a malpractice suit.
Level of Evidence: Level V, economic and decision analysis. See the Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC2628505  PMID: 18989734
23.  Gibney as Surgeon-in-Chief: The Earlier Years, 1887–1900 
HSS Journal  2006;2(2):95-101.
Dr. James Knight's death in 1887 resulted in a change of course for the Hospital for the Ruptured and Crippled (renamed the Hospital for Special Surgery in 1940). The Board of Managers appointed Dr. Virgil Pendleton Gibney as the second Surgeon-in-Chief. The hospital's professional staff was expanded with introduction of surgical procedures. Gibney, raised in Kentucky, was trained under Lewis H. Sayre, M.D., a prominent orthopaedic surgeon at Bellevue Hospital. Dr. Gibney introduced the first residency training, expanded the physical plant, and continued to care for the disabled children in the hospital while maintaining a private practice outside the hospital. He was one of the founding members of the American Orthopaedic Association and served as its first president. He was the only member ever to serve as president twice, the second time in 1912.
PMCID: PMC2488170  PMID: 18751820
Hospital for the Ruptured and Crippled; Hospital for Special Surgery; William T. Bull; William Bradley Coley; Virgil P. Gibney; John Ridlon; James Knight; Newton M. Shaffer
24.  A Clinical Practice Update on the Latest AAOS/ADA Guideline (December 2012) on Prevention of Orthopaedic Implant Infection in Dental Patients 
Journal of Dentistry  2013;14(1):49-52.
The American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association (ADA), along with 10 other academic associations and societies recently (December 2012) published their mutual clinical practice guideline “Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures.” This evidence-based guideline ,detailed in 325 pages, has three recommendations and substitutes the previous AAOS guideline. The new published clinical guideline is a protocol to prevent patients undertaking dental procedures from orthopaedic implant infection. The guideline is developed on the basis of a collaborative systematic review to provide practical advice for training clinicians, dentists and any qualified physicians who need to consider prevention of orthopaedic implant (prosthesis) infection in their patients. This systematic review found no explicit evidence of cause-and-effect relationship between dental procedures and periprosthetic joint infection (PJI).
This LTTE wishes to present a vivid summary of AAOS/ADA clinical practice guideline as a clinical update and an academic implementation to inform and assist Iranian competent clinicians and dentists in the course of their treatment decisions, to enrich the value and quality of health care on the latest international basis.
PMCID: PMC3927664  PMID: 24724118
Guideline; Prostheses and Implants; American Dental Association; Antibiotic Prophylaxis
25.  Aligning Physician and Hospital Incentives: The Approach at Hospital for Special Surgery 
Healthcare administrators and physicians alike are navigating an increasingly complex and highly regulated healthcare environment. Unlike in the past, institutions now require strong collaboration among physician and administrative leaders. As providers and managers are trained and work differently, new methods are needed to provide the infrastructure and resources necessary to create, nurture, and sustain alignment between them. We describe four initiatives by administrators and physicians at Hospital for Special Surgery to work together in mutually beneficial relationships that help us achieve the highest level of patient care, satisfaction and safety. These initiatives include improving management efficiency through an orthopaedic service line structure, helping individual physicians grow their practices through the demand-office-operating room initiative of the Physicians Service Department, controlling costs through the supply effectiveness policy, and promoting teamwork in innovation through the technology transfer program.
PMCID: PMC2745477  PMID: 19597894

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