Telemedicine in orthopaedics and its potential applications during COVID-19 and beyond: A systematic review

Introduction

Telemedicine is the delivery of healthcare across a distance using some form of communication technology. The COVID-19 pandemic has led to increased adoption of telemedicine with national orthopaedic governing bodies advocating its use, as evidence suggests that social distancing maybe necessary until 2022. This systematic review aims to explore evidence for telemedicine in orthopaedics to determine its advantages, validity, effectiveness and utilisation.

Methods

Databases of PubMed, Web of Science, Scopus and CINAHL were systematically searched and articles were included if they involved any form of telephone or video consultation in an orthopaedic population. Findings were synthesised into four themes: patient/clinician satisfaction, accuracy and validity of examination, safety and patient outcomes and cost effectiveness. Quality assessment was undertaken using Cochrane and Joanna Briggs Institute appraisal tools.

Results

Twenty-one studies were included consisting of nine randomised controlled trials (RCTs). Studies revealed high patient satisfaction with telemedicine for convenience, less waiting and travelling time. Telemedicine was cost effective particularly if patients had to travel long distances, required hospital transport or time off work. No clinically significant differences were found in patient examination nor measurement of patient-reported outcome measures. Telemedicine was reported to be a safe method of consultation.

Discussion

Evidence suggests that telemedicine in orthopaedics can be safe, cost effective, valid in clinical assessment and with high patient/clinician satisfaction. However, more high-quality RCTs are required to elucidate long-term outcomes. This systematic review presents up-to-date evidence on the use of telemedicine and provides data for organisations considering its use during the COVID-19 pandemic and beyond.

Life-Threatening, Bleeding Pseudoaneurysm of the External Iliac Artery in the Setting of an Infected Total Hip Arthroplasty from Pasteurella multocida

We present a bleeding, infected (mycotic) pseudoaneurysm from the organism Pasteurella multocida. The patient presented septic from an infected total hip arthroplasty and was treated with surgical debridement, component retention, and antibiotics. She re-presented with hip pain and a marked hemoglobin decrease. Vascular studies revealed a pseudoaneurysm of the external iliac artery and large hematoma secondary to contiguous spread of her hip infection. The pseudoaneurysm was treated with an endovascular stent before further debridement surgery to avoid exsanguinating hemorrhage with surgical release of her tamponade. This case demonstrates the utmost importance of recognizing and treating vascular pathology in a patient with an infected prosthetic hip, large hematoma, and decreased hemoglobin.

Does Lowering Hemoglobin A1c Reduce Penile Prosthesis Infection: A Systematic Review

INTRODUCTION

Hemoglobin A1c (HbA1c), a glycated form of hemoglobin, develops when glucose is elevated in the blood. It is used as a marker of how well a diabetic patient has been controlling their blood sugar over the previous 3-4 months. Some use HbA1c as a predictor of infection risk during prosthetic surgery, and many surgeons require patients to lower it preoperatively.

OBJECTIVE

This study was designed to comprehensively review the literature relating HbA1c and penile prosthesis (PP).

METHODS

A PubMed search of English-language articles identified studies that investigate the relationship between HbA1c levels and PP infection. Studies were only included if they reported the mean HbA1c of all PP patients and compared patients who did/did not develop a prosthetic infection. References from relevant articles are included.

RESULTS

A total of 6 studies, 1992-2020, were identified. 2 studies occurred before the advent of antibiotic-enhanced devices in the early 2000s and have limited applicability to the modern era. Of the 4 studies published after, 2 reported a significant difference in mean HbA1c when comparing patients who developed a prosthetic infection and those who did not (9.1% vs 7.5%, P = .000 and 9.5% vs 7.8%, P < .001). The other 2 studies reported no significant difference in mean HbA1c when comparing patients who developed a prosthetic infection and those who did not (7.0% vs 7.6%, P > .05; and 7.6% vs 7.5%, P = .598).

CONCLUSION

Current data regarding HbA1c as a predictor of PP infection are inconclusive, with no consensus. HbA1c is increasingly used as a predictor of postsurgical prosthetic infection, with some urologists requiring patients with elevated HbA1c to acutely lower it before elective surgery. While there are a number of established health benefits of controlling elevated blood sugar, larger randomized controlled trials need to validate whether acutely lowering perioperative HbA1c decreases risk of prosthetic infection. Dick BP, Yousif A, Raheem O, et al. Does Lowering Hemoglobin A1c Reduce Penile Prosthesis Infection: A Systematic Review. Sex Med Rev 2021;9:628-635.

Leveraging subject-specific musculoskeletal modeling to assess effect of anterior cruciate ligament retaining total knee arthroplasty during walking gait

Bi-cruciate retaining total knee arthroplasty has several potential advantages including improved anteroposterior knee stability compared to contemporary posterior cruciate-retaining total knee arthroplasty. However, few studies have explored whether there is significant differences of knee biomechanics following bi-cruciate retaining total knee arthroplasty compared to posterior cruciate-retaining total knee arthroplasty. In the present study, subject-specific lower extremity musculoskeletal multi-body dynamics models for bi-cruciate retaining, bi-cruciate retaining without anterior cruciate ligament, and posterior cruciate-retaining total knee arthroplasty were developed based on the musculoskeletal modeling framework using force-dependent kinematics method and validated against in vivo telemetric data. The experiment data of two subjects who underwent total knee arthroplasty were obtained for the SimTK “Grand Challenge Competition” repository, and integrated into the musculoskeletal model. Five walking gait trials for each subject were used as partial inputs for the model to predict the knee biomechanics for bi-cruciate retaining, bi-cruciate retaining without anterior cruciate ligament, and posterior cruciate-retaining total knee arthroplasty. The results revealed significantly greater range of anterior/posterior tibiofemoral translation, and significantly more posterior tibial location during the early phase of gait and more anterior tibial location during the late phase of gait were found in bi-cruciate retaining total knee arthroplasty without anterior cruciate ligament when compared to the bi-cruciate retaining total knee arthroplasty. No significant differences in tibiofemoral contact forces, rotations, translations, and ligament forces between bi-cruciate retaining and posterior cruciate-retaining total knee arthroplasty during normal walking gait, albeit slight differences in range of tibiofemoral internal/external rotation and anterior/posterior translation were observed. The present study revealed that anterior cruciate ligament retention has a positive effect on restoring normal knee kinematics in bi-cruciate retaining total knee arthroplasty. Preservation of anterior cruciate ligament in total knee arthroplasty and knee implant designs interplay each other and both contribute to restoring normal knee kinematics in different types of total knee arthroplasty. Further evaluation of more demanding activities and subject data from patients with bi-cruciate retaining and posterior cruciate-retaining total knee arthroplasty via musculoskeletal modeling may better highlight the role of the anterior cruciate ligament and its stabilizing influence.

How to predict early clinical outcomes and evaluate the quality of primary total knee arthroplasty: a new scoring system based on lower-extremity angles of alignment

Background

A method that can accurately predict the outcome of surgery can give patients timely feedback. In addition, to some extent, an objective evaluation method can help the surgeon quickly summarize the patient’s surgical experience and lessen dependence on the long wait for follow-up results. However, there was still no precise tool to predict clinical outcomes of total knee arthroplasty (TKA). This study aimed to develop a scoring system to predict clinical results of TKA and then grade the quality of TKA.

Methods

We retrospectively reviewed 98 primary TKAs performed between April 2013 and March 2017 to determine predictors of clinical outcomes among lower-extremity angles of alignment. Applying multivariable linear-regression analysis, we built Models (i) and (ii) to predict detailed clinical outcomes which were evaluated using the Knee Society Score (KSS). Multivariable logistic-regression analysis was used to establish Model (iii) to predict probability of getting a good clinical outcome (PGGCO) which was evaluated by Knee Injury and Osteoarthritis Outcome Score (KOOS) score. Finally, we designed a new scoring system consisting of 3 prediction models and presented a method of grading TKA quality. Thirty primary TKAs between April and December 2017 were enrolled for external validation.

Results

We set up a scoring system consisting of 3 models. The interpretations of Model (i) and (ii) were good (R² = 0.756 and 0.764, respectively). Model (iii) displayed good discrimination, with an area under the curve (AUC) of 0.936, and good calibration according to the calibration curve. Quality of surgery was stratified as follows: “A” = PGGCO ≥0.8, “B” = PGGCO ≤0.6 but < 0.8, and “C” = PGGCO < 0.6. The scoring system performed well in external validation.

Conclusions

This study first developed a validated, evidence-based scoring system based on lower-extremity angles of alignment to predict early clinical outcomes and to objectively evaluate the quality of TKA.

Intraarticular vancomycin powder is effective in preventing infections following total hip and knee arthroplasty

Locally applied vancomycin is increasingly being used in primary hip and knee arthroplasty to reduce the risk of infection. Despite encouraging initial results, considerable debate remains on the basis of the data currently available. In particular, it has been unclear up to now whether local vancomycin is suitable to further reduce the risk of infection even if the rate of infection is already low (< 1%). In this monocentric retrospective cohort study, all primary total hip and knee arthroplasties performed between 2013 and 2018 were included. After a change in procedure at the hospital, 1 g vancomycin powder was applied intraarticularly before wound closure. The remaining perioperative procedure was constant over the investigation period. The follow-up was one year. The presence of an infection according to the currently valid MSIS criteria was defined as the endpoint. In patients with TKA two infections (0.3%) were observed under vancomycin prophylaxis in contrast to 44 infections (1.3%) in the control group (p = 0.033). In patients with THA two infections (0.5%) were observed under vancomycin prophylaxis and 48 infections (1.1%) in the control group without local vancomycin but this difference was statistically not significant. No wound complications requiring revision were observed as a result of the vancomycin. On the basis of the results of this study, intraarticular application of vancomycin powder in total hip and knee arthroplasty may be considered. Prospective randomized studies have to confirm this promising results prior a common recommendation.Level of Evidence III Retrospective cohort study.

Implant positioning among the surgical approaches for total hip arthroplasty: a Bayesian network meta-analysis

INTRODUCTION

Although there is anatomical individuality among patients, some standardized requirements for component orientation for total hip arthroplasty (THA) exist. To date, no study has compared implant positioning using a network meta-analysis (NMA). Hence, the purpose of this study was to perform a NMA comparing implant positioning among the various approaches for THA.

METHODS

This study was conducted according to the PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions. All randomized (RCT) and non-randomized (nRCT) clinical trials comparing two or more different approaches for THA were considered for inclusion. For the statistical analysis, the STATA Software/ MP, Version 14.1 (Stata Corporation, College Station, Texas, USA) was used. The NMA was performed through a Stata routine for Bayesian hierarchical random-effects model analysis.

RESULTS

We enrolled in the present study, a total of 4060 patients, with a mean of 17.84 ± 16.41 months follow-up. The patient baseline data were very homogeneous across the groups concerning age (P = 0.91), sex (P = 0.52), and BMI (P = 0.83). Concerning the cup anteversion, the anterolateral approach reported the value closest to the reference value. The test for overall inconsistency, however, was not statistically significant (P = 0.30). Concerning cup inclination, the lateral approach reported the value closest to the reference value. The test for overall inconsistency was statistically significant (P = 0.01).

CONCLUSION

The anterolateral approach for total hip arthroplasty detected the best femoral stem alignment and cup anteversion. Data concerning cup inclination detected no sufficient transitivity to draw consistent conclusions.

Recurrent and radiographically unrecognized iatrogenic intra-prosthesis hip dislocations

Hip dislocation is a common complication after total hip arthroplasty surgery. Newer prosthetic implants aim to reduce the risk of dislocation. The new dual mobility implant has a unique design that may result in intra-prosthetic dislocation. We report a case of a recurrently missed iatrogenic intra-prosthetic dislocation following closed reduction efforts in the emergency department (ED). Emergency physicians must be aware of the design, pitfalls, and management of this new prosthetic hip design.

Low-Dose Aspirin Is Safe and Effective for Venous Thromboembolism Prevention in Patients Undergoing Revision Total Hip Arthroplasty: A Retrospective Cohort Study

BACKGROUND

Currently, there is no established universal standard of care for prophylaxis against venous thromboembolism (VTE) in orthopedic patients undergoing revision total hip arthroplasty (rTHA). The aim of this study is to determine whether a protocol of 81-mg aspirin (ASA) bis in die (BID) is safe and/or effective in preventing VTE in patients undergoing rTHAs vs 325-mg ASA BID.

METHODS

In 2017, a large academic medical center adopted a new protocol for VTE prophylaxis in arthroplasty patients at standard risk. Initially, patients received 325-mg ASA BID but switched to 81-mg ASA BID. A retrospective review (2011-2019) was performed to identify 1361 consecutive rTHA patients and their associated 90-day postoperative complications such as VTE, including pulmonary embolism (PE) and/or deep vein thrombosis (DVT), as the primary outcome; and gastrointestinal and wound bleeding, acute periprosthetic joint infection, and mortality as the secondary outcome.

RESULTS

From 2011 to 2017, 973 rTHAs were performed and 13 total VTE cases were diagnosed (1.34%). From 2017 to 2019, 388 rTHAs were performed with 3 total VTE cases identified (0.77%). Chi-squared analyses and logistic regression models showed no differences in rates or odds in postoperative PE (P = .09), DVT (P = .79), PE and DVT (P = .85), and total VTE (P = .38) using either dose. There were also no differences between bleeding complications (P = .14), infection rate (P = .46), and mortality (P = .53).

CONCLUSION

Using a protocol of 81-mg of ASA BID is noninferior to 325-mg ASA BID and may be safe and effective in maintaining low rates of VTE in patients undergoing rTHA.

Publication Productivity and Academic Rank in Medicine: A Systematic Review and Meta-Analysis

PURPOSE

Academic medical faculty members are assessed on their research productivity for hiring, promotion, grant, and award decisions. The current work systematically reviews, synthesizes, and analyzes the available literature on publication productivity by academic rank across medical specialties.

METHOD

The authors searched PubMed for medical literature, including observational studies, published in English from 2005 to 2018, using the term "h-index," on July 1, 2018. Studies had to report on h-indices for faculty in academic medicine and, if available, other publication metrics, including number of citations, number of publications, and m-indices, stratified by academic rank. The DerSimonian and Laird method was used to perform meta-analyses for the primary (h-index) and secondary (m-index) outcome measures.

RESULTS

The systematic review included 21 studies. The meta-analysis included 19 studies and data on 14,567 academic physicians. Both h- and m-indices increased with academic rank. The weighted random effects summary effect sizes for mean h-indices were 5.22 (95% confidence interval [CI]: 4.21-6.23, n = 6,609) for assistant professors, 11.22 (95% CI: 9.65-12.78, n = 3,508) for associate professors, 20.77 (95% CI: 17.94-23.60, n = 3,626) for full professors, and 22.08 (95% CI: 17.73-26.44, n = 816) for department chairs. Mean m-indices were 0.53 (95% CI: 0.40-0.65, n = 1,653) for assistant professors, 0.72 (95% CI: 0.58-0.85, n = 883) for associate professors, 0.99 (95% CI: 0.75-1.22, n = 854) for full professors, and 1.16 (95% CI: 0.81-1.51, n = 195) for department chairs.

CONCLUSIONS

Both h- and m-indices increase with successive academic rank. There are unique distributions of these metrics among medical specialties. The h- and m-indices should be used in conjunction with other measures of academic success to evaluate faculty members for hiring, promotion, grant, and award decisions.

Preoperative Predictors of Patients Requiring Inpatient Admission for Total Hip Arthroplasty Following Removal From the Medicare Inpatient-Only List

BACKGROUND

The Centers for Medicare and Medicaid Services has removed total hip arthroplasty from the inpatient-only (IO) list in January 2020. Given the confusion created when total knee arthroplasty came off the IO list in 2018, this study aims to develop a predictive model for guiding preoperative inpatient admission decisions based upon readily available patient demographic and comorbidity data.

METHODS

This is a retrospective review of 1415 patients undergoing elective unilateral primary THA between January 2018 and October 2019. Multiple logistic regression was used to develop a model for predicting LOS ≥2 days based on preoperative demographics and comorbidities.

RESULTS

Controlling for other demographics and comorbidities, increased age (odds ratio [OR], 1.048; P < .001), female gender (OR, 2.284; P < .001), chronic obstructive pulmonary disorder (OR, 2.249; P = .003), congestive heart failure (OR, 8.231; P < .001), and number of comorbidities (OR, 1.216; P < .001) were associated with LOS ≥2 days while patients with increased body mass index (OR, 0.964; P = .007) and primary hypertension (OR, 0.671; P = .008) demonstrated significantly reduced odds of staying in the hospital for 2 or more days. The area under the curve was found to be 0.731, indicating acceptable discriminatory value.

CONCLUSION

For patients undergoing primary THA, increased age, female gender, chronic obstructive pulmonary disorder, congestive heart failure, and multiple comorbidities are risk factors for inpatient hospital LOS of 2 or more days. Our predictive model based on readily available patient presentation and comorbidity characteristics may aid surgeons in preoperatively identifying patients requiring inpatient admission with removal of THA from the Medicare IO list.

A Multimodal Protocol to Diminish Pain Following Common Orthopedic Sports Procedures: Can We Eliminate Postoperative Opioids?

PURPOSE

To determine whether postsurgical pain, measured by the visual analog scale (VAS), following common orthopaedic sports procedures could be managed effectively with a nonopioid multimodal analgesic protocol.

METHODS

This prospective study evaluated a custom multimodal nonopioid pain protocol in patients undergoing common orthopaedic sports procedures by a single fellowship-trained orthopaedic sports surgeon from May 2018 to December 2018. Procedures included anterior cruciate ligament reconstruction, rotator cuff repair, arthroscopic partial meniscectomy, and labrum repair. The nonopioid pain protocol consisted of preoperative analgesics, intraoperative local infiltration analgesia, and a postoperative pain regimen. Patient pain was immediately reported after surgery and 1 week postoperatively using the VAS, whereas rescue opioids (oxycodone 5 mg) used were recorded using a prescription opioid journal. Statistical analysis of patient VAS scores, demographic correlations, and comparison between opioid rescue users versus nonusers was performed.

RESULTS

A total of 141 patients were included. One week following surgery, patients reported a mean VAS level of 3.2 ± 2.3 and required on average 2.6 ± 3.6 breakthrough oxycodone pills (8.6 ± 12.0 morphine equivalents). Forty-five percent of patients did not require any breakthrough prescription opioids and reported satisfaction with pain management. Patients who required opioids were more likely to have a history of anxiety/depression (44.2% vs 23.8%, P = .012) and reported greater pain scores as compared with nonusers (3.94 ± 2.5 vs 2.41 ± 1.75, P = .016). The most common side effect of the pain protocol was feeling drowsy (23.5%). All patients were satisfied with their pain management postoperatively.

CONCLUSIONS

A multimodal, nonopioid pain protocol was found to be effective in managing postoperative pain following common orthopedic sports procedures. Patients were found to have low levels of pain, require minimal rescue opioids, and had no severe side effects related to the protocol. These results suggest a nonopioid alternative to pain management following common orthopedic sports procedures.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Predictors of (Un)successful Same-Day Discharge in Selected Patients Following Outpatient Hip and Knee Arthroplasty

BACKGROUND

It is generally accepted that only selected patients are suitable for outpatient joint arthroplasty (OJA); however, no consensus exists on the optimal selection criteria. We believe patients undergoing OJA should undergo risk stratification and mitigation in an attempt to optimize quality and minimize costs.

METHODS

Patient factors of 525 patients who were selected to have primary elective unicompartmental knee arthroplasty (N = 158), total knee arthroplasty (N = 277), or total hip arthroplasty (N = 90) in an outpatient setting were retrospectively reviewed. A complete case multivariable logistic regression analysis of 440 patients was conducted to identify factors that were independently associated with (un)successful same-day discharge (SDD).

RESULTS

One hundred ten patients (21%) were not able to be discharged on the day of surgery. Charnley class B2 was associated with a higher chance of successful SDD (odds ratio [OR], 0.29; 95% confidence interval [CI], 0.12-0.72), whereas female gender (OR, 1.7; 95% CI, 1.0-2.8), total knee arthroplasty (OR, 1.9; 95% CI, 1.1-3.4), and a higher American Society of Anesthesiologists (ASA) physical function score (ASA II: OR, 1.9; 95% CI, 1.1-3.3; ASA III: OR, 3.9; 95% CI, 1.1-13) were associated with a higher risk of unsuccessful SDD.

CONCLUSION

These results in a preselected population suggest the need for further specifying and improving selection criteria for patients undergoing OJA and emphasize the importance of an in-hospital backup plan for patients at risk of unsuccessful SDD. Previous contralateral joint arthroplasty is a protective factor for successful SDD.

The Effect of Povidone-Iodine Lavage in Preventing Infection After Total Hip and Knee Arthroplasties: Systematic Review and Meta-Analysis

BACKGROUND

Dilute povidone-iodine (PI) lavage, a simple disinfection method, could reduce postoperative infection risk. However, there is no clinical consensus regarding its efficacy in total joint arthroplasties (TJAs). This systematic review and meta-analysis evaluated PI lavage's efficacy in preventing infection after TJA.

METHODS

MEDLINE, Embase, and the Cochrane Library were systematically searched for studies published before November 22, 2019, that compared postoperative infection rates in patients who underwent TJA with or without PI lavage before wound closure. Subgroup analyses were designed to identify the differences in infection site (overall or deep), type of surgery (total hip arthroplasty or total knee arthroplasty), time until diagnosis of infection (3 or 12 months postoperatively), and primary/aseptic revision arthroplasties.

RESULTS

We included 7 studies with 31,213 TJA cases, comprising 8861 patients who received PI lavage and 22,352 who did not. Pooled odds ratio for overall infection rate for the PI and non-PI lavage groups was 0.67 (95% confidence interval, 0.38-1.19, P = .17) and for the deep infection rate was 0.90 (95% confidence interval, 0.27-2.98, P = .86). Subgroup analyses revealed no differences in postoperative infection rates between the PI and non-PI lavage groups in terms of total hip arthroplasty and total knee arthroplasty, diagnosis of infection at 3 and 12 months postoperatively, or primary and aseptic revision arthroplasties.

CONCLUSION

We detected no differences in the overall postoperative infection rates between the PI and non-PI lavage groups before wound closure in TJA including all studies in the subgroup analyses.

Direct Anterior Approach in Crowe Type III-IV Developmental Dysplasia of the Hip: Surgical Technique and 2 years Follow-up from Southwest China

OBJECTIVES

To summarize our pioneering surgical practice and clinical outcome of Crowe type III-IV developmental dysplasia of the hip (DDH) with a direct anterior approach total hip arthroplasty in a single teaching hospital in Southwest China.

METHODS

Fourteen patients (15 hips) diagnosed with Crowe type III-IV developmental dysplasia of the hip were involved in this single-center retrospective study between 2016 and 2018. A comprehensive surgical procedure, including preoperative planning and algorithms for leg length equalization, intraoperative stepwise soft tissue release, bone defect reconstruction, and an innovative subtrochanteric osteotomy, was described. Furthermore, advancements in intraoperative CT guidance, computer navigation, and nerve monitoring were available for specific demands. The short-term clinical outcome was evaluated at the endpoint of follow-up by three patient-reported functional scales (Harris, WOMAC, and SF-12 scores), and objective data collected at the clinic, including functional recovery (muscle strength of hip flexor and abductor, correction of the pelvic tilt, leg length discrepancy, and limp), radiographic analysis, and complication occurrence.

RESULTS

The intraoperative variables were carefully recorded. The mean operating times in Crowe type III and IV groups were 115.8 min and 156.2 min, and the median blood loss volumes were 520.5 mL and 810.2 mL, respectively. The general changes in the Harris, SF-12, and WOMAC scores of the two groups were 46.2, 8.7 and 134.3, respectively, at a mean follow-up of 25.4 months. Enhanced recovery of hip abductor muscle strength was identified in 85.7% of the population at the third postoperative month. The equalization of leg length and correction of the pelvic tile were observed at the sixth postoperative month, with a 36-mm decrease in leg length discrepancy. No radiographic evidence of the loosening or migration of the components was observed. A self-innovated subtrochanteric shortening osteotomy was performed in five patients, and they healed after 6 months. Specific complications included two cases of distal femoral cracks and one case of a periprosthetic fracture needing internal fixation. Two patients received a late iliotibial band release at the 3rd month postoperatively due to progressive genu valgum. No records of infection, dislocation, nerve palsy, bone non-union, or revision surgery were identified.

DISCUSSION

The direct anterior approach total hip arthroplasty showed potential advantages, including optimum component positioning, improved hip stability, steerable complication rate, and enhanced functional recovery with Crowe type III-IV DDH. The short-term outcome is comparable to that of the traditional posterolateral approach.

Outpatient, Home-Based Physical Therapy Promotes Decreased Length of Stay and Post-Acute Resource Utilization After Total Joint Arthroplasty

BACKGROUND

Patients and healthcare systems are increasingly focused on evaluating interventions that increase the value of care delivered. Our objective of this study is to evaluate early post-operative outcomes among those patients who underwent total joint arthroplasty with and without the participation in our piloted Outpatient Physical Therapy Home Visits (OPTHV) program.

METHODS

A retrospective analysis of patients undergoing total hip arthroplasty and total knee arthroplasty at a single institution from July 2016 to September 2017 was performed. Matched cohorts were compared according to OPTHV enrollment status.

RESULTS

In total, 1729 patients were included in this study. Two hundred ninety-three patients were enrolled in OPTHV, while 1436 patients received institutional standard care. Patients were matched by gender (56.7% vs 57.7% female, P = .751), age (67.75 vs 66.95 years, P = .167), body mass index (30.18 vs 30.12 kg/m², P = .859), and average American Society of Anesthesiologists score (2.31 vs 2.36, P = .131). OPTHV patients had a shorter length of stay (1.39 vs 1.64 days, P < .001) and were more likely to discharge to home (89.8% vs 74.7%, P < .001). Ninety-day re-admissions (2.7% vs 2.6%, P = .880) and emergency room visits (4.1% vs 4.3%, P = .864) were equivalent.

CONCLUSION

OPTHV is a novel program that facilitates discharge home and decreased length of stay after total joint arthroplasty without increasing re-admissions or emergency room visits. Utilization of OPTHV may contribute toward reducing the episode of care costs by reducing utilization of skilled nursing facility and home health services. Further prospective studies are needed to evaluate the effect of OPTHV on the total cost of care and functional outcomes.

Evaluation of stability of deep venous thrombosis of the lower extremities using Doppler ultrasound

Objective

This study aimed to assess using Doppler ultrasound for analyzing stability of deep venous thrombosis (DVT) of the lower extremities.

Methods

Patients with DVT of the lower extremities who were treated from August 2017 to December 2019 were selected. The patients were divided into stable and unstable groups according to whether thrombus was collected in a filter. Related ultrasound and blood test results were analyzed and compared.

Results

A total of 126 patients with DVT of the lower extremities were included, of whom 74 were in the stable group and 52 were in the unstable group. There were significant differences in the prothrombin time (PT), and lipoprotein alpha, D-dimer, and triglyceride levels between the groups. D-dimer levels >2800 ug/L, smoking, history of venous thrombosis, PT >13.15 s, and body mass index >24.45 kg/m² were independent risk factors for stability of DVT of the lower extremities. The area under the curve with combined detection of DVT was significantly higher than that for body mass index, PT, and D-dimer alone.

Conclusion

Doppler ultrasound may be reliable for analyzing the stability of DVT of the lower extremities. Related strategies targeting risk factors are required for reducing DVT of the lower extremities.

Risk factors and outcome of patients with periprosthetic joint infection admitted to intensive care unit

INTRODUCTION

Prosthetic joint infection (PJI) is a severe complication after total joint replacement surgery. The current study analyzes the outcome and mortality of patients admitted to an intensive care unit following PJI.

METHODS

Retrospective analysis of all patients treated between 2012 and 2016 due to PJI in the surgical intensive care unit of a university hospital.

RESULTS

A total of 124 patients were included. The mean age was 75 ± 11 years. Of those 124 patients, 85 patients (68.5%) suffered a prosthetic infection of the hip, 33 patients (27.3%) of the knee, six patients (4.8%) of hip and knee. 52 patients were male (40.9%). The assessed mean Simplified Acute Physiology Score II (SAPSII) was 29.6 ± 5.9. The mortality rate was 21% (26/124). Of surviving patients, 53.1% were discharged home, 25.5% were transferred to a nursing home, and 21.4% were transferred to a geriatric rehabilitation center. Comparing survivors to non-survivors, the non-survivor group showed a higher incidence of renal replacement therapy (46.1 vs 3.0%; p < 0.01), higher SAPSII on admission (35.7 vs. 29.0; p = 0.01) and higher Charlson Comorbidity Indices (CCI) (5.5 vs. 2.82; p < 0.01). The multivariate regression identified CCI (odds ratio 1.49; p < 0.01) and renal replacement therapy (odds ratio 12.4; p < 0.01) as independent risk factors for increased mortality.

CONCLUSIONS

Admission to an intensive care unit was associated with a mortality rate of 21%. Factors associated with poor outcomes included renal replacement therapy, higher admission SAPII scores, and higher admission Charlson comorbidity index. These factors could be used for individual risk assessment on admission to the ICU.

Hemiarthroplasty Through a Direct Anterior Approach for Femoral Neck Fractures

This video demonstrates the direct anterior approach (DAA) for placement of an uncemented hemiarthroplasty for a displaced femoral neck fracture. The DAA is an intranervous and intramuscular approach that is believed to allow patients a quicker recovery and decrease the rate of dislocation. Femoral exposure is the most challenging component of the approach. In this video, the approach is performed with the assistance of the fracture table to facilitate exposure of the femur. This step-by-step description demonstrates how to expose the femur, measure for the femoral head size, and place an uncemented femoral stem in for a unipolar hemiarthroplasty. A full capsular closure is performed by reapproximating the iliofemoral ligament after reduction. This DAA video is taken from the surgeon's point of view to facilitate visualization of the anatomy and orientation of implant placement.

The effect of Staphylococcus aureus on the electrochemical behavior of porous Ti-6Al-4V alloy

Ti-6Al-4V alloy has been widely investigated for biomedical applications due to its low density, high specific strength, and favorable corrosion resistance. However, some reported failures have imposed a challenge to improve bone regeneration and fixation, as well as antibacterial properties. A further opportunity for solving this problem is the introduction of porosity. However, this can induce metallic release and corrosion product formation. In this work, a Ti-6Al-4V alloy was exposed to Hank's solution, sterilized and inoculated with Staphylococcus aureus at 37 °C. Surface analysis was carried out by SEM-EDS and XPS. Electrochemical measurements were also performed using chronopotentiometry at open circuit potential, polarization curves, and electrochemical impedance spectroscopy. After exposure, FE-SEM showed some colonies of S. aureus on the sample with 22% porosity. However, XPS analysis revealed that the presence of bacterium influenced the composition of the oxide layer, even more drastically with the increase in added porosity. Moreover, the impedance analysis showed De Levie's behavior, revealing a reduction of pore resistance and modulus of the impedance in the low frequency range in inoculated medium, and polarization curves showed that the passivity potential range was decreased, whereas the passivity current increased in the presence of the S. aureus.

Acute pseudogout presenting as an exception to Musculoskeletal Infection Society criteria in total knee arthroplasty: a case report

In this case, a 78-year-old female with no previous medical history of crystalline arthropathy presented with pain, effusion, and erythema about a total knee arthroplasty (TKA) performed 13 years prior. Implementation of a novel synovial fluid alpha-defensin assay ruled out periprosthetic joint infection (PJI) despite a positive 2018 Musculoskeletal Infection Society (MSIS) minor criteria score of 8 points, a significant diagnostic differentiation which prevented secondary invasive debridement or joint irrigation intervention. Confirmatory histologic study was positive for calcium pyrophosphate crystals, indicative of acute pseudogout inflammation rather than PJI or septic arthritis manifestation. The patient was then conservatively managed medically for a pseudogout flare and had no evidence of infection with normal physical exam and laboratory study at one- and two-years post treatment, respectively. Given the predominantly clinical nature of current PJI assessment in-clinic coupled with notable risks associated with aggressive re-intervention in the setting of suspected infection, critical need exists for the maturation of sensitive, reliable empiric measures which may assist in guiding orthopaedic surgeon evaluation of patients presenting with inflammatory symptomology around a previous surgical site. In this case, we conclude that patients with a negative alpha-defensin assay alongside crystalline arthropathy on histology may be cautiously yet successfully treated non-operatively despite clinical MSIS criteria concerning for PJI.

Changes in actual daily physical activity and patient-reported outcomes up to 2 years after total knee arthroplasty with arthritis

The current study aimed 1) to describe changes in patient-reported outcomes and physical activity measured with an accelerometer preoperatively, 6 months and 2 years postoperatively in older patients undergoing total knee arthroplasty (TKA) for arthritis, and 2) to examine the predictors of the changes in physical activity (PA). This study included 58 patients (mean age 72.6 years, 84.5% women) who completed the Oxford Knee Score (OKS) and the 8-item Short Form Health Survey. Physical activity measured mean steps per day, duration of light physical activity and moderate-to-vigorous physical activity (MVPA) per week. All PA indicators and patient-reported outcomes improved 6 months postoperatively. After 6 months, knee-related pain and function gradually improved, and MVPA increased. The OKS was a sole predictor of improvement in PA during the 2-year study period, suggesting the importance of disease-specific quality of life.

Autologous Mesenchymal Stem Cell Treatment is Consistently Effective for the Treatment of Knee Osteoarthritis: The Results of a Systematic Review of Treatment and Comparison to a Placebo Group

Background: Numerous studies have used autologous mesenchymal stem cell injections (AMSCI) to treat osteoarthritis. We hypothesized that AMSCI is an effective osteoarthritis treatment with increasing efficacy at higher doses. Methods: We conducted a PubMed search for human clinical studies using AMSCI for the treatment of osteoarthritis (OA) and a second search for placebo arms of injectate OA treatment. Inclusion criteria included treatment outcomes ratings both pre-treatment and at least 6 months post-treatment. Results: 45 AMSCI cohorts from 34 studies met criteria. All AMSCI cohorts showed improvement at mean 15.3 months post-treatment. Mean WOMAC and VAS scores improved at 6-months and at final follow-up (p < 0.0001 for all). Scores > 2 years were also significant (WOMAC p = 0.001/VAS p = 0.004). Results greatly exceeded the minimal clinically important difference (MCID) at each time point. AMSCI improvement also substantially exceeded previously published 6-month placebo-treatment improvement. No dose-response relationship was seen. AMSCI cohorts showed continuing improvement ≥ 6 months, and continued upward at one year. Placebo scores were already trending downward by 6 months. Conclusions: AMSCI is a consistently significantly effective treatment for osteoarthritis. It should no longer be stated that data is insufficient to establish AMSCI efficacy for OA. Given its excellent safety profile, AMSCI should be widely used for the treatment of osteoarthritis.

Electronic patient portal utilization by neurology patients and association with outcomes

Existing literature on electronic patient portals demonstrates mixed findings for portal user demographic patterns and relationships between portal usage and clinical outcomes. This study sought to determine characteristics of portal users specific to a neurology patient population and examine whether usage predicted decreased clinic visits and risk of hospitalization. A cross-sectional analysis on 13,483 patients seen at a tertiary neurology outpatient clinic over a 1-year period found significant associations between demographics, and interactions between age, sex, and race. Black and Hispanic patients were less likely to be portal users. While females had higher odds of portal usage overall, their probability decreased with increasing age. Portal users had higher rates of clinic utilization but no difference in hospitalization risk. These results highlight demographics that may need strategic targeting to increase portal uptake and the need for other interventions for populations more likely to experience health events resulting in hospitalization.

The Effectiveness and Safety of General and Spinal Anesthesia on Systemic Inflammatory Response in Patients with Tumor-Type Total Knee Arthroplasty

BACKGROUND

The anesthesia procedure in tumor-type total knee arthroplasty (TKA) may contribute to systemic inflammatory response. Therefore, we aim to investigate the effectiveness and safety of general and spinal anesthesia in patients with tumor-type TKA.

PATIENTS AND METHODS

Twenty-five patients with tumors around the knee undergoing primary unilateral TKA were randomly divided into the general anesthesia group (n = 13) and spinal anesthesia group (n = 12). Knee joint HSS scores and Western Ontario and McMaster University osteoarthritis index (WOMAC osteoarthritis) were recorded before surgery and 12 months after surgery. Visual analogue scale, C-reactive protein (CPR), tumor necrosis factor-α (TNF-α), and interleukin-8 (IL-8) concentration were measured preoperatively (T0), on the day of the operation (T1), and on the first day (T2) after the operation. Complications in the two groups were recorded.

RESULTS

The operative time, intraoperative blood loss, postoperative drainage, tourniquet time, and complication rate were not significantly different between the general anesthesia and spinal anesthesia groups (all p > 0.05). There were no significant differences in CPR (7.6 ± 3.1, 8.1 ± 4.1, 91.3 ± 24.2 vs. 7.1 ± 2.9, 7.6 ± 3.8, 85.1 ± 19.3 pg/mL, respectively), IL-8 (12.2 ± 6.6, 13.4 ± 7.3, 19.2 ± 10.5 vs. 11.9 ± 5.7, 12.9 ± 8.6, 22.2 ± 12.4 pg/mL, respectively), and TNF-α (2.5 ± 1.7, 2.2 ± 1.9, 2.8 ± 2.1 vs. 2.4 ± 1.3, 2.7 ± 2.1, 2.9 ± 1.6 pg/mL, respectively) between the two groups at T0, T1, and T2 (all p > 0.05). There were no statistical differences in pre- and postoperative HSS knee scores (39.78 ± 11.3, 90.24 ± 15.3 vs. 42.68 ± 12.5, 91.21 ± 16.3) and WOMAC indexes (49.89 ± 7.9, 25.12 ± 6.2 vs. 51.3 ± 8.3, 23.15 ± 5.3) between the two groups (p > 0.05).

CONCLUSION

General anesthesia and spinal anesthesia in patients with tumor-type TKA had the same effectiveness and safety.

The Use of Cement in Hip Arthroplasty: A Contemporary Perspective

Notable advances in hip arthroplasty implants and techniques over the past 60 years have yielded excellent survivorship of fully cemented, hybrid, and reverse hybrid total hip replacements as demonstrated in joint registries worldwide. Major advances in noncemented implants have reduced the use of cement, particularly in North America. Noncemented implants predominate today based on procedural efficiency, concern related to thromboembolic risk, and a historic belief that cement was the primary cause of osteolysis and implant loosening. With the decline of cemented techniques, press-fit fixation has become common even in osteoporotic elderly patients. Unfortunately, there is a troubling rise in intraoperative, as well as early and late postoperative periprosthetic fractures associated with the use of noncemented implants. Despite the success of noncemented fixation, an understanding of modern cement techniques and cemented implant designs is useful to mitigate the risk of periprosthetic fractures. Cemented acetabular components can be considered in elderly patients with osteoporotic or pathologic bone. Cemented stems should be considered with abnormal proximal femoral morphology, conversion of failed hip fixation, inflammatory arthritis, patient age over 75 (especially women), osteoporotic bone (Dorr C), and in the treatment of femoral neck fractures.

Bilateral Femoral Component Fractures After Primary Total Knee Arthroplasty With Cruciate-Retaining Femoral Component

A 69-year-old male presented with atraumatic bilateral femoral component fractures at different time intervals after simultaneous bilateral total knee arthroplasty using the cemented Biomet Ascent Knee System. The right and left knee implant fractures occurred 12 and 17 years after primary arthroplasty, respectively. This patient was notably tall (190.5 cm, 98th percentile) and maintained an active lifestyle before implant fractures. Sequential, bilateral knee implant fractures in a system with a previously acceptable track record suggest that biomechanics, patient characteristics, and surgical factors can significantly influence the risks for fracture of an implant.

Absence of instabilities and intra-prosthetic dislocations at 7 to 11 years following THA using a fourth-generation cementless dual mobility acetabular cup

PURPOSE

Dual-mobility (DM) cups are increasingly used in total hip arthroplasty (THA) but there lacks literature on their long-term results. We aimed to investigate outcomes of a fourth-generation cementless DM acetabular cup at 7-11 years.

METHODS

We retrospectively evaluated 240 consecutive hips that received cementless THA using the same dual mobility cup (Novae Sunfit TH) and femoral stem (Corail). Patients were recalled at ≥7 years to collect Oxford hip scores (OHS), Harris hip scores (HHS), and inspect for radiolucent lines and granulomas. Multi-variable analyses were performed to determine whether HHS or OHS were associated with pre- or intra-operative variables.

RESULTS

At 8.4 ± 0.8 years (range, 7-11), 6 hips were revised (2.5%), 54 deceased (22.5%), and 14 could not be reached (5.8%). Four revisions (2 cup+stem, 2 liners only) were due to sepsis (1.7%), one (cup and stem) for trauma (0.4%), and one (stem) due to aseptic loosening (0.4%). For the remaining 166 hips, HHS was 83.6 ± 13.2 and OHS was 20.3 ± 6.7. Multi-variable analysis confirmed that HHS (β = - 0.38; p = 0.039) and OHS (β = 0.36; p < 0.001) worsened with age, and that OHS was worse for Charnley C patients (β = 3.17; p = 0.009). Neither granulomas nor radiolucenies were observed around any cups, but radiolucenies were seen around 25 stems (20.3%).

CONCLUSIONS

This fourth-generation DM cup demonstrated satisfactory outcomes at 7-11 years, with no instabilities or cup revisions due to aseptic loosening. Better OHS was observed for younger patients and those presenting higher Charnley grade.

LEVEL OF EVIDENCE

Level IV, retrospective case study.

Three-step technique for implantation of rotating hinge knee prostheses : Demonstration using the Enduro prosthesis

OBJECTIVE

Implantation of an axis-guided knee prosthesis with consideration of the joint line and balanced flexion and extension gap to reduce the mechanical load on the prosthesis axis and to improve the movement of the prosthesis.

INDICATIONS

Distinct unilateral instability due to ligament insufficiency in association with knee prostheses. Primary implantation of axis-guided knee prostheses with pronounced axial malalignment (>20-25° valgus or varus malalignment) or/and severe flexion contracture > 40°. Replacement of prosthesis with nonsignificant imbalance between flexion and extension gap.

CONTRAINDICATIONS

Clearly unstable flexion gap such that the extension gap cannot be adjusted appropriately. Significant femoral bone defects requiring distal femoral replacement prostheses.

SURGICAL TECHNIQUE

Reconstruction of the tibial platform with the trial prosthesis with regard to height in relation to the tip of the fibula. Determination of the femoral prosthesis size. Adjustment of the anteroposterior (AP) cutting block of the selected size, referenced anteriorly and in correct rotation. Determination of the flexion gap with spacers using the stable side of the collateral ligaments. Positioning the distal cutting block and determination of the height of the extension gap. Moving the distal cutting block until the same height of spacer as used in the flexion gap fits into the extension gap, taking into account the stable side of the collateral ligaments. The extent of the displacement D1 is noted. Reverse displacement of the distal cutting block by the distance D2 until a satisfactory bony contact surface for the femoral component in the distal femur can be created. The thickness of the required distal augments on the following chamfer-cutting guide (4-in‑1 cutting block) and thus on the femoral prosthetic component is the sum of D1 + D2. The chamfer-cutting guide (4-in‑1 block) with distal augments of the calculated height (D = D1 + D2) is placed in position. Definition and preparation of the posterior contact surface with positioning of any necessary posterior augments. Completion of the femoral preparation taking into account the distal and posterior augments. Assembly of the trial prostheses with a trial inlay having the height of the spacers used. Implantation of the selected prosthesis components.

POSTOPERATIVE MANAGEMENT

Thrombosis prophylaxis, physiotherapy under full weight-bearing and mobility exercises.

RESULTS

After implantation of 104 axis-guided Enduro™ knee prostheses (Aesculap AG, Tuttlingen, Germany) (73 knee prosthesis revisions and 31 primary implantations), the Knee Society Score increased from 42.8 ± 18.8 preoperatively to 84.8 ± 13.9 after 24 months. Complications comprised one deep vein thrombosis and one periprosthetic infection.

Unintentional Epidural Anesthesia Mimicking Cauda Equina Syndrome from Suprafascial Injection of Liposomal Bupivacaine After Lumbar Foraminotomy: A Case Report

CASE

This case report describes a 46-year-old woman undergoing right-sided L5 to S1 decompression who received liposomal bupivacaine (LB) for postoperative analgesia and developed unintentional epidural anesthesia with symptoms mimicking cauda equina syndrome. The patient's symptoms resolved 72 hours postoperatively, approximately the length that LB typically lasts. At the 16-month follow-up, the patient demonstrated complete neurological function with no lower extremity strength or sensation deficits.

CONCLUSIONS

Tracking of LB into the epidural space after lumbar surgery may cause transient epidural anesthesia with symptoms that mimic cauda equina syndrome.

The Effect of the False Acetabulum on Femoral Proximal Medullary Canal in Unilateral Crowe Type IV Developmental Dislocation of the Hip

Purpose

To investigate the effect of the false acetabulum on femoral proximal medullary canal in unilateral Crowe type IV developmental dislocation of the hip (DDH) patients on anteroposterior radiographs.

Patients and Methods

We measured the following parameters of DDH and contralateral normal hip (CNH) of proximal morphology of femurs on 65 patients with unilateral Crowe type IV DDH (30 hips with no false acetabulum (type IVA) and 35 hips with a false acetabulum (type IVB)) in our hospital between September 2009 and July 2019 on anteroposterior radiographs: the widths of medullary canals at 20 mm above the center of lesser trochanter (CLT), 20 mm below the CLT and the isthmus. Canal flare index (CFI), metaphyseal canal flare index (MCFI), diaphyseal canal flare index (DCFI) were calculated.

Results

The values of CFI of DDH and CNH in unilateral type IVA patients were 2.8 and 4.4, respectively (p < 0.001), and those in type IVB patients were 3.9 and 4.6, respectively (p < 0.001). The MCFIs of DDH and CNH in type IVA group were 2.2 and 2.3, respectively (p = 0.032), and those in type IVB group were 2.4 and 2.4, respectively (p = 0.242). The DCFIs of DDH and CNH in type IVA group were 1.3 and 1.9, respectively (p < 0.001), and those in type IVB group were 1.7 and 1.9, respectively (p = 0.002).

Conclusion

The false acetabulum stimulated the development of the proximal femur in Crowe type IV DDH. The variation of the femoral proximal medullary canal in type IVA DDH mainly occurred at the metaphyseal and proximal diaphyseal levels, and that in type IVB DDH mainly occurred at the proximal diaphyseal level.

Robotic Arm-Assisted Total Knee Arthroplasty in the Setting of Combined Extra-articular Deformities of the Femur and Tibia

In this case, we will describe a 68-year-old man with combined femoral and tibial bone deformities who underwent robotic arm-assisted total knee arthroplasty (RATKA) to treat his severe osteoarthritis in the setting of extra-articular deformities that altered the native anatomical axis and the kinematics of the deformed extra-articular bony structures which chronically generated a neomechanical axis. The combination of severe osteoarthritis with extra-articular deformities made the RATKA method the best surgical treatment option taking into account altered kinematics of the native joint which conventional jig-based total knee arthroplasty would not have prioritized during bony cuts and implant positioning. The patient underwent successful knee arthroplasty with robotic arm-assisted technology with restoration of the mechanical axis.

Evaluation of Usability, Perception of Usefulness, and Efficiency of an Application in Interpreting Imaging Examinations and Supporting Decision-Making in Orthopedics

Background: Medical smartphone applications have rendered positive results in daily practice and also serve as potentially valuable educational tools. In orthopedics, radiograph analysis and angle measurements comprise an essential mechanism in the diagnosis, treatment, planning, and evaluation of the results in orthopedic surgery. Purpose: Thus, the present study aimed to evaluate an application for mobile devices for orthopedic doctors and orthopedic residents. The application proposes the analysis and interpretation of radiographic imaging examinations through assessments and angle measurements. In this survey, we analyzed the parameter usability and usefulness of a mobile application for the iOS system, in addition to conducting its validation. Patients and Methods: The application was tested by 26 volunteers: 13 orthopedists and 13 orthopedic residents. Results: After applying the System Utility Score (SUS) questionnaire, which assesses the usability of an application, a score of 84.5 was obtained, a value that represents an A+ rating on the Sauro and Lewis scale. There was no statistically significant difference when comparing the SUS between the orthopedic residents and orthopedists. According to the usefulness perception analysis, 90% of the residents responded positively to the questions, while among orthopedists, the percentage was 75%, denoting a statistically significant difference (p = 0.002). Subsequently, the application underwent validation to assess whether the calculated angle measurements were reliable when compared with those obtained using the goniometer. No significant differences were observed when comparing the angles measured by the two evaluated methods. Conclusion/Clinical Relevance: In conclusion, the developed application can reliably contribute to the measurement of angles in radiographs, assisting in therapeutic decision-making, and may be used as an instrument to promote the teaching and learning processes in orthopedics.

Accurate reconstructions of pelvic defects and discontinuities using statistical shape models

Treatment of large acetabular defects and discontinuities remains challenging and relies on the accurate restoration of the native anatomy of the patient. This study introduces and validates a statistical shape model for the reconstruction of acetabular discontinuities with severe bone loss through a two-sided Markov Chain Monte Carlo reconstruction method. The performance of the reconstruction algorithm was evaluated using leave-one-out cross-validation in three defect types with varying severity as well as severe defects with discontinuities. The two-sided reconstruction method was compared to a one-sided methodology. Although, reconstruction errors increased with defect size and this increase was most pronounced for pelvic discontinuities, the two-sided reconstruction method was able to reconstruct the native anatomy with higher accuracy than the one-sided reconstruction method. These findings can improve the preoperative planning and custom implant design in patients with large pelvic defects, both with and without discontinuities.

Surgical Approaches in Total Hip Arthroplasty Cost Per Case Analysis: A Retrospective, Matched, Micro-costing Analysis in a Socialised Healthcare System

BACKGROUND

Total hip arthroplasty (THA) offers an effective method of pain relief and restoration of function for patients with end-stage arthritis. The anterior approach (AA) claims to benefit patients with decreased pain, increased mobilisation and decreasing length of hospital stay (LOS). In a socialised healthcare platform we questioned whether the AA, compared to posterior (PA) and lateral (LA) approaches, can decrease the cost burden.

METHODS

Using a retrospective matched cohort study, we matched 69 AA patients to 69 LA and 69 PA patients for age (p = 0.99), gender (p = 0.99) and number of pre-surgical risk factors (p = 0.99). First, we used the Resource Intensity Weights (RIW) using the Health Services agreed on method of calculating cost. Secondly, micro-costing analysis was performed using the financial services data for each patient's hospital stay.

RESULTS

Using the RIW based cost analysis and 2-day reduction (95% CI 1.8-2.4) in LOS, the AA offers an estimated savings per case of $4099 (p < 0.001) compared to the LA and PA. Using micro-costing analysis, we found a total saving of $1858.00 per case (95% CI 1391-2324) when comparing the AA to the PA and LA. There was a statistically significant cost savings using every category: Net Direct Salary ($901.00, p < 0.001), Net Drug ($8.00, p = 0.003), Patient Supply ($454.00, p = 0.001), Patient Drug ($15.00, p = 0.008), Indirect Cost ($385.00, p < 0.001), Patient Care Administration ($106.00, p < 0.001). Furthermore, the AA saved 142 minutes of in-hospital rehabilitation time.

CONCLUSION

The AA THA provides statistically significant reductions in cost compared to PA and LA while releasing rehabilitation resources.

Extra-Articular Hip Resection and Reconstruction with Custom Acetabular Resection Guide and Implants in a Case of High-Grade Spindle Cell Sarcoma of the Proximal Femur: A Case Report

CASE

A 29-year-old man was admitted with acute atraumatic left hip pain and inability to bear weight. Subsequent workup revealed an intracapsular pathologic fracture of the femoral neck secondary to a high-grade spindle cell sarcoma. A unique method of extra-articular resection and reconstruction using a 3-dimensional (3D)-printed custom cutting jig and a custom acetabular component was pursued. Wide margins were achieved without violating the joint capsule but preserving pelvic integrity, allowing a return to an active lifestyle.

CONCLUSION

Three-dimensional-printed custom resection guides and implants can help achieve adequate resection margins while preserving pelvic integrity and function.

New developments and future challenges in prevention, diagnosis, and treatment of prosthetic joint infection

Prosthetic joint infection (PJI) is a devastating complication that results in substantial costs to society and patient morbidity. Advancements in our knowledge of this condition have focused on prevention, diagnosis, and treatment, in order to reduce rates of PJI and improve patient outcomes. Preventive measures such as optimization of patient comorbidities, and perioperative antibiotic usage are intensive areas of current clinical research to reduce the rate of PJI. Improved diagnostic tests such as synovial fluid (SF) α-defensin enzyme-linked immunosorbent assay, and nucleic acid-based tests for serum, SF, and tissue cultures, have improved diagnostic accuracy and organism identification. Increasing the diversity of available antibiotic therapy, immunotherapy, and alternative implant coatings remain promising treatments to improve infection eradication in the setting of PJI.

Out Patient Department practices in orthopaedics amidst COVID-19: The evolving model

Severe Acute Respiratory Syndrome COVID-19 was declared as a pandemic on 11th March 2020 by the World Health Organization and consequent lockdown imposed in several areas resulted in a marked reduction in orthopaedic practices. Although some guidelines for patient care in orthopaedic practice have been published, overall, publications focusing exclusively on guidelines on starting orthopaedic outpatient departments (OPD) after the COVID-19 lockdown amidst the on-going pandemic are lacking. We hereby propose the evolving knowledge in changes in OPD management practices for orthopaedic surgeons in the COVID- 19 era. The emphasis on online registration (e-registration) should be given impetus and become the new norm supplemented by telephonic and spot registration for the uneducated patients. The review highlights the safety of patient and orthopaedic surgeons in OPD by screening and maintaining hygiene at various levels. The article also mentions the duties of the help desk, OPD hall supervisor and the new norms of air conditioning, ventilation, safe use of elevators, sanitization of OPD premises and biomedical waste disposal. The optimum and safe utilization of human & material resources, DO's and DON'Ts for patients & health staff have also been proposed. The reorganization of plaster room, the precaution during plastering, fracture clinic, dressing and injection room services are discussed as per evolving guidelines. This article will also give deep insight into the OPD plan & telemedicine graphically. The authors suggest updating and downward permeation of existing e-infrastructure of government health services that is up-gradation of existing tertiary level online registration services, a paperless model of OPD consultation & dispensation. The future updating of Aarogya Setu App (https://mygov.in/aarogya-setu-app/) for convenient online OPD registration and dispensation has been discussed and proposed. This review will help in containing the spread of COVID 19 and build upon the health gains achieved after lockdown. The easy concept of CCCATTT has been introduced, and the OPD Plan has also been suggested. We have endeavoured to holistically detail an orthopaedic OPD setup and its upkeep in COVID-19 pandemic, but since the knowledge of COVID 19 is ever-evolving it needs replenishment by regular education for health staff.

Disparities in Hip Arthroplasty Outcomes: Results of a Statewide Hospital Registry From 2016 to 2018

BACKGROUND

In November 2019, Centers for Medicare and Medicaid Services announced total hip arthroplasty (THA) will be removed from the inpatient-only list. This may lead to avoidance of patients who have prolonged hospitalizations and discharge to skilled nursing facilities or push providers to unsafely push patients to outpatient surgery centers. Disparities in hip arthroplasty may worsen as patients are "risk stratified" preoperatively to minimize cost outliers. We aimed to evaluate which patient characteristics are associated with extended length of stay (eLOS)-greater than 2 days-and nonhome discharge in patients undergoing hip arthroplasty.

METHODS

The Illinois COMPdata administrative database was queried for THA admissions from January 2016 to June 2018. Variables included age, sex, race and ethnicity, median household income, Illinois region, insurance status, principal diagnosis, Charlson comorbidity index, obesity, discharge disposition, and LOS. Hospital characteristics included bundled payment participation and arthroplasty volume. Using multiple Poisson regression, we examined the association between these factors and the likelihood of nonhome discharge and eLOS.

RESULTS

There were 41,832 THA admissions from January 2016 to June 2018. A total of 36% had LOS greater than 2 midnights and 25.3% of patients had nonhome discharges. Female patients, non-Hispanic black patients, patients older than 75, obese patients, Medicaid or uninsured status, Charlson comorbidity index > 3, and hip arthroplasty for fracture were associated with increased risk of eLOS and/or nonhome discharge (P < .05).

CONCLUSION

With the Centers for Medicare and Medicaid Services emphasis on cost containment, patients at risk of extended stay or nonhome discharge may be deemed "high risk" and have difficulty accessing arthroplasty care. These are potentially vulnerable groups during the transition to the bundled payment model.

Vault perforation after eccentric glenoid reaming for deformity correction in anatomic total shoulder arthroplasty

BACKGROUND

The management of glenoid deformity during anatomic total shoulder arthroplasty remains controversial. In this study, we evaluate variable correction of glenoid deformity by eccentric reaming. We hypothesize that partial correction of modified Walch B/C-type glenoid deformities can achieve 75% bone-implant contact area (BICA) with a reduced vault perforation risk compared with complete correction.

METHODS

Fifty shoulder computed tomographic scans with glenohumeral osteoarthritis were retrospectively evaluated. The Tornier BluePrint v2.1.5 software simulated 3 eccentric reaming scenarios including no, partial, and complete deformity correction. Each scenario was evaluated at 4 BICAs and using 3 implant fixation types. Three-dimensional surface representations were used to evaluate medialization and vault perforation.

RESULTS

The patients had mean glenoid retroversion and inclination of 18.5° and 8.8°, respectively, and mean posterior humeral head subluxation of 76%. With 75% BICA, the 3 fixation types had glenoid vault perforation in 6%-26% and 26%-54% of cases for partial and complete glenoid deformity correction, respectively. The central and posterior-inferior implant components were most likely to perforate across all scenarios.

DISCUSSION

Eccentric reaming for glenoid deformity correction increases the risk of vault perforation. Severe glenoid deformity required increased medialization to achieve 75% BICA. Pegged implants have increased chances of perforation compared with a keeled design; the central and posterior-inferior components were most likely to perforate during deformity correction.

CONCLUSION

Partial deformity correction of modified Walch B/C-type glenoid deformities can achieve 75% BICA while reducing the risk of vault perforation compared with complete correction at the time of anatomic total shoulder arthroplasty.

High-Quality Skilled Nursing Facilities Are Associated With Decreased Episode-of-Care Costs Following Total Hip and Knee Arthroplasty

BACKGROUND

With the increasing popularity of alternative payment models following total hip (THA) and knee arthroplasty (TKA), efforts have focused on reducing post-acute care (PAC) costs, particularly patients discharged to skilled nursing facilities (SNFs). The purpose of this study is to determine if preferentially discharging patients to high-quality SNFs can reduce bundled payment costs for primary THA and TKA.

METHODS

At our institution, a quality improvement initiative for SNFs was implemented at the start of 2017, preferentially discharging patients to internally credentialed facilities, designated by several quality measures. Claims data from Centers for Medicare and Medicaid Services were queried to identify patients discharged to SNF following primary total joint arthroplasty. We compared costs and outcomes between patients discharged to credentialed SNF sites and those discharged to other sites.

RESULTS

Between 2015 and 2018, of a consecutive series of 8778 primary THA and TKA patients, 1284 (14.6%) were discharged to an SNF. Following initiation of the program, 498 patients were discharged to an SNF, 301 (60.4%) of which were sent to a credentialed facility. Patients at credentialed facilities had significantly lower SNF costs ($11,184 vs $8198, P < .0001), PAC costs ($18,952 vs $15,148, P < .0001), and episode-of-care costs ($34,557 vs $30,831, P < .0001), with no difference in readmissions (10% vs 12%, P = .33) or complications (8% vs 6%, P = .15). Controlling for confounding variables, being discharged to a credentialed facility decreased SNF costs by $1961 (P = .0020) and PAC costs by $3126 (P = .0031) per patient.

CONCLUSION

Quality improvement efforts through partnership with selective SNFs can significantly decrease PAC costs for patients undergoing primary THA and TKA.

Are current DRG-based bundled payment models for revision total joint arthroplasty risk-adjusting adequately?

Aims

Currently, the US Center for Medicaid and Medicare Services (CMS) has been testing bundled payments for revision total joint arthroplasty (TJA) through the Bundled Payment for Care Improvement (BPCI) programme. Under the BPCI, bundled payments for revision TJAs are defined on the basis of diagnosis-related groups (DRGs). However, these DRG-based bundled payment models may not be adequate to account appropriately for the varying case-complexity seen in revision TJAs.

Methods

The 2008-2014 Medicare 5% Standard Analytical Files (SAF5) were used to identify patients undergoing revision TJA under DRG codes 466, 467, or 468. Generalized linear regression models were built to assess the independent marginal cost-impact of patient, procedural, and geographic characteristics on 90-day costs.

Results

A total of 9,263 patients (DRG-466 = 838, DRG-467 = 4,573, and DRG-468 = 3,842) undergoing revision TJA from 2008 to 2014 were included in the study. Undergoing revision for a dislocation (+$1,221), periprosthetic fracture (+$4,454), and prosthetic joint infection (+$5,268) were associated with higher 90-day costs. Among comorbidities, malnutrition (+$10,927), chronic liver disease (+$3,894), congestive heart failure (+$3,292), anaemia (+$3,149), and coagulopathy (+$2,997) had the highest marginal cost-increase. The five US states with the highest 90-day costs were Alaska (+$14,751), Maryland (+$13,343), New York (+$7,428), Nevada (+$6,775), and California (+$6,731).

Conclusion

Under the proposed DRG-based bundled payment methodology, surgeons would be reimbursed the same amount of money for revision TJAs, regardless of the indication (periprosthetic fracture, prosthetic joint infection, mechanical loosening) and/or patient complexity. Cite this article: Bone Joint J 2020;102-B(7):959–964.

Cement-In-Cement All-Polyethylene Tibial Revision: A Report of 3 Cases

CASE

Debonding of the tibial component of total knee arthroplasty is a known complication that is typically treated with revision surgery, most commonly revision to a metal-backed tibial component with or without stems. Here, we present 3 cases of tibial component debonding revised to all-polyethylene tibial components with a cement-in-cement technique.

CONCLUSION

In instances of tibial component debonding, if specific criteria are met, revising to an all-polyethylene tibia with retention of the primary cement mantle is an alternative to revision surgery with cement extraction and implantation of a modular metal-backed tibia.

Comparison of infection in cemented, cementless and hybrid primary total knee arthroplasty: a network meta-analysis and systematic review of randomized clinical trials

BACKGROUND

Prosthetic joint infection (PJI) is a serious complication of joint replacement surgeries. Surgeons often take extra measures to reduce the risk of PJI. Whilst many studies have compared between cemented, cementless and hybrid fixation (femoral cementless, tibial cemented), most focus on survivorship, clinical and function outcome scores as primary endpoints. This meta-analysis aims to study the association between fixation methods and risk of PJI in primary total knee arthroplasty (TKA).

METHODS

A systematic review and network meta-analysis of randomized controlled trials (RCT) were performed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Data from studies assessing prevalence of PJI in each fixation type were extracted and analysed.

RESULTS

Twelve RCT comprising a total of 1573 knees were included. Six RCT compared between cemented (n = 486 knees) and cementless (n = 440 knees) fixation, while six RCT compared between hybrid (n = 324 knees) and cementless (n = 323 knees) fixation. Network meta-analysis did not reveal any fixation type that significantly increased the infection rate in TKA. Rate of all infection was lowest in cemented TKA as compared to cementless (odds ratio (OR) 0.90, 95% confidence interval (CI) 0.35-2.28) and hybrid (OR 0.63, 95%CI 0.13-2.99) TKA. Rate of PJI requiring revision surgery was lowest in cementless TKA as compared to cemented (OR 0.89, 95%CI 0.30-2.41) and hybrid (OR 0.57, 95%CI 0.09-2.71) TKA. Rate of PJI not requiring revision surgery was lowest in cemented TKA as compared to hybrid (OR 0.56, 95%CI 0.06-6.10) and cementless (OR 0.55, 95% 0.14-5.63).

CONCLUSION

Unlike total hip arthroplasties, fixation method is not a predisposing risk factor for infections in TKA. However, this meta-analysis may not have sufficient statistical power to show a significant difference between fixation types. It is recommended that prophylactic precautions against other known risk factors for infection should still be clinically practiced.

LEVEL OF EVIDENCE

Level I, meta-analysis of randomized controlled trials.

Is Outpatient Arthroplasty Safe? A Systematic Review

BACKGROUND

Advances in perioperative care and growing demand for hospital beds have progressively reduced the length of stay in lower limb arthroplasty. Current trends in population demographics and fiscal climate have also added to this change. Individual institutions have reported good outcomes with outpatient hip and knee arthroplasty. Debate remains regarding the safety of this practice, the optimal protocol, and the applicability in different subsections of population. The primary purpose of this review is to assess the complication and reoperation rates of outpatient arthroplasty.

METHODS

We performed a systematic review of all papers reporting on 30 and/or 90-day complication rates of outpatient total hip, total knee, and unicondylar knee arthroplasty published from January 1, 2009 to November 1, 2019. Patient demographics, anesthesia, analgesic protocol, selection criteria, and reasons for failed discharge were also extracted.

RESULTS

Nineteen manuscripts with a total of 6519 operations between them were analyzed as a part of this systematic review. Mean 90-day readmission rates were 2.3% (range 0%-6%) with 1.61% (range 0%-4%) rate. Overall rate of successful same calendar day discharge was 93.4%. Nausea/dizziness was the most common reason identified (n = 45) for failure of discharge.

CONCLUSION

The patients recruited for outpatient joint arthroplasty were younger, more active, and had suffered from less medical comorbidities than the more typical lower limb arthroplasty patient. There are significant differences in the reported complications between the studies reviewed. More research is needed to establish if an outpatient program can produce similar outcomes to a fast-track program. Further research is also needed to establish the optimal perioperative protocols.