Episode Transcript
[00:00:02] Speaker A: Welcome to your Cases on Hold. The JVGS podcast hosted by Andrew Schoenfeld and Aisha Adkeen.
[00:00:08] Speaker B: Here we discuss the best of what each issue of JBJS has to offer with the usual dose of entertainment and pop culture.
[00:00:16] Speaker A: Take us with you in the gym, on the commute, and as ever, whenever your case is on hold.
Welcome back everyone to your Case is on hold. This is episode 107. If you're listening, on the day we Release it is June 2nd.
For the June 3rd issue of JBJS, we are bringing you the best that orthopedic research has to offer and some really exciting, great insights. A lot of really good articles in this issue.
As per the usual the lawyers tell us, we have to say that the opinions that you hear are those of myself and the co host and not those of the editorial board, the other constituent editors, the board of trustees, or anybody else that works at JBJS Corporate. With that in mind, I am Andrew Schoenfeld, professor of Orthopedic Surgery and Vice Chair of Education, Harvard Medical School and as always I have with me hi
[00:01:19] Speaker B: everyone, I'm Aisha Abdeen. I'm Chief of the Division of Hip and Knee Arthroplasty at Boston Medical center and and Associate professor of Orthopedic Surgery at Boston University.
[00:01:30] Speaker A: This episode is brought to you by JB JS cme. It is literally one stop shopping for everything that you need in terms of getting your scored self assessment exams, CME developing learning plans. Get credit for what you're reading. Get credit for listening to us with these super interesting insights into the articles that are in the orthopedic space. Cash in on the effort that you're already putting in the time that you're spending with JBJS with JBGS cme. If you're not already subscribed and already participating, go to jbgs.org and check that out. I think we're good with the advertisements and the disclaimers at this point we can finally get into the content.
So we will start with Top of the Pile Sports Unites all of Us. This is by Chen and colleagues and it's permanently free.
What's new in Sports Medicine? Always love the what's new stuff. I always think it's great. This is by Al Harani and is permanently free. Then we have Enhancing Surgeon Longevity and Performance Six Lanes from Elite Athlete Optimization Applied to Surgical Leadership.
And this is by Hassan and colleagues with a highlight acl surgery in 2026. Is there a reason not to add A lateral extraarticular tenodesis. This is by Frank, the first of many ACL articles that are appearing in this issue.
Then we have Beyond Elite Performance Lessons on Health and Identity from Pablo, Insights from the former Elite Soccer player and current World Cup Winning Assistant coach of the Argentine National Team by Omar. And it's free for registered users, so make sure you're registered. From Sidelines to Specialty the Birth of Sports Medicine by Bergfeld, Malformation in Medicine by Stidham and that's permanently free. And then we have Cell Therapy by Lee, also permanently free.
Next is a novel hybrid training model for open fracture management in Rwanda and this is by Katyala, followed by Evaluation and Management of Meniscal Tears by Morgan and then another article, Multi Ligament Knee Injuries by Super.
Next we have comparison of autograft types and anterior cruciate ligament reconstruction. See, I told you there was going to be more ACL articles. A systematic review and Bayesian Network meta analysis of randomized clinical trials. This is by Vasugi and colleagues with a visual summary and it's 30 days free.
Then we have Knee Injectables in Young Athletes, Evidence Recommendations and Clinical Application by Han Tooli and Professional Athlete Redefined how to Think about the Changing Youth Sports Landscape by Paredes Barbato. That's about all about the time that we have for this episode. No, I'm just kidding.
We didn't even get into the headlines yet. What about the headlines?
Yeah, it's a jam packed issue for sure. Lots of good stuff in those.
Deservedly in the top of the pile.
[00:04:39] Speaker B: Absolutely.
[00:04:40] Speaker A: Now we are going to go into the headlines. What's new in orthopedic research this week my headline is Survivorship of Femoroacetabular Impingement Surgery at Mean Tenure Follow Up a prospective multi center cohort study. This is by Nepel and colleagues with a comment infographic and it is 30 days free. So don't just take it from me. You can read what someone else thought about it, visualize it and also read it for yourself even if you're not subscribed.
So this study is a multicenter prospective cohort of patients undergoing surgical treatment, ephemeral acetabular impingement with hip arthroscopy or open surgical hip dislocation.
It's a longer term follow up study. It was conducted at four institutions amongst six surgical practitioners and the patients were actually treated between 2008 and 2012.
The inclusion criteria is a diagnosis of out isolated CAM type or combined CAM and pincer FAI in patients indicated for primary surgery after failure of at least three months of non operative treatment.
Patients with prior ipsilateral surgery, isolated pincer type diagnosis of scfi, leg calvated perthes. None of these patients were included. The study cohort at baseline was 452 hips.
18 were excluded due to patient withdrawal and 4 due to patient demise. Unfortunately, the author's analytic plan was a Cox proportional hazards regression used to identify independent risk factors for conversion to total hip arthroplasty while controlling for age, sex, and bmi.
So have you been on where we've done the dude and the Brandt paradigm before?
[00:06:46] Speaker B: I have, yeah.
[00:06:47] Speaker A: Okay.
[00:06:47] Speaker B: Or at least I wasn't. Yeah, I was listening at that time.
[00:06:50] Speaker A: Oh, you were just an avid listener. Well, well, here's the first. You know, they had me at. We're going to do a long term follow up of patients who are treated going back to 2008 to 2012.
That's, you know, just excellent.
An epidemiologic retrospective.
And then they were like, and then we're going to do a risk. We're going to identify risk factors. It's like. No, don't say that we expressly want to identify risk factors. Mr. Lebowski asked me to say that. Exactly, that. We want to identify independent risk factors for conversion to total hip arthroplasty.
And they do this in one of the suboptimal ways, which is they basically look at P value performance in a bunch of head to head comparisons, like a tournament style sort of thing. And then we let the people advance who score highly, and then they do a, you know, basically like a stepwise elimination.
But then they say variables that have been removed were added back into the model to confirm that they were not significant.
But, but that is not really a value add or any, any kind of assurance in situations like these.
You know, they say the purpose of the current study was to determine the rate of hip survivorship. And I think that's great. I think that's what this kind of work can do.
Identifying predictors of survivorship.
I don't think you can do that as well.
One, this is a clinical retrospective. Granted. Yes. It's from four centers.
It's a small group of surgeons, and I don't know if those are the same surgeons who are even deciding whether or not these patients get hip replacements or not. Maybe in some situations they are, and in others not.
That's hard for me to determine here, but there's going to be selection indication expertise bias.
We don't know how this multicenter group was, was, you know, put together. Like is this, is this an Avengers sort of thing where you're getting, you know, independent people who are at the leading edge of their orthopedic skills, you know, that, that they come together as like a super research team or is it more like somebody's, you know, coaching tree of trainees that they're all together? My, I have several trainees, mentees who have come out of my research shop who have put together their own little research team and they, they, you know, pool data like this to do studies.
So when they're all, you know, essentially my academic progeny, that's very different than if they're all coming from independently, like different training backgrounds and different, that's really where the multi center, you know, having people who trained at one location and then now just happen to be working at different hospitals, that's a much different flavor of multi center than when it really is, you know, kind of in independent, different practice patterns and paradigms. So that's one of the things that's very hard to say from this, but it also impairs what you're going to get. The translational capacity and the generalizability of a risk factor analysis.
This is going to be unique to this data set. I'm not sure how much it applies to someone sitting in someone's office today thinking about are they going to have a hip arthroscopy surgery most likely, and we'll get to that a little bit later, but hip arthroscopy surgery most likely.
And then, you know, if that means that they're going to need a hip replacement in the future.
So, you know, what did they find at the minimum, eight year follow up, and this is the next point. 34 hips had undergone conversion to total, total hip arthroplasty. So that, you know, when you do these, especially with a Cox and a risk factor analysis in this regard, and you know, that's, that's considering time to event. But ultimately at the end of the day it breaks down to did you have a hip replacement or not? And there are 34 people who did, which means that it's only these 34 individuals that are really informing what were the characteristics of these 34 individuals? And that's what they're calling their risk factor analysis. I think a lot of the findings were probably not that surprising. Like if I was just thinking about people who may need hip arthroplasty regardless of the nature of the substrate hip fracture, Sciffy early osteoarthritis Seronegative spondyloarthritis, whatever it may be, whatever the substrate is, bmi, femoral head chondromalacia, or the extent of the involvement, age, femoral head chondromalacia was strongly associated with conversion to total hip arthroplasty.
Seven of the hips with high grade femoral head delamination or defects underwent conversion to total hip arthroplasty.
As someone who does total hip arthroplasties, which I do not in my practice, but is that surprising to you?
[00:12:25] Speaker B: It's not surprising. Right. You would expect the ones with chondromalacia, the femoral head, to have a higher incidence of, you know, being converted to a total hip replacement. I mean, you make some very good points about the methodology and I agree. I would say that, you know, it is very meaningful data in the sense it can kind of help us predict, you know, what patients are going to do well in 10 years with a hip preservation procedure versus ones that are going to fail. And, you know, they could have that division between the patients with tonus stage 2 or more osteoarthritis had a higher chance of failure and versus the patients with tonus grade 0 or 1.
I think one of the pitfalls, of course, is that when we're looking at these survival curves, we have to choose something as endpoint for failure. Right. And in this instance, endpoint for failure is a total hip replacement. But it doesn't necessarily reflect patients that were still having pain and failed that didn't go on to a total hip replacement. So we're not capturing those patients that still may have not been functioning well. So I think the one major limitation, despite having long term follow up and being conducted very well, is it would be helpful to have patient reported outcomes and some sort of functionality assessment because we're only measuring success on the basis of having a total hip replacement, assuming that the other patients are still doing well and they may not be.
[00:13:43] Speaker A: Yes, all very good points. Some additional thoughts, there's not a uniform indication across the board for all these individuals. So over older age at surgery being a risk factor for the total hip arthroplasty may just mean that they're getting to the point sooner where a surgeon is like, okay, we're going to move forward with the hip replacement versus you're going to have to tough it out. Or we're not, you know, like there could be individuals who are converting to the. It's not a, it's not an independent risk factor. It's almost like it could be a mediator or a modulator. I think, you know, those who are listening do not take this as research nihilism on my part. Mark my words very carefully. These like 10 year survival probabilities and things like that, I think you're going to see these again. This is like absolute testable information, 100%.
I think the heterogeneity and you know, they're upfront and frank about this but but the heterogeneity in terms of clinical practice and changes Open surgical dislocation was much more common in this time window than it is at this juncture and there's also not equal indications between the hip arthroscopy and the FAI and the open surgical group, meaning the open surgical group could be a much more severe state, particularly at this point, or have different clinical characteristics.
So now where hip arthroscopy is much more refined and advanced than, you know, I think it was in in this time window.
These findings, while useful and potentially informative, may not be accurately reflective of current clinical practice.
[00:15:31] Speaker B: Yeah, exactly right.
[00:15:33] Speaker A: So we are moving into the next paper which is Greater valgus alignment in pediatric and adolescent patients with a primary ACL tear compared with healthy controls by Braum and colleagues with a comment and an infographic. Take us away.
[00:15:51] Speaker B: Very good.
So the aim of this study was to determine whether pediatric patients with ACL injury have different coronal plane alignment than pediatric controls that did not sustain an ACL injury.
The premise of the study comes from data that shows that sagittal plane malalignment, specifically increased tibial slope, has been identified as a risk factor for ACL tear. So the authors were intending to determine whether coronal plane alignment also plays a role in the background. The authors cite the PLUTO study which is the pediatric ACL understanding treatment outcomes and state the limitation of the study was that their results in ACL injured patients was compared to historical normative data rather than the same pediatric population which was novel in this study.
The current study is a retrospective matched case control study of pediatric and adolescent patients with ACL rupture treated with fellowship trained pediatric sports surgeon from January 2016 to August 2025 who had EOS hip to ankle radiographs. Patients with multi ligamentous injuries were excluded as well as those lacking more than or equal to 5 degrees of extension extension which would affect coronal plane assessment.
The control group consisted of patients with similar available imaging performed for other lower extremity conditions such as leg length discrepancy or flat foot or non traumatic knee pain and were found to not have pathology that would affect alignment.
The parameters measured were hip knee angle, mechanical axis deviation, mechanical lateral distal femoral angle, medial proximal tibial angle and anatomic posterior tibial slope. The coronal plane alignment was compared between cases and controls using conditional logistic regression. Inverse odds ratios were used for MAD, hip knee angle and LDFA.
100 patients were in each group and this was needed to detect a clinically relevant difference of 2 degrees in alignment parameters.
Intra rater reliability was measured across two raters for 20 radiographs and inter rater observer. Reliability was deemed to be excellent for all parameters.
With 100 patients in the ACL tear group and 100 matched controls. The mean age in the acl group was 12.7 and 13.1 years in the controls.
Patients in the ACL group demonstrated increased valgus alignment across all four parameters of coronal plane alignment.
With regard to MAD, the differences were minus 4.1 versus 1.4 degrees and MPTA or the posterior stubble slope was 88 degrees versus 87.2. Conditional logistic regression demonstrated consistently increased odds of an ACL tear with increased valgus. Each 1 millimeter increase in MAD valgus alignment increased the odds of an ACL tear by 6%, whereas each 1% increase in hip knee angle valgus alignment increased the odds of ACL tear by 14%.
All parameters showed more valgus alignment in the ACL group than in the control group.
An additional decision stump analysis was used to identify clinically relevant threshold values for each alignment measurement. For MAD, this threshold was minus 3.5 minus indicating valgus which demonstrated the best separation and 67% of patients with more than or equal to 3.5 millimeters of valgus alignment had an ACL tear compared with 39% of patients with neutral alignment varus alignment or with less than 3.5 millimeters of valgus alignment. For the hip knee angle, a value of minus 0.5 degrees demonstrated that 60% of participants with more than 0.5 degrees of valgus alignment had an ACL tear compared with 38% of patients with neutral alignment varus alignment or less than half a degree of valgus alignment and similar valgus based thresholds were identified for both the MLDFA and the mpta, so the authors conclude that their findings reinforce previous studies suggesting the association between valgus alignment and ACL injury.
The results demonstrate that each 1% increase in hip knee angle valgus alignment increased the odds of an acl tear by 14%, which is pretty compelling.
Taking these results into account, it stands to reason that individuals with Valgus alignment may be especially vulnerable to valgus collapse and subsequent ACL injuries.
And in addition to highlighting the role of valgus alignment as a risk factor for primary ACL injury, this study provides sort of initial evidence suggesting that there may be a role for increased concomitant use of hemie epiphysioidesis with the ACL reconstruction, either unilaterally or bilaterally, in skeletally immature patients who are at elevated risk of ACL injuries.
They're saying that given that greater valgus alignment has been shown to put greater strain on the ACL graft, ultimately this potentially predisposes the graft to higher risk of rupture. Their argument is that potentially by doing these hemie epiphysioidesis that might be preventative. The authors also gave in their discussion their threshold to do one of these hemiapiphysioidesis on the ipsilateral and contralateral side based on the amount of valgus. Basically, if the valgus alignment went lateral to the tibial spine, was their threshold for doing this procedure.
The authors appropriately outlined their limitations, the primary one being that it's a retrospective study. These findings represent an association rather than causation of the deformity, the coronal plane deformity causing acl, but more of an association.
Also, the control group was not necessarily a normal group. These were patients that had come in and had full length X rays for another reason.
They might have other pathology that could have affected alignment, even though they were deemed not to necessarily have alignment abnormalities. But I think that it was the most reasonable way to ethically establish this type of study would be to have patients that have already had X rays that are full length, rather than exposing normal pediatric controls to unnecessary radiation.
I think this is a reasonable way of conducting the study.
I think it's very interesting, the concept of potentially identifying patients at risk and thinking about preventative surgery on the contralateral side.
As a mother of three kids, two of whom are girls that play soccer, you know, we're seeing a lot of kids in this age group that are sustaining ACL injuries.
I think certainly there's also that difference between, in genders between women and boys, or girls and boys. It would have been interesting to see also a subgroup analysis of their male versus female patients as well, just based on the higher risk in girls at this age having ACL injuries. But overall, I thought it was a very interesting study. I thought it was well conducted.
I'm interested to hear that, Sandra.
[00:23:02] Speaker A: Yeah, I think you covered it quite well. I don't I don't have too, too much to add. The, the one thing that really stood out to me when we get these, you know, regression results where they, they have these, you know, per millimeter or per degree incremental increase.
I always want to look at like, well, what's actually the variation that's informing that. So they're Talking about a 1 degree increase in HKA valgus alignment increases the odds of an ACL tear. But then so you look at the case group and the control group and the HKA for the HKA between the two groups is minus 1.4 on the average versus minus 0.5 degrees.
[00:23:53] Speaker B: That's a good one. I mean how do we measure that accurately?
[00:23:56] Speaker A: Yeah, that's, that's a very, the, the level of precision there is, is quite small.
There should be a 95 confidence interval around that 14.
And it, these things are never like linear because you're, you know, you're not going to have a 10 degree increase in HKA.
[00:24:19] Speaker B: Right? Exactly. There's not severe, there's going to be
[00:24:22] Speaker A: an asymptote at some point or so. These sort of things where they just, you know, they, they just interpret the regression for you and it's like it's, it's for every 1 degree increase within I think a pretty small range.
[00:24:36] Speaker B: Right, right. And I think that's where the mad comes into play as well because that's a little bit easier to reliably measure with respect to the distance from the center of the knee. Measuring that mechanical axis deviation can be a little more reliable. So you know, they did show the similar finding with that as well. But I agree with you, it's hard to measure these increments.
[00:25:00] Speaker A: So if you haven't had enough of ACLs, you're in luck because the your cases on hold featurette is drivers of labor and supply cost variation in anterior cruciate ligament reconstruction.
A multi center time driven activity based costing analysis by Munn and colleagues with a comment highlight. This is a highlight 30 days free.
So this study was multi center but I think the main center was Mass General.
So here in Boston and it includes 861 patients who underwent ACL at eight different hospitals.
And they're interested in looking at time driven activity based costing which they state and is true has emerged as a granular and transparent patient centric costing methodology.
It's a very powerful analytic technique.
It tends to work best where there's a lot of inputs on costs, including potentially hidden costs.
So for example, high acuity patients or patients with High degrees of frailty with like sepsis in the ICU or a hospital admission for sepsis. And you have the time that they're in the ICU and then the time that they're on the floor and sometimes they bounce back and there's the nursing care and the, the supply cost and the antibiotics and the doctor's time and the rehab. Right. Like all of these things, pdabc, the time driven activity based policy. I'm not sure which one takes longer to say.
That that mechanism really can unpack and show you areas of cost savings. And that's ultimately what you're trying to get at here. From a health policy, health economic econometric standpoint are the areas where they're potential savings. It doesn't translate as well to like an outpatient go procedure that it's basically just like the surgery. A short time in the PACU and we'll see you.
And you know the, the, the time based activity costing that, that I see. You know, we're talking about like episodes of care that are in the hundreds of thousands of dollars. Right. And for this procedure the average cost was 4,233.
It's very hard to like tease out where you're going to get the savings because like ultimately from a health econometric standpoint, $4,000 in and of itself is like a rounding error.
[00:28:02] Speaker B: Exactly.
[00:28:03] Speaker A: That's like three minutes in an icu.
[00:28:07] Speaker B: We're in trouble if any of these patients can go to the icu, Right?
[00:28:10] Speaker A: Well, yes. No, that is for sure. For sure. All right, so they used multivariable linear regression performed to identify drivers of cost variation, adjusting for demographics, interoperative variable, surgeon and surgical center. They also did a mixed effects model which is appropriate here because the surgeons are often going to be nested within particular facilities.
Linear regression here, for those who are avid listeners will know I don't love it when you're talking about money and dollars because that's typically non parametric and usually violates the assumptions of linear regression.
So just a caveat for those who might explore doing these type of studies going forward. So they had 861 patients, 14 hospitals. But well, it started 890 cases across 14 hospitals and then they're down to 861 across eight hospitals.
The mean patient age was 31.
I thought that was a little bit high for ACL reconstruction. But most patients underwent aperture tibial fixation at 80% and suspensory femoral fixation at 53%. That's also a problem because you know where you're going to get the variation in costs in these types of things is going to be a lot in terms of how the procedure is done or what supplies are used. So when 80% of the procedures are being done with aperture tibial fixation and more, slightly more than half are doing suspensory femoral fixation, you know, there's, there's a lot of restricted clinical variation there. And, and you know, maybe that's just again the nature of ACL reconstruction. And so we cannot fault them for that. It just reduces the, the power of the time driven activity based costing analysis.
[00:30:09] Speaker B: Right.
[00:30:11] Speaker A: So then they, they had about a quarter of the cases were done with additional procedures. Chondroplasty was the most frequently performed. And then 76% of patients received an autograph again.
So, you know, allograft is probably more expensive than autograft. And we have, you know, 22% received at purely allograft. And every small minority received hybrid grafts. So the mean cost per Procedure was about $4,200.
Supply costs are about 58%. Labor costs are about 42%.
The intraoperative phase was the greatest generator of total cost at 90%.
And so then they get into the, there's threefold variation in supply costs between the 10th percentile in terms of cost and the 90th percentile and essentially almost slightly more than 1.5 fold variation in labor costs.
But when you look at the actual numbers, so if we just look at the labor costs, if you're going from the 10th percentile in terms of cost to the 90th percentile, it's, it's $940.
It's just very, very, very small. You know, like it basically comes down to if you want to save money, don't do the acl. If you don't want to save money, then just do the ACL however you want. Because that, I think $940 is no kind of savings, especially when you're considering that that's spanning the 10th percentile in terms of cost and the 90th percentile.
So it's basically like 9, $94 per percent.
Obviously that's, that's just that kind of an average and it's not exactly reflective of that. But you get my point. Yeah, so they say that, you know, the total cost was most effectively explained by the graph type surgeon, surgery center, primary surgical status and meniscal repair. I have a problem with the meniscal repair because of course, if you do another procedure within or on top of the procedure that you're already doing, it's going to be more expensive. You're doing something else.
[00:32:27] Speaker B: Exactly.
[00:32:29] Speaker A: So you're using, you know, if only because you're using more supplies or just the amount of time that it takes. So then they get into their discussion and I really don't love this. They say no study to date has applied TDABC to acls using a large multi center cohort.
That's like appealing to authority in a way that you really shouldn't. Because like you don't do studies just because they haven't been done before. You do them because they are necessary to help inform or advance the paradigm or change the landscape or help you think differently. And there are just a lot of caveats here. And again, you know, don't at me. We read what we are given. I don't, I don't go and call, you know, call the literature to find other articles in other places that are not JB js Like I'm not even sure we're allowed to do that. But this is the JBJS podcast, of course. So you know, they say like it hasn't been done to acl, but with this caveat, using a large multi center cohort. Well, if it's been done in a single center cohort with a lot of patients, that may be just as good. You know, like these are, these are very like interesting caveats here. I'm not sure that they, one to the end user should come across as, oh, this is something better than what previously existed out there, because it very well may not be. And ultimately at the end of the day, you know, they say, they say a couple of things that I just think have to be contextualized. So first they say their findings are consistent with several other orthopedic sports medicine studies about the origins of costs. I don't think anything that they said in terms of where the costs are coming from should be surprising. Then they say hospital policymakers may consider implementing vendor consolidation strategies to reduce variability and lower supply expenditures. That's a total non sequitur that had nothing to do with this study. They don't know if that's going to necessarily work or not.
Obviously it makes sense that it would, but how exactly it would change. Again, if you, if you implement vendor consolidation, is it going to save you $300? Is it going to save you $500? I mean, there's a certain base case cost estimate for what it costs to do an ACL and they're already at 4200 with all their variation. So my guess is it's, it's probably not much lower than that.
And then they say they're talking about the proportional improvements. I thought it was interesting what they found about operative time savings of ACL with allograph did not offset with the higher implant costs associated with it. So that part is good. But then they start talking about, you know, it may be required to look at the clinical impact of these decisions and things like that, and that that's not germane to time driven activity based costing where the, like you want to pick the optimal surgery for the patient, not say we're going to try and save costs here and maybe it'll compromise the outcome.
I think they got into some, some, some murky waters there that they probably shouldn't. They kind of tread too far, I think on, on that point. At the end of the day, it's an interesting study. I think it provides some really fascinating things for people to think about. The application of TDABC in this context I think is somewhat limited.
[00:35:53] Speaker B: Agreed.
You know, it's interesting your point about their first statement about how they're the only study to look at this in a multi centered context and therefore by being novel, we should be published. I almost get the sense that authors feel the need to state that when they're submitting to a publication to sort of put yourself above the crowd and say this is new, therefore it's worthy of publications. It almost seems that's the trend that we're moving toward where we have to sort of say that we're, we're novel in order to get published. But you make a very good point.
[00:36:22] Speaker A: It is absolutely a best practice. You always want to emphasize to the editor, the reviewers, the handling deputy editor and the end user. Why do what? Why should I as the reader even care about this article? Hey folks, this is the first time that it's been done. But if you're saying it's the first time that it's been done, it should be the first time that it's being done in a way that actually advances the field.
So yes, there is some of this is best practices in terms of strategic strategy and gamesmanship in terms of like, how do you situate your people for success at a journal? And if you're just asking me as a consultant, hey, help us publish our work, I'm actually telling you find the spin on this, that this is novel, this has never been done before and that's why it should be accepted.
[00:37:09] Speaker B: Yep. I thought it was interesting that they Found that allograft versus Autograft was associated with higher costs, and that's understandable. But also that revision ACL was associated with higher costs, which we would expect. But wouldn't more ACL revisions be using allograft? And I'm not sure that they necessarily teased that out with their statistics in terms of that as a confounding factor.
[00:37:29] Speaker A: They definitely didn't because you'd have to do like an interaction analysis or something to that effect, which they didn't report that in the methods. I don't think they should have included revisions. Thanks for bringing that up because I think that really confounds and muddies some of the. They should have left the revisions out.
[00:37:46] Speaker B: Yeah, the revisions and probably the mcl. I mean, sorry, the media, the miniscule repairs as well.
[00:37:51] Speaker A: Agreed.
[00:37:53] Speaker B: And I also thought it was interesting that the cost was driven based on the surgeon. Right. And then they sort of speculate that it might be due to multiple factors, including obviously surgeon operative time, but also patient selection. That suggests that a subgroup analysis based on patient factors would have been meaningful because surgeon factors aren't patient factors. Unless you're saying it has to do with patient selection. But then patient factors are probably relevant here. They didn't delve into that too much.
They also found that cost varied depending on the hospital site.
There were eight hospitals here. They're all under the same umbrella. But it was unclear whether or not all of these hospitals are the same. Are they all academic hospitals? Were there some community hospitals? Were there some ASCs in there? I think just that finding warrants some further clarification, perhaps in the discussion to help the reader understand what setting it was in that would have driven this cost variation.
[00:38:48] Speaker A: Yeah. And certainly if it's multiple centers under the same healthcare system. Just to my analogy from earlier this episode, that's very different than multiple centers from, you know, we got Toronto and Philadelphia and St. Louis and San Diego versus. Yeah, it's multiple centers, but they're all in Boston and they're all part of Mass General, Brigham and beholden to the same.
And by the way, all the surgeons were trained by the same senior surgeon or.
All right, so that, I think, brings us to the end of this episode. No, no honorable mentions in this episode, but we'll be sure to have some of those in the next one.
Thanks for taking the time to listen to us. I thought it was a great discussion and some really interesting insights and interesting articles. So make sure you. You dig in and consume all this before you're back in two weeks. Because who are we kidding? We know you're going to be back.
Hopefully you'll be back. Thanks for taking the time. We're about out of time at this point and we'll try to do better next time.
Wherever you are, hopefully your cases are ready to go. But where we are here, even when we like the articles, the cases are still on hold.
[00:40:05] Speaker B: That's right. Thanks, everyone.
