Differences in Total Hip Arthroplasty Utilization Across Subspecialties and Practice Environments for Geriatric Displaced Femoral Neck Fractures: Secondary Analysis of Bullet Health Analysis (BHA) I
Clary J. Foote1, Chirag Soni2, Shaun P. Patel3, Derek Moore4,5, Jan P Szatkowski2,4*
1McMaster University, Hamilton, Canada
2Department of Orthopedics, Indiana University Health, Indianapolis, USA
3Department of Orthopedics, Southern California Permanente Medical Group, Irvine, USA
4Orthobullets, Santa Barbara, California, USA
5Santa Barbara Orthopedic Associates, Santa Barbara, USA
Abstract
Purpose: The growing geriatric population has led to a sharp rise in geriatric displaced femoral neck fractures (DFNF). Global reporting is pivotal in deciphering surgeons' decision-making, managing geriatric DFNF. This study aims to further analyze the nuanced utilization preferences and stratifies these across various subspecialities, practice environments, and countries.
Methods: A longitudinal survey from 2020 to 2023 was conducted online via Orthobullets Case Studies, a global orthopaedic collaboration platform, to ascertain treatment preferences for geriatric DFNF. Standardized peer-reviewed polls were used to capture surgeon preferences for total hip arthroplasty (THA). A multivariable regression analysis assessed THA utilization odds across practice environments, subspecialities, and geographic factors, followed by a robust analysis to furnish precise estimates of THA preferences to represent the general population.
Results: Among the 2606 respondents surveyed, 51.5% expressed a preference for THA. Subspecialty preferences were distributed as follows: Arthroplasty (63.4%), Trauma (53.4%), General orthopaedics (51.4%), and Sports (40.2%). Notably, hospitals exhibited a higher inclination towards THA (53.3%) compared to private practices (41.2%) (i.e. one additional THA for every seven fractures managed in a hospital setting). Regression analyses unveiled a significant 3-fold odds difference in THA rates across diverse practice environments and subspecialties. Academic arthroplasty surgeons displayed a 5.4 times higher inclination for THA (i.e. two additional THAs for every five fractures encountered).
Conclusion: Practice environment profoundly influences THA utilization for geriatric DFNF. The study findings underscore the critical need for future trials, advocating for randomized evaluations across subspecialties, geographical regions, and varied practice settings to holistically inform best practices in orthopaedic care.
Level of Evidence
Level III Surgical Practice Survey (Global Practice Trends).
Introduction
Global demographics are rapidly changing, with projections anticipating a doubling in the population aged 65 or older by 2030 compared to 20191. This shift coincides with a notable increase in disabilities among older adults, especially in terms of physical limitations2. Hip fractures, displaced femoral neck fractures (DFNF) in particular, have surged sevenfold since 1990, exceeding previous forecasts3. World Health Organization (WHO) and United Nations (UN) data highlight two key trends: a steep rise in individuals aged 65 and older and associated increase in life expectancy for those with chronic diseases among geriatric populations4.
Despite the growing aging population, effectively managing DFNFs in patients over 60, remains a challenge. Clinical trials favour arthroplasty, yet a debate persists regarding the efficacy of total hip arthroplasty (THA) versus hemiarthroplasty (HA)5. Understanding orthopedic surgeons' preferences for THA in displaced femoral neck fractures among older patients is crucial for several reasons. Global reporting provides insights into geographical variations of these determinants and serves as a foundation for refining evidence tailored to diverse subspecialties, regions, and practice settings. This data also informs innovative trial designs by integrating "higher-order factors" beyond patient characteristics for context-specific outcomes.
The impact of surgeon- and practice-related factors on the choice of arthroplasty globally remains uncertain. Discerning these factors are important to understand practice patterns that are not commonly analyzed in larger clinical trials, especially given the increased incidence of DFNF and variation in treatment options. In response, the Worldwide Orthopaedic Research Collaboration: Leveraging Big Data (WOLRD) initiated a global survey to understand determinants of surgical management for DFNF in a series titled Bullet Health Analysis (BHA). In the first series, BHA I reported that there is a significant increase in THA utilization and a predominance of cement femoral fixation in the United Kingdom6. Increases in THA preference may stem from recent literature reporting that THA may not have greater rates of morbidity and secondary operations as previously thought5. In a continuation of the BHA series, we present BHA II conducted to furnish precise estimates establishing representativeness compared to the overall respondent pool, supported by 95% confidence intervals, delineating surgeon preferences for THA in geriatric DFNF. This analysis offers detailed insights across various subspecialties and practice environments, illuminating THA preferences in diverse settings for each subspecialty.
Materials and Methods
Survey Development
In 2020, a team of orthopaedic surgeons from various specialities designed a thorough survey to explore treatment preferences for geriatric DFNF among orthopedic professionals. This case-based questionnaire, accredited for Continuing Medical Education (CME), was distributed through Orthobullets, an online global orthopedic education platform with 200,000 members.
The survey methodology centers around clinical cases preceding surveys. The inclusion of clinical cases ahead of the survey optimizes surgeon recall of similar cases facilitating more focused responses within a familiar clinical context. Orthobullets.com has a team dedicated of content and methodological experts with various specialized orthopaedic backgrounds deploying surveys pertaining a wide range of topics in orthopaedic practice.
The survey featured a scenario of a Garden IV DFNF in an elderly patient who was previously an ambulatory community member followed by a 13-item questionnaire. The adjunct survey accompanying the clinical scenario covered diagnostics, preventive strategies, intervention timing, and surgical management preferences of DFNF in patients similar in age and functional status to the patient mentioned in the clinical scenario. The survey also collected detailed demographic data, including country, practice type, subspecialty, and practice environment. The full survey can be found in Appendix 1.
Survey Administration
The survey was available online from April 2020 until June 2023, presenting the aforementioned clinical case to orthopedic professionals. Distribution occurred via email to members of the education platform. Extensive outreach efforts were undertaken across social media channels to stimulate participation. Robust measures were implemented to safeguard data integrity throughout the survey.
Before the survey, we introduced a detailed clinical case featuring an elderly, active-smoking woman. This case included socio-demographic data and three radiographs (Figures 1A to 1D). Presenting this case before the survey, as per established evidence-based practices, aimed to enhance memory recall among respondents. This approach aids in recalling clinical cases and decision-making processes, especially concerning geriatric displaced femoral neck fractures7.
Figure 1A: Anteroposterior Radiograph Pre-Survey Clinical Case Presentation
This anteroposterior radiograph illustrates the clinical scenario of a 76-year-old female smoker who experienced a mechanical fall. She was an active community ambulator and had a history of ambulation. These radiographs were provided before surveying geriatric displaced femoral neck fractures
Figure 1B: Supplementary Right Hip Anteroposterior Radiograph
This dedicated right hip anteroposterior radiograph was included in the clinical case provided to respondents before the survey for reference.
Figure 1C: Supplementary Cross-Table Lateral Radiograph
Additional cross-table lateral radiographs were included within the clinical case for respondents' reference before the survey. This image allowed surgeons to evaluate the tilt of the femoral neck and head in the sagittal plane.
Figure 1D: Supplementary Post-operative Anteroposterior Radiograph
This anteroposterior radiograph illustrates the treatment method used in this specific clinical scenario.
Data Verification
To address the potential sampling bias given that the Orthobullets platform is widely used by orthopaedic residents and fellows, only responses from validated practicing surgeons were included in the analysis. A comprehensive multimodal data algorithm was utilized to validate physicians to ensure data integrity. The algorithm consisted of the following criteria: national provider identifier (NPI) number, Pubmed publications, medial school attended, year of graduation, affiliation with academic institutions, assessment of years in practice, social media mapping for professional networking, and purchase history related to medical education resources. These measures were taken to mitigate risk of false data provided in survey responses. These methods strengthened reliability and validity of the data used in the analysis to the best of the authors ability.
Primary and Secondary Outcomes
Primary Outcome
- Comparative assessment of THA utilization between hospital based and private practice environments.
Secondary Outcomes
- Calculate predicted percentages with 95% confidence intervals for respondents to establish representativeness of respondents within subspeciality (General, Sports, Trauma, and Arthroplasty) and practice environment respondent pool.
- Perform meta-analytic comparisons of THA utilization rates between hospital-based and private practice settings for each subspeciality to assess overall heterogeneity.
- Analyze difference in odds, with 95% confidence intervals, in choosing THA between arthroplasty and non-arthroplasty surgeons.
- Evaluate heterogeneity across countries in rates of surgeon favouring THA for each subspeciality.
- Conduct multivariable regression analysis to determine percentage difference in THA preference associated with specific subspecialties and countries to assess independent influences of geography and subspeciality on THA utilization.
Statistical Analysis
We estimated THA utilization rates across various subspecialties and practice environments, furnishing nuanced estimates for selected countries. Primary analyses compared hospital-based settings with private practices, generating odds ratios. Subgroup analyses delved into comparisons across major orthopedic subspecialties, while regression analyses scrutinized the impact of geographical factors and subspecialties on THA utilization rates.
The study utilized multivariable Bayesian regression to analyze Total Hip Arthroplasty (THA) rates, complemented by metaregression (THA Rates) and multivariable logistic regression using individual surgeon data. Additional model specifics are detailed in Appendices 1.0 and 2.0. Model significance was determined by overall p-values adhering to conventional statistical thresholds (p≤0.05 for frequentist models). Credible intervals were reported for Bayesian models, consistent with accepted statistical standards, ensuring representativeness through percentage meta-analysis. All statistical tests were two-tailed, with significance set at 0.05. Supplementary materials containing additional methodological details, forest plots, and graphical representations of primary analyses are available in Appendices 1.0 and 2.0.
GRADE Approach to Survey Reporting
We employed the GRADE approach to report the findings of this study8 . Further details regarding the results of the GRADE process can be found in Table 1, in the supplementary material.
Results
Characteristics of Respondents
Of the 2606 respondents, 2392 (91.8%) disclosed their subspecialization during registration, accounting for 62.9% to 74.8% of survey viewers. Among these, 1752 (74.3%) categorized themselves as generalists while 615 (25.7%) specified a subspeciality. Additionally, 1056 (44.7%) revealed their practice environment, which was distributed across academic hospitals (12.1%), non-university affiliated hospitals (34.3%), or private practices (53.6%). The respondents’ geographic distribution was as follows: 38.8% from North America, 32.1% from Europe, 10.8% from Asia, 7.0% from the Middle East, 2.3% from Africa, 2.3% from Latin America.
Impact of Practice Environment on THA Preference
The weighted percentage of THA preference among respondents specifying their practice environment was 48.7% (95% CI 39.9 to 57.5%), suggesting representation of the entire cohort (51.5%, 95% CI 49.6 to 53.4%). Large hospital systems favoured THA 53.3% of the time (95% CI 49.6 to 57.0%), while private practice leaned towards HA, with 41.2% favouring THA (95% CI 36.1 to 46.2%) (Difference: 13.3%, 95% CI 8.0 to 18.6%, p<0.001). Comparative analysis showed 1.69-fold higher odds of preferring THA in large hospital environments versus private practice (OR 1.69, 95% CI 1.31 to 2.17, p<0.001).
Visual representations in Figure 2 exhibit THA preferences by subspecialty across large hospital-based systems and private practice, highlighting preference variations. Figure 3, a Forest plot, demonstrates the meta-analytic aggregate rate of THA preference within subspecialties and practice environments. Significant conclusions should be drawn from comparative odds ratio estimates in Figure 2 rather than heterogeneity tests in Figure 3 as detailed by the internal validity and validation analyses in BHA Appendix 2.
Figure 2: Diagram Illustrating Surgeon Preferences for THA Across Subspecialties and Practice Types
This diagram displays the proportions of respondents who chose THA, categorized by practice type (Hospital-based vs. Private Practice). The legend indicates the corresponding odds ratios with 95% confidence intervals derived from hospital-based versus private practice comparisons for each subspecialty. Across subspecialties, hospital-based surgeons preferred THA more in geriatric displaced femoral neck fractures. Generally, hospital-based surgeons had 1.7 times higher odds of preferring THA than private practice surgeons (OR 1.69, 95% CI 1.31 to 2.17, p<0.001). Error bars represent 95% confidence intervals of the proportion. *p<0.05
Figure 3: Forest Plot Depicting THA Preferences by Subspecialty
This forest plot illustrates proportions choosing total hip arthroplasty (THA) with 95% confidence intervals (CI), substratified by subspecialty. Estimates for hospital-based systems (academic and non-university large hospitals) and private practice are provided for each subspecialty, along with meta-analytic aggregate estimates. Statistical significance can be inferred from 95% CI (overlap between estimates) and p-values for heterogeneity.
Variation in Total Hip Arthroplasty Use Among Subspecialties
Among respondents reporting their subspecialty, the weighted preference for THA was 52.3% (95% CI 45.2 to 59.3%), aligning with the overall respondent pool (51.5%, 95% CI 49.6 to 53.4%), confirming representativeness. Subspecialty-wise THA preferences were: arthroplasty 63.4% (95% CI 56.7 to 70.0%), trauma 53.4% (95% CI 47.2 to 59.6%), general orthopaedic surgery 51.4% (95% CI 49.1 to 53.7%), and sports 40.2% (95% CI 32.6 to 47.9%) (p<0.001). A subgroup meta-analysis for arthroplasty versus non-arthroplasty surgeons showed THA utilization rates of 63.4% (95% CI 56.7 to 70.0%) versus 49.1% (95% CI 42.9 to 59.3%, Test for Heterogeneity: p<0.001). A meta-analysis of surgeons who had a practice type resulted in similar THA rates with an analogous gradient of utilization across subspecialties (Figure 3).
Raw analysis (i.e. count approach) of THA rates between arthroplasty and non-arthroplasty surgeons resulted in a 12.7% higher THA preference (95% CI 5.1 to 20.3%, p=0.001) among joint specialists (OR 1.67, 95% CI 1.24 to 2.26, p=0.001). Meta-analytic subgroup analysis demonstrated arthroplasty subspecialization was associated with a 14.3% increment in the THA rate (95% CI 7.1 to 21.5%, p<0.001). Unadjusted simple metaregression provided a slightly more modest estimate than subgroup analysis in favour of arthroplasty surgeons (13.6% higher THA, 95% CI 4.4 to 22.9%, p=0.004). Yet, after adjusting for practice type, the arthroplasty subspecialty showed a 19.8% increase in THA utilization (95% CI 8.3 to 31.2%, p<0.001). Academic arthroplasty surgeons were 5.4 times more inclined towards THA than private sports surgeons (95% CI 2.09 to 14.2, p=0.001).
We conducted a multivariable binary logistic regression analysis involving practice type and subspecialty, with an interaction term between these covariates. The findings revealed a threefold increase in the THA rate for hospital-based arthroplasty specialists compared to non-arthroplasty surgeons in private practice (OR 3.13, 95% CI 1.76 to 5.57, p<0.001).
The interaction term generated nuanced THA rates, demonstrating a gradient of increasing utilization correlated with hospital-based practice and arthroplasty specialization. In hospital based settings, arthroplasty specialities demonstrated an increased estimated THA rate compared to non-arthroplasty based specialities, 67.3% (95% CI: 58.0% - 75.4%) versus 52.8% (95% CI: 48.3% - 57.2%), respectively. In private practice settings arthroplasty based specialities demonstrated an increased estimated THA rate compared to non-arthroplasty based specialities, 52.0% (95% CI: 38.3% - 65.4%) versus 39.6% (95% CI: 33.8% - 45.7%) respectively.
Geographic Impact of THA Utilization
Survey analysis demonstrated notable variations in THA preferences across subspecialties. Arthroplasty-trained surgeons displayed minor variation (I2=0%, p=0.91) across countries including the US, UK, Canada, Australia, and India, whereas generalists (I2=50.3%) and traumatologists (I2=85.3%) showed substantial variability in THA preferences among the analyzed countries (US, UK, Canada, Australia, India, Germany). Figure 4 presents meta-analytic estimates showcasing THA utilization rates across selected countries. Subsequent Bayesian multivariable regression analysis, as detailed in Table 2 (adjusting for geographic status), revealed significant associations between subspecialization and THA utilization. Arthroplasty specialization showed a notable 22.4% increase in THA utilization (95% CrI 18.7 to 26.1%) compared to traumatologists.
Figure 4: Proportions Preferring THA in the United States and Selected Countries
This figure displays the proportions with 95% confidence intervals (CI) of respondents from the United States and other selected countries who preferred THA.
Orthopaedic trauma specialists formed the baseline THA rate of 37.4% (Crl 33.4 to 41.3). When we adjusted the Bayesian model to group all non-arthroplasty specialties (Sports, Trauma, and General Orthopaedics), arthroplasty surgeons exhibited a 21.4% higher THA rate (95% CrI 18.3 to 24.5%), akin to the results when traumatologists were the reference group in the principal Bayesian model.
Adjusted THA rates for non-arthroplasty and arthroplasty surgeons were derived from the Bayesian model. A percentage odds estimate and 95% confidence interval were calculated to clarify the observed THA rate discrepancy. Arthroplasty specialists exhibited a 2.4-fold higher THA utilization rate than non-arthroplasty surgeons (OR 2.39, 95% CI 1.54-3.7, p<0.001).
Notably, the United Kingdom and Australia demonstrated higher THA frequencies than the United States, performing approximately one additional THA per five cases. Conversely, Canada tended to perform THA less frequently, with roughly one less THA per ten cases. Other countries showed THA preferences similar to the baseline.
The frequentist analysis in the Appendix yielded a p-value of <0.001, signifying statistical significance. The Bayesian model used credible intervals instead of p-values, aligning with the robustness of the Bayesian approach. The credible intervals, as shown above and reported in Table 2, corroborated the findings obtained from the frequentist model.
Discussion
Hip fractures place a significant burden upon the healthcare system. Clinical trials favour arthroplasty opposed to open reduction internal fixation as studies have shown an increase in revision rates establishing arthroplasty as the standard of treatment9,10. Consensus regarding optimal arthroplasty choice is more limited. In a meta-analysis by Migliorini et al., it was reported that trials with less than five years of follow up reported reduced revision in favour of HA while trials with greater than five years of follow up revealed reduced revisions for THA11. This can potentially be explained by the progression of acetabular erosion in HA requiring conversions to THA which would be increased in patients with greater follow up12. While previous studies have reported an increased dislocation rates with THA, more recent studies such as the HEALTH trial reported no significant difference in unplanned revision procedures between THA and HA5,11. Studies analyzing function are more limited as follow up is heterogenous. The HOPE trial reported no difference in hip function, health related quality of life, reoperations, pain, and activities of daily living with an endpoint of 2 years13. Consequently, there is controversy regarding the optimal treatment option, and limited research surveying current practice patterns.
The BHA Project, encompassing 2,500+ respondents from 76 nations, illuminates insights into geriatric DFNFs. Notably, hospital-based practice substantially boosts THA preference by 1.7-fold, translating to one additional THA per seven fractures (p<0.001). Subgroup analyses exhibit a notable impact of hospital-based environments on specific subspecialties, increasing THA utilization by up to 2.5 times (p=0.006). Regression analysis reveals a three-fold variation in THA likelihood across practice types and subspecialties (p<0.001). Arthroplasty surgeons consistently favour THA across regions. Arthroplasty specialization increases THA usage by 23.3% (p<0.001), equating to one more THA per four fractures compared to traumatologists (p<0.001). Adjusted models demonstrate Canadian respondents were less inclined to perform THA, indicating one less THA performed per ten cases similar to the findings reported by Tohidi et al.14. On the contrary, respondents from the UK and Australia demonstrated an increased likelihood of THA, performing an additional THA in every five cases (p<0.001). Other nations exhibited comparable THA utilization rates.
Implications & Factors Influencing Variation in Surgical Decision-making
Findings suggest potential expansion of THA indications with notable variations across subspecialties and practice settings. Recent trials (e.g HEALTH Trial5) hint at improved post-arthroplasty outcomes, potentially expanding THA indications13,15. Variations in THA utilization across subspecialties and practice settings might relate to diverse patient and surgeon factors not analyzed in this study. Tohidi et al. reported surgeon volume of THA procedure in the 365 prior to surgery as the strongest predictor THA preference along with patient factors such as younger age, male sex, and diagnosis of rheumatoid arthritis16. Extensive survey studies are crucial for understanding how practice factors influence THA utilization14. This study demonstrates that hospital-based surgeons consistently demonstate higher inclincation towards THA (OR 1.68, p=0.001) across various subspecialities, even among non-arthroplasty specialists like sports surgeons. The increase in THA utilization in hospital-based settings may be attributed to enhanced protocols, perioperative care, and increased availability of resources that is present in hospital based settings. Conducting comprehensive outcome studies and randomized subgroup analyses can provide more precise estimates.
Several factors contribute to the wide variability in surgical decision-making for geriatric DFNF. Surgeon preference for THA can be driven by familiarity and comfort with the procedure, likely influenced by established habits or perceived efficiency14. Additionally, the distribution of patients allocated among subspecialities within hospital systems can lead to homogenous case mix, further influencing surgical decision making14. Surgeons who routinely perform THA may likely favor THA and similarly those with limited experience with THA may have bias towards HA. Educational training, experience, and initiatives also plays a substantial role in current practice16,17. Resource availability- such as operating room space, staff, and prosthesis availability- can also influence procedural choices18-20. Other considerations include perceived lower complication rates with THA, varied approach preferences, intraoperative assessment abilities and the capacity to handle adverse events with either procedure14,21-26. While much of the current literature investigates patient specific characteristics in relation to outcomes, this study highlights the importance of integrating and potentially adjusting for surgeon specific factors such as practice type and location.
Amidst the controversy between THA and HA, diverse interpretations of the available literature further complicate decision making. As Hubruck et al. noted, while the majority of global hip fractures occur in Asia, most of the evidence forming guidelines come from Western studies27. These complexities underscore the necessity for ongoing, high-quality research to navigate surgical decisions in geriatric DFNF. This study highlights the importance of obtaining accurate global data to analyze treatment variations and associated factors such as practice type and subspeciality. This data can assist with advancing future study methodologies to tailor evidence to various subspecialties, geographic regions, and practice settings.
Limitations & Future Directions
While our survey addressed the clinical scenario of geriatric DFNF, numerous unaccounted variables could influence surgeons' choices beyond the study's scope. Factors such as preoperative patient condition, hematological parameters, presentation timing, operating room logistics, staffing, and specific hospital protocols are vital considerations that were not fully captured.
Although our survey noted surgeons' anticipated timing for surgery, a comprehensive analysis linking this information to arthroplasty choices will be a focus of future investigations.
It's essential to recognize that our study had a global reach, predominantly capturing responses from high-income or upper-middle-income countries per the World Health Organization's classification. However, the data from low-income countries were limited, and there might have been selective reporting in lower-middle-income countries. Additionally, some upper-middle-income countries might have been underrepresented due to surgeons' varying engagement in continuing medical education.
Future surveys should incentivize responses to bridge these gaps and contribute to more informed surgical decision-making across all global clinical contexts. This study demonstrated management preferences are dependent on practice setting. Many current guidelines are formed from interpretation of randomized controlled trials of conducted in large academic hospitals, which may not be representative for those practicing in smaller community based private practices. Future trials should acknowledge these practice differences. Addressing these gaps is crucial for enhancing surgical choices and optimizing outcomes, and engaging surgeons through survey practices before trial enrollment could be beneficial. Hence, survey-based and trial-based studies are imperative for advancing orthopedics in diverse clinical settings worldwide. Additional studies surrounding surgical management preferences should be focused to encompass surgical populations not commonly represented whether that be in low resource populations or private practice communities.
Conclusion
A nearly three-fold discrepancy exists in the propensity to prefer THA for geriatric DFNF across subspecialties and practice environments. Extensive global surveys and future large randomized controlled trials can help understand these differences' underlying factors. These efforts should consider randomization strategies for stratified analyses, explaining heterogeneous estimates from previous data, and enhancing training, education, and quality improvement initiatives for specific practice systems.
Declarations
Funding
This research was entirely self-funded with no external financial support.
Financial Interests
The authors declare they have no financial interest in this manuscript. Jan Szatkowski and Derek Moore have ownership (stock) in Orthobullets.com. No honoraria unrelated to this project or any content in this manuscript was received.
Non-Financial Interests
DM is the Chief Executive Officer and Founder of OrthoBullets. JS is a managing editor of OrthoBullets.
Proper Credit
Proper credit has been given to all cited sources, ensuring transparency and academic integrity.
Ethics Approval
We confirm that we meticulously adhered to all ethical requirements, particularly in the proprietary utilization of data collected by Orthobullets. The investigation was conducted at Orthobullets in Santa Barbara, California, USA, and Ontario, Canada.
Informed Consent
Informed consent was diligently obtained from all study participants, entirely in compliance with ethical standards.
Consent for Publication
All authors wholeheartedly endorse the publication of this manuscript in the Journal of Orthopedics and Orthopedic Surgery.
Availability of Data and Materials
We are ready to provide the data used in this study or conduct additional analyses when you'd like.
Code Availability
This study's software applications or custom code are accessible upon request.
Authors' Contributions
All authors contributed significantly to this work. The survey development, research project design, and manuscript preparation were collaborative efforts involving all authors. Jan Szatkowski, Derek Moore, and Shaun Patel performed material preparation and data collection. C.J. Foote conducted the analyses, regularly consulting and editing with Jan Szatkowski. The initial manuscript draft was composed by C.J. Foote and edited by Chirag Soni. All authors offering valuable insights on earlier versions. The final manuscript underwent review and approval by all authors.
Acknowledgements
We would like to express our gratitude to the members of the Orthobullets Specialty Group, who provided valuable input during the survey's development and offered constructive comments on the survey message board. These contributions formed the basis of the qualitative analysis for this project.
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