Drivers of surgery for the degenerative hip, knee, and spine: a systematic review

Regional variation in the use of revascularisation for peripheral artery disease in Japan: a cross-sectional observational study

OBJECTIVES

We aimed to investigate the regional variations in the number of interventions and surgeries for peripheral artery disease (PAD) and explore the major determinants of the variations.

DESIGN

Cross-sectional study.

SETTING

The Japanese Ministry of Health, Labour and Welfare National Database and Diagnostic Procedure Combination database in 2018.

DATA

The rates of endovascular treatment (EVT), bypass surgery per 100 000 individuals in the population were calculated for all 47 prefectures in Japan. The total annual changes in the rates of EVT and bypass surgery in Japan from 2012 to 2019 were calculated.

ANALYSIS

A linear regression model was developed with rates of EVT and bypass surgery as dependent variables and regional medical supply in each prefecture as explanatory variables. These regional factors included the rate of percutaneous coronary intervention (PCI) for angina, the numbers of cardiovascular specialists, specialists in cardiac surgery, interventional radiology (IVR) training facilities and cardiovascular surgery training facilities, per 100 000, respectively.

RESULTS

There was a 5.7-fold difference (143 and 25 per 100 000 individuals aged ≥40 years) in the highest and lowest EVT rates. The highest and lowest rates of bypass surgery were 34 and <10 per 100 000 individuals aged ≥40 years in a prefecture, respectively. The rate of PCI contributed most significantly positive to the rate of EVT (p<0.001). However, the numbers of IVR and cardiovascular surgery training facilities had significant positive and negative relationships, respectively, with the rate of EVT. The numbers of specialists in cardiac surgery and cardiovascular specialists had significant positive (p=0.01) and negative (p=0.01) correlations, respectively, with the rate of bypass surgery.

CONCLUSIONS

Considerable regional variations in the rates of revascularisation for PAD were found. Unbalanced presence of medical resources, preference of suppliers and the training system had larger effects on the regional variation in Japan.

Rural-Urban Differences in Hospital and Patient-Reported Outcomes Following Total Hip Arthroplasty

Background

Rural patients have unique health-care factors influencing outcomes of arthroplasty, hypothetically putting these patients at increased risk for complications following total joint arthroplasty. The aim of this study is to better understand differences in patient outcomes and satisfaction between rural and urban patients receiving care in an urban setting and to provide more equitable care.

Methods

A retrospective chart review was performed on patients undergoing primary total hip arthroplasty at a single large academic center between January 2013 and August 2020. Demographic, operative, and hospital outcomes were obtained from the institutional electronic medical record. Rurality was determined by rural-urban code (RUC) classifications by zip code with RUC codes 1-3 defined as urban and RUC 4-10 defined as rural.

Results

Patients from urban areas were more likely to visit the emergency department within 30 days postoperatively (P = .006) and be readmitted within 90 days (P < .001). However, unplanned (P < .001) admissions were higher in the rural group. There was no statistical difference in postoperative complications (P = .4). At 6 months, rural patients had higher patient-reported outcome measures (PROMs) including Hip Disability and Osteoarthritis Outcome Score total (P = .05), Hip Disability and Osteoarthritis Outcome Score interval (P = .05), self-reported functional improvement (P < .05), improvements in pain (P < .05), and that the surgery met expectations (P < .05). However, these values did not reach minimal clinically important difference.

Conclusions

There may be differences in emergency department visits, readmissions, and PROMs in rural vs urban populations undergoing total hip arthroplasty in an urban setting. Patient access to care and attitudes of rural patients toward health care may underlie these findings. Understanding differences in PROMs, satisfaction, and hospital-based outcomes based on rurality is essential to provide equitable arthroplasty care.

Incidence of spine surgery in the South African private healthcare sector: ten-year trends within a large open medical scheme

PURPOSE

Studies from developed countries suggest a dramatic increase in the utilization of spine surgery in recent decades, however less is known about spine surgery rates in the developing world. The aim of this study was to investigate ten-year trends in the incidence of spine surgery within South Africa's largest open medical scheme.

METHODS

This retrospective review included adult inpatient spine surgeries funded by the scheme between 2008 and 2017. The incidence of spine surgery was investigated by age group-overall and for degenerative pathologies, fusion and instrumentation. Surgeons per 100,000 members were determined. Trends were evaluated by linear regression and by crude 10-year change in incidence.

RESULTS

A total of 49,575 spine surgeries were included. The incidence of surgery for lumbar degenerative pathology showed a significant upward trend among 60-79 year olds but declined among 40-59 year olds. The incidence of lumbar fusion and lumbar instrumentation declined significantly among 40-59 year olds with little change among 60-79 year olds. The ratio of orthopaedic spinal surgeons decreased from 10.2 to 6.3 per 100,000 members whereas the ratio of neurosurgeons decreased from 7.6 to 6.5 per 100,000.

CONCLUSION

Spine surgery in the South African private healthcare sector bears some similarity to developed countries in that it is dominated by elective procedures for degenerative pathology. However, the findings did not reflect the marked increases in the utilization of spine surgery reported elsewhere. It is hypothesized that this may be partly related to differences in the supply of spinal surgery.

Provider Referral Patterns and Surgical Utilization Among New Patients Seen in Spine Clinic

STUDY DESIGN

Retrospective chart review.

OBJECTIVE

The objective of this study was to elucidate the demographics of patient referrals from different sources and identify factors that affect a patient's likelihood of undergoing surgery.

SUMMARY OF BACKGROUND DATA

Despite baseline factors for surgical consideration, such as attempting conservative management, surgeons encounter many patients who are not surgically indicated. Overreferrals, that is, a patient referred to a surgeon that does not need surgery, can result in long wait times, delayed care, worse outcomes, and resource waste.

MATERIALS AND METHODS

All new patients at a single academic institution seen in the clinic by eight spine surgeons between January 1, 2018, and January 1, 2022, were analyzed. Referral types included self-referral, musculoskeletal (MSK), and non-MSK provider referral. Patient demographics included age, body mass index (BMI), zip code as a proxy for socioeconomic status, sex, insurance type, and surgical procedures undergone within 1.5 years postclinic visit. Analysis of variance and a Kruskal-Wallis test was used to compare means among normally and non-normally disturbed referral groups, respectively. Multivariable logistic regressions were run to assess demographic variables associated with undergoing surgery.

RESULTS

From 9356 patients, 84% (7834) were self-referred, 3% (319) were non-MSK, and 13% (1203) were MSK. A statistically significant association with ultimately undergoing surgery was observed with MSK referral type compared with non-MSK referral [odds ratio (OR)=1.37, CI: 1.04-1.82, P =0.0246]. Additional independent variables observed to be associated with patients undergoing surgery included older age (OR=1.004, CI: 1.002-1.007, P =0.0018), higher BMI (OR=1.02, CI: 1.011-1.029, P <0.0001), high-income quartile (OR=1.343, CI: 1.177-1.533, P <0.0001), and male sex (OR=1.189, CI: 1.085-1.302, P =0.0002).

CONCLUSIONS

A statistically significant association with undergoing surgery was observed with a referral by an MSK provider, older age, male sex, high BMI, and a high-income quartile home zip code. Understanding these factors and patterns is critical for optimizing practice efficiency and reducing the burdens of inappropriate referrals.

Does Time to Imaging and Surgery for Distal Radius Fractures Vary based on Geographic Socioeconomic Disadvantage?

BACKGROUND

While disparities in aspects of distal radius fracture (DRF) management and orthopedics at large have been studied, disparities in time to DRF evaluation and treatment are unknown. We sought to determine if geographic socioeconomic disadvantage is associated with time to imaging in the emergency department (ED) and time to surgery for DRFs.

METHODS

We performed a time-to-event analysis of 105 patients undergoing DRF surgery after ED triage within our hospital system between January 1, 2015, and January 1, 2020. Area Deprivation Index (ADI) national percentile was used as the metric of geographic socioeconomic disadvantage for each patient's ZIP code of residence. We performed Cox regression analysis to determine hazard ratios to undergo DRF imaging and surgery for patients in each ADI group, adjusting for potential confounders, α = 0.05.

RESULTS

There was no association between geographic socioeconomic disadvantage and time to DRF imaging, after adjusting for confounders. However, compared to patients from the least disadvantaged areas, patients from the most disadvantaged areas (ADI Quartiles 3 and 4) had an adjusted hazard ratio for surgery of 0.55 [0.32, 0.94] (P = .03), and were thus 45% [6%, 68%] less likely to undergo surgery for DRF at any time following ED triage.

CONCLUSIONS

Operative patients from more socioeconomically disadvantaged neighborhoods see disparities in time to surgery for DRF. Equitable access to timely surgical care is needed and may be improved with increased access to orthopedic surgeons, patient education, support in navigating the health system, and improved continuity of fracture care.

LEVEL OF EVIDENCE

Level III.

Cross-Cultural Adaptation and Validation of the Arabic Version of the Harris Hip Score

Background

The Harris Hip Score (HHS) questionnaire has been translated and validated into many languages including Italian, Portuguese, and Turkish but not Arabic. The goal of this study was to translate HHS into the Arabic language with cross-cultural adaptation to include and benefit Arabic speaking communities as it is the most widely used instrument for disease-specific hip joint evaluation and measurement of total hip arthroplasty outcome.

Methods

This questionnaire was translated following a clear and user-friendly guideline protocol. The Cronbach's alpha was used to assess the reliability and internal consistency of the items of HHS. Additionally, the constructive validity of HHS was evaluated against the 36-Item Short Form Survey (SF-36).

Results

A total of 100 participants were included in this study, of which 30 participants were re-evaluated for reliability testing. Cronbach's alpha of the total score of Arabic HHS is 0.528, and after the standardization, it changed to 0.742 which is within the recommended range (0.7-0.9). Lastly, the correlation between HHS and SF-36 was r = 0.71 (P < .001) which represents a strong correlation between the Arabic HHS and SF-36.

Conclusions

Based on the results, we believe that the Arabic HHS can be used by clinicians, researchers, and patients to evaluate and report hip pathologies and total hip arthroplasty treatment efficacy.

Indication for spinal surgery: associated factors and regional differences in Germany

BACKGROUND

Rising surgery rates have raised questions about the indications for spinal surgery. The study investigated patient-level and regional factors associated with spinal surgery for patients with spinal diseases.

METHODS

We undertook a cohort study based on routine healthcare data from Germany of 18.4 million patients within 60.9 million episodes of two patient-years before a possible spinal surgery in the time period 2008 to 2016. Using a Poisson model, the effects of a broad range of patient-related (sociodemographic, morbidity, social status), disease- and healthcare-related (physicians' specialty, conservative treatments) and regional variables were analyzed.

RESULTS

There was substantial regional heterogeneity in the occurrence of spinal surgery which decreased by only one quarter when controlling for the various determinants assessed. Previous musculoskeletal and mental health disorders as well as physical therapy were associated with a lower probability of surgery in the fully-adjusted model. Prescriptions for pain medication and consultations of specialists were associated with a higher probability of surgery. However, the specific severity of the vertebral diseases could not be taken into account in the analysis. Furthermore, a substantial proportion of patients with surgery did not receive a consultation with an outpatient specialist (29.5%), preoperative diagnostics (37.0%) or physical therapy (48.3%) before hospital admission.

CONCLUSION

This large study on spinal diseases in Germany highlights important patterns in medical care of spinal diseases and their association with the probability of spinal surgery. However, only a relatively small proportion of the regional heterogeneity in spinal surgery could be explained by the extensive consideration of confounders, which suggests the relevance of other unmeasured factors like physicians' preferences.

Explaining regional variation in elective hip and knee arthroplasties in Finland 2010 - 2017-a register-based cohort study

Background

A persistent research finding in industrialised countries has been regional variation in medical practices including elective primary hip and knee arthroplasty. The aim of the study was to examine regional variations in elective total hip and knee arthroplasties over time, and the proportions of these variations which can be explained by individual level or area-level differences in need.

Methods

We obtained secondary data from the Care Register for Health Care to study elective primary hip and knee arthroplasties in total Finnish population aged 25 + years between 2010 and 2017. Two-level Poisson regression models – individuals and hospital regions – were used to study regional differences in the incidence of elective hip and knee arthroplasties in two time periods: 2010 − 2013 and 2014 − 2017. The impact of several individual level explanatory factors (age, socioeconomic position, comorbidities) and area-level factors (need and supply of operations) was measured with the proportional change in variance. Predictions of incidence were measured with incidence rate ratios. The relative differences in risk of the procedures in regions were described with median rate ratios.

Results

We found small and over time relatively stable regional variation in hip arthroplasties in Finland, while the variation was larger in knee arthroplasties and decreased during the study period. In 2010 − 2013 individual socioeconomic variables explained 10% of variation in hip and 4% in knee arthroplasties, an effect that did not emerge in 2014 − 2017. The area-level musculoskeletal disorder index reflecting the need for care explained a further 44% of the variation in hip arthroplasties in 2010 − 2013, but only 5% in 2014 − 2017 and respectively 22% and 25% in knee arthroplasties. However, our final models explained the regional differences only partially.

Conclusions

Our results suggest that eligibility criteria in total hip and knee arthroplasty are increasingly consistent between Finnish hospital districts. Factors related to individual level and regional level need both had an important role in explaining regional variations. Further study is needed on the effect of health policy on equity in access to care in these operations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08305-7.

Learning from the past to plan for the future: A scoping review of musculoskeletal clinical research in Sweden 2010-2020

BACKGROUND

The aims of this study are to 1) determine the scope of musculoskeletal (MSK)-related clinical research in Sweden; 2) collate the amount of first-tier funding received; 3) discuss strategies and infrastructure supporting future MSK clinical trials in Sweden.

METHODS

A systematic scoping review protocol was applied in PubMed, Scopus, and SweCRIS databases. The articles were examined, and data were extracted in multiple stages by three blinded authors.

RESULTS

The search strategy resulted in 3,025 publications from 479 Swedish-affiliated authors. Primary health care was the basis for 14% of the publications, 84% from secondary health care, and 2% from occupational health care with a similar proportional distribution of first-tier research grant financing. Approximately one in six publications were randomized controlled trials (RCTs), while the majority were of observational cohort design. The majority of publications in primary and occupational health care were related to pain disorders (51 and 67%, respectively), especially diagnosis, prognosis, and healthcare organizational-related interventions (34%) and rehabilitation (15%) with similar proportional distribution of first-tier research grant financing. In secondary health care, rheumatic inflammatory disorder-related publications were most prevalent (30%), most frequently concerning diagnosis, prognosis, and healthcare organizational-related interventions (20%), attracting approximately half of all first-tier funding. Publications related to degenerative joint disorders (25%), fractures (16%), and joint, tendon, and muscle injuries (13%) frequently concerned surgical and other orthopedic-related interventions (16, 6, and 8%, respectively). Pain disorder-related publications (10%) as well as bone health and osteoporosis-related publications (4%) most frequently concerned diagnosis, prognosis, and healthcare organizational-related interventions (5 and 3%, respectively).

CONCLUSIONS

Swedish-affiliated MSK disorder research 2010-2020 was predominantly observational cohort rather than RCT based. There was skewed first-tier funding allocation considering prevalence/incidence and burden of disease. Use of infrastructure supporting register-based RCTs, placebo-controlled RCTs, and hybrid effectiveness-implementation studies on prevention and clinical intervention is important strategies for the future in all healthcare sectors.

Understanding Variation in Postacute Care: Developing Rehabilitation Service Areas Through Geographic Mapping

OBJECTIVE

The aims of the study were to demonstrate a method for developing rehabilitation service areas and to compare service areas based on postacute care rehabilitation admissions to service areas based on acute care hospital admissions.

DESIGN

We conducted a secondary analysis of 2013-2014 Medicare records for older patients in Texas (N = 469,172). Our analysis included admission records for inpatient rehabilitation facilities, skilled nursing facilities, long-term care hospitals, and home health agencies. We used Ward's algorithm to cluster patient ZIP Code Tabulation Areas based on which facilities patients were admitted to for rehabilitation. For comparison, we set the number of rehabilitation clusters to 22 to allow for comparison to the 22 hospital referral regions in Texas. Two methods were used to evaluate rehabilitation service areas: intraclass correlation coefficient and variance in the number of rehabilitation beds across areas.

RESULTS

Rehabilitation service areas had a higher intraclass correlation coefficient (0.081 vs. 0.076) and variance in beds (27.8 vs. 21.4). Our findings suggest that service areas based on rehabilitation admissions capture has more variation than those based on acute hospital admissions.

CONCLUSIONS

This study suggests that the use of rehabilitation service areas would lead to more accurate assessments of rehabilitation geographic variations and their use in understanding rehabilitation outcomes.

How Do Medical Students Perceive Diversity in Orthopaedic Surgery, and How Do Their Perceptions Change After an Orthopaedic Clinical Rotation?

BACKGROUND

A diverse physician workforce improves the quality of care for all patients, and there is a need for greater diversity in orthopaedic surgery. It is important that medical students of diverse backgrounds be encouraged to pursue the specialty, but to do so, we must understand students' perceptions of diversity and inclusion in orthopaedics. We also currently lack knowledge about how participation in an orthopaedic clinical rotation might influence these perceptions.

QUESTIONS/PURPOSES

(1) How do the perceptions of diversity and inclusion in orthopaedic surgery compare among medical students of different gender identities, races or ethnicities, and sexual orientations? (2) How do perceptions change after an orthopaedic clinical rotation among members of demographic groups who are not the majority in orthopaedics (that is, cis-gender women, underrepresented racial minorities, other racial minorities, and nonheterosexual people)?

METHODS

We surveyed students from 27 US medical schools who had completed orthopaedic rotations. We asked about their demographic characteristics, rotation experience, perceptions of diversity and inclusion in orthopaedics, and personal views on specialty choice. Questions were derived from diversity, equity, and inclusion climate surveys used at major academic institutions. Cis-gender men and cis-gender women were defined as those who self-identified their gender as men or women, respectively, and were not transgender. Forty-five percent (59 of 131) of respondents were cis-men and 53% (70 of 131) were cis-women; 49% (64 of 131) were white, 20% (26 of 131) were of underrepresented racial minorities, and 31% (41 of 131) were of other races. Eighty-five percent (112 of 131) of respondents were heterosexual and 15% (19 of 131) reported having another sexual orientation. We compared prerotation and postrotation perceptions of diversity and inclusion between majority and nonmajority demographic groups for each demographic domain (for example, cis-men versus cis-women). We also compared prerotation to postrotation perceptions within each nonmajority demographic group. To identify potential confounding variables, we performed univariate analysis to compare student and rotation characteristics across the demographic groups, assessed using an alpha of 0.05. No potential confounders were identified. Statistical significance was assessed at a Bonferroni-adjusted alpha of 0.0125. Our estimated response percentage was 26%. To determine limitations of nonresponse bias, we compared all early versus late responders and found that for three survey questions, late responders had a more favorable perception of diversity in orthopaedic surgery, whereas for most questions, there was no difference.

RESULTS

Before rotation, cis-women had lower agreement that diversity and inclusion are part of orthopaedic culture (mean score 0.96 ± 0.75) compared with cis-men (1.4 ± 1.1) (mean difference 0.48 [95% confidence interval 0.16 to 0.81]; p = 0.004), viewed orthopaedic surgery as less diverse (cis-women 0.71 ± 0.73 versus cis-men 1.2 ± 0.92; mean difference 0.49 [95% CI 0.20 to 0.78]; p = 0.001) and more sexist (cis-women 1.3 ± 0.92 versus cis-men 1.9 ± 1.2; mean difference 0.61 [95% CI 0.23 to 0.99]; p = 0.002), believed they would have to work harder than others to be valued equally (cis-women 2.8 ± 1.0 versus cis-men 1.9 ± 1.3; mean difference 0.87 [95% CI 0.45 to 1.3]; p < 0.001), and were less likely to pursue orthopaedic surgery (cis-women 1.4 ± 1.4 versus cis-men 2.6 ± 1.1; mean difference 1.2 [95% CI 0.76 to 1.6]; p < 0.001). Before rotation, underrepresented minorities had less agreement that diversity and inclusion are part of orthopaedic surgery culture (0.73 ± 0.72) compared with white students (1.5 ± 0.97) (mean difference 0.72 [95% CI 0.35 to 1.1]; p < 0.001). Many of these differences between nonmajority and majority demographic groups ceased to exist after rotation. Compared with their own prerotation beliefs, after rotation, cis-women believed more that diversity and inclusion are part of orthopaedic surgery culture (prerotation mean score 0.96 ± 0.75 versus postrotation mean score 1.2 ± 0.96; mean difference 0.60 [95% CI 0.22 to 0.98]; p = 0.002) and that orthopaedic surgery is friendlier (prerotation 2.3 ± 1.2 versus postrotation 2.6 ± 1.1; mean difference 0.41 [95% CI 0.14 to 0.69]; p = 0.004), more diverse (prerotation 0.71 ± 0.73 versus postrotation 1.0 ± 0.89; mean difference 0.28 [95% CI 0.08 to 0.49]; p = 0.007), less sexist (prerotation 1.3 ± 0.92 versus postrotation 1.9 ± 1.0; mean difference 0.63 [95% CI 0.40 to 0.85]; p < 0.001), less homophobic (prerotation 2.1 ± 1.0 versus postrotation 2.4 ± 0.97; mean difference 0.27 [95% CI 0.062 to 0.47]; p = 0.011), and less racist (prerotation 2.3 ± 1.1 versus postrotation 2.5 ± 1.1; mean difference 0.28 [95% CI 0.099 to 0.47]; p = 0.003). Compared with before rotation, after rotation cis-women believed less that they would have to work harder than others to be valued equally on the rotation (prerotation 2.8 ± 1.0 versus postrotation 2.5 ± 1.0; mean difference 0.31 [95% CI 0.12 to 0.50]; p = 0.002), as did nonheterosexual students (prerotation 2.4 ± 1.4 versus postrotation 1.8 ± 1.3; mean difference 0.56 [95% 0.21 to 0.91]; p = 0.004). Underrepresented minority students saw orthopaedic surgery as less sexist after rotation compared with before rotation (prerotation 1.5 ± 1.1 versus postrotation 2.0 ± 1.1; mean difference 0.52 [95% CI 0.16 to 0.89]; p = 0.007).

CONCLUSION

Even with an estimated 26% response percentage, we found that medical students of demographic backgrounds who are not the majority in orthopaedics generally perceived that orthopaedic surgery is less diverse and inclusive than do their counterparts in majority groups, but these views often change after a clinical orthopaedic rotation.

CLINICAL RELEVANCE

These perceptions may be a barrier to diversification of the pool of medical student applicants to orthopaedics. However, participation in an orthopaedic surgery rotation is associated with mitigation of many of these negative perceptions among diverse students. Medical schools have a responsibility to develop a diverse workforce, and given our findings, schools should promote participation in a clinical orthopaedic rotation. Residency programs and orthopaedic organizations can also increase exposure to the field through the rotation and other means. Doing so may ultimately diversify the orthopaedic surgeon workforce and improve care for all orthopaedic patients.

Is Geographic Socioeconomic Disadvantage Associated with the Rate of THA in Medicare-aged Patients?

BACKGROUND

Disparities in THA use may lead to inequitable care. Prior research has focused on disparities based on individual-level and isolated socioeconomic and demographic variables. To our knowledge, the role of composite, community-level geographic socioeconomic disadvantage has not been studied in the United States. As disparities persist, exploring the potential underlying drivers of these inequities may help in developing more targeted recommendations on how to achieve equitable THA use.

QUESTIONS/PURPOSES

(1) Is geographic socioeconomic disadvantage associated with decreased THA rates in Medicare-aged patients? (2) Do these associations persist after adjusting for differences in gender, race, ethnicity, and proximity to hospitals performing THA?

METHODS

In a study with a cross-sectional design, using population-based data from five-digit ZIP codes in Maryland, USA, from July 1, 2012 to March 31, 2019, we included all inpatient and outpatient primary THAs performed in individuals 65 years of age or older at acute-care hospitals in Maryland, as reported in the Health Services Cost Review Commission database. This database was selected because it provided the five-digit ZIP code data necessary to answer our study question. We excluded THAs performed for nonelective indications. We examined the annual rate of THA in our study population for each Maryland ZIP code, adjusted for differences across areas in distributions of gender, race, ethnicity, and distance to the nearest hospital performing THAs. Four hundred fourteen ZIP codes were included, with an overall mean ± SD THA rate of 371 ± 243 per 100,000 persons 65 years or older, a rate similar to that previously reported in individuals aged 65 to 84 in the United States. Statistical significance was assessed at α = 0.05.

RESULTS

THA rates were higher in more affluent areas, with the following mean rates per 100,000 persons 65 years or older: 422 ± 259 in the least socioeconomically disadvantaged quartile, 339 ± 223 in the second-least disadvantaged, 277 ± 179 in the second-most disadvantaged, and 214 ± 179 in the most-disadvantaged quartile (p < 0.001). After adjustment for distributions in gender, race, ethnicity, and hospital proximity, we found that geographic socioeconomic disadvantage was still associated with THA rate. Compared with the least-disadvantaged quartile, the second-least disadvantaged quartile had 63 fewer THAs per 100,000 people (95% confidence interval 12 to 114), the second-most disadvantaged quartile had 136 fewer THAs (95% CI 62 to 211), and the most-disadvantaged quartile had 183 fewer THAs (95% CI 41 to 325).

CONCLUSION

Geographic socioeconomic disadvantage may be the underlying driver of disparities in THA use. Although our study does not determine the "correct" rate of THA, our findings support increasing access to elective orthopaedic surgery in disadvantaged geographic communities, compared with prior research and efforts that have studied and intervened on the basis of isolated factors such as race and gender. Increasing access to orthopaedic surgeons in disadvantaged neighborhoods, educating physicians about when surgical referral is appropriate, and educating patients from these geographic communities about the risks and benefits of THA may improve equitable orthopaedic care across neighborhoods. Future studies should explore disparities in rates of appropriate THA and the role of density of orthopaedic surgeons in an area.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Predicting knee replacement in participants eligible for disease-modifying osteoarthritis drug treatment with structural endpoints

OBJECTIVE

Evaluate associations between 2-year change in radiographic or quantitative magnetic resonance imaging (qMRI) structural measures, and knee replacement (KR), within a subsequent 7-year follow-up period.

METHOD

Participants from the Osteoarthritis Initiative were selected based on potential eligibility criteria for a disease-modifying osteoarthritis (OA) drug trial: Kellgren-Lawrence grade 2 or 3; medial minimum joint space width (mJSW) ≥2.5 mm; knee pain at worst 4-9 in the past 30 days on an 11-point scale, or 0-3 if medication was taken for joint pain; and availability of structural measures over 2 years. Mean 2-year change in structural measures was estimated and compared with two-sample independent t-tests for KR and no KR. Area under the receiver operating characteristic curve (AUC) was estimated using 2-year change in structural measures for prediction of future KR outcomes.

RESULTS

Among 627 participants, 107 knees underwent KR during a median follow-up of 6.7 years after the 2-year imaging period. Knees that received KR during follow-up had a greater mean loss of cartilage thickness in the total femorotibial joint and medial femorotibial compartment on qMRI, as well as decline in medial fixed joint space width on radiographs, compared with knees that did not receive KR. These imaging measures had similar, although modest discrimination for future KR (AUC 0.62, 0.60, and 0.61, respectively).

CONCLUSIONS

2-year changes in qMRI femorotibial cartilage thickness and radiographic JSW measures had similar ability to discriminate future KR in participants with knee OA, suggesting that these measures are comparable biomarkers/surrogate endpoints of structural progression.

Differences in Baseline Joint Moments and Muscle Activation Patterns Associated With Knee Osteoarthritis Progression When Defined Using a Clinical Versus a Structural Outcome

Both structural and clinical changes can signify knee osteoarthritis progression; however, these changes are not always concurrent. A better understanding of mechanical factors associated with progression and whether they differ for structural versus clinical outcomes could lead to improved conservative management. This study examined baseline gait differences between progression and no progression groups defined at an average of 7-year follow-up using 2 different outcomes indicative of knee osteoarthritis progression: radiographic medial joint space narrowing and total knee arthroplasty. Of 49 individuals with knee osteoarthritis who underwent baseline gait analysis, 32 progressed and 17 did not progress using the radiographic outcome, while 13 progressed and 36 did not progress using the arthroplasty outcome. Key knee moment and electromyography waveform features were extracted using principal component analysis, and confidence intervals were used to examine between-group differences in these metrics. Those who progressed using the arthroplasty outcome had prolonged rectus femoris and lateral hamstrings muscle activation compared with the no arthroplasty group. Those with radiographic progression had greater mid-stance internal knee rotation moments compared with the no radiographic progression group. These results provide preliminary evidence for the role of prolonged muscle activation in total knee arthroplasty, while radiographic changes may be related to loading magnitude.

Nonoperative Management Prior to Hip Arthroscopy for Femoroacetabular Impingement Syndrome: An Investigation Into the Utilization and Content of Physical Therapy

BACKGROUND

There has been a significant increase in surgeries for femoroacetabular impingement syndrome in recent years, but little is known about the use of physical therapy prior to surgery.

OBJECTIVES

To investigate the use of physical therapy prior to hip arthroscopy for femoroacetabular impingement syndrome, by assessing the number of visits and use of exercise. A secondary objective was to evaluate whether comorbidities prior to surgery were associated with the use of physical therapy.

METHODS

In this retrospective observational cohort study, eligible participants between the ages of 18 and 50 years undergoing hip arthroscopy between 2004 and 2013 in the Military Health System were included. Patients were categorized based on whether they saw a physical therapist for their hip in the year prior to surgery. For physical therapy patients, dosing variables were identified, including total number of visits and visits that included an exercise therapy procedure code.

RESULTS

Of 1870 participants, 1106 (59.1%) did not see a physical therapist for their hip prior to surgery. For those who did, the median number of visits was 2. Only 220 (11.8%) had 6 or more unique visits with an exercise therapy procedure code. Exercise was coded in 43.4% to 63.0% of the total visits in each individual course of care (mean, 52.3%). There was an association between substance abuse and exercise utilization. No other comorbidities were associated with physical therapy or exercise therapy utilization.

CONCLUSION

Physical therapy was not commonly used before undergoing arthroscopic hip surgery by patients seeking care in the Military Health System. Further research is needed to understand the reasons for poor utilization and better define failed nonoperative management.

LEVEL OF EVIDENCE

Therapy, level 2b. J Orthop Sports Phys Ther 2019;49(8):593-600. Epub 15 May 2019. doi:10.2519/jospt.2019.8581.

The Influence of Insurance Status on the Surgical Treatment of Acute Spinal Fractures

STUDY DESIGN

A retrospective, propensity score, multivariate analysis of the National Trauma Data Bank (NTDB) between 2008 and 2011.

OBJECTIVE

The aim of this study was to determine the relationship between insurance status and rates of surgery for acute spinal fractures with and without spinal cord injury (SCI).

SUMMARY OF BACKGROUND DATA

The decision for surgery in patients with spinal fractures is often based on fracture pattern and stability, associated SCI, and the presence of ligamentous and other associated injuries. It is poorly understood how nonclinical factors, such as insurance status, influence the decision for surgical intervention in patients sustaining spinal trauma.

METHODS

Using NTDB admission years 2008 to 2011, we included patients 18 to 64 years old who sustained a fracture of the cervical or thoracolumbar spine. Patients were excluded if they sustained polytrauma (Injury Severity Score ≥27) or a major injury (Abbreviated Injury Scale severity ≥3) to the head, thorax, or abdomen. Our main outcome measure was surgical versus nonsurgical treatment for spinal injury; our main predictor was insurance status. Hierarchical multivariate regression analysis and propensity scores were used to determine the relationship between insurance status and surgical treatment, controlling for other factors. We calculated adjusted odds ratios (ORs) for rates of surgery.

RESULTS

Our propensity score multivariate analysis demonstrated significantly higher rates of surgery in patients with SCI (OR = 11.76, P < 0.001), insurance (OR = 1.27, P < 0.001), white (OR = 1.21, P = 0.018) versus black race, blunt trauma (OR = 5.63, P < 0.001), shock (OR = 1.62, P < 0.001), higher Glasgow Coma Scale (GCS) score (OR = 1.02, P = 0.002), transfer from lower acuity hospital (OR = 1.51, P < 0.001), and treatment at teaching hospitals (OR = 1.49, P < 0.001). Multivariable subgroup analysis of SCI patients similarly revealed higher surgical rates for insured patients (OR = 1.46, P < 0.001) than those without insurance.

CONCLUSION

Patients with traumatic spine fractures were more likely to receive surgery if they were insured, regardless of the presence of SCI.

OARSI Clinical Trials Recommendations: Design, conduct, and reporting of clinical trials for knee osteoarthritis

The goal of this document is to update the original OARSI recommendations specifically for the design, conduct, and reporting of clinical trials that target symptom or structure modification among individuals with knee osteoarthritis (OA). To develop recommendations for the design, conduct, and reporting of clinical trials for knee OA we initially drafted recommendations through an iterative process. Members of the working group included representatives from industry and academia. After the working group members reviewed a final draft, they scored the appropriateness for recommendations. After the members voted we calculated the median score among the nine members of the working group who completed the score. The document includes 25 recommendations regarding randomization, blocking and stratification, blinding, enhancing accuracy of patient-reported outcomes (PRO), selecting a study population and index knee, describing interventions, patient-reported and physical performance measures, structural outcome measures, biochemical biomarkers, and reporting recommendations. In summary, the working group identified 25 recommendations that represent the current best practices regarding clinical trials that target symptom or structure modification among individuals with knee OA. These updated recommendations incorporate novel technologies (e.g., magnetic resonance imaging (MRI)) and strategies to address the heterogeneity of knee OA.

Geographic and facility variation in inpatient stroke rehabilitation: multilevel analysis of functional status

OBJECTIVE

To examine geographic and facility variation in cognitive and motor functional outcomes after postacute inpatient rehabilitation in patients with stroke.

DESIGN

Retrospective cohort design using Centers for Medicare and Medicaid Services (CMS) claims files. Records from 1209 rehabilitation facilities in 298 hospital referral regions (HRRs) were examined. Patient records were analyzed using linear mixed models. Multilevel models were used to calculate the variation in outcomes attributable to facilities and geographic regions.

SETTING

Inpatient rehabilitation units and facilities.

PARTICIPANTS

Patients (N=145,460) with stroke discharged from inpatient rehabilitation from 2006 through 2009.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Cognitive and motor functional status at discharge measured by items in the CMS Inpatient Rehabilitation Facility-Patient Assessment Instrument.

RESULTS

Variation profiles indicated that 19.1% of rehabilitation facilities were significantly below the mean functional status rating (mean ± SD, 81.58±22.30), with 221 facilities (18.3%) above the mean. Total discharge functional status ratings varied by 3.57 points across regions. Across facilities, functional status values varied by 29.2 points, with a 9.1-point difference between the top and bottom deciles. Variation in discharge motor function attributable to HRR was reduced by 82% after controlling for cluster effects at the facility level.

CONCLUSIONS

Our findings suggest that variation in motor and cognitive function at discharge after postacute rehabilitation in patients with stroke is accounted for more by facility than geographic location.

Effect of obesity and clinical factors on pre-incision time: study of operating room workflow

As the obese population is increasing rapidly worldwide, there is more interest to study the different aspects of obesity and its impact especially on healthcare outcomes and health related issues. Targeting non-surgical times in the operating room (OR), this study focuses on the effect of obesity along with clinical factors on pre-incision times in OR. Specifically, both the individual and combined effect of clinical factors with obesity on pre-incision times is studied. Results show that with the confidence of 95%, pre-incision time in the OR of obese patients is significantly higher than those for non-obese patients by approximately five percent. Findings also show that more complex cases do not exhibit significant differences between these patient subgroups.

Trends in the surgical treatment of articular cartilage defects of the knee in the United States

PURPOSE

The purpose of this study was to evaluate trends in surgical treatment of articular cartilage defects of the knee in the United States.

METHODS

The current procedural terminology (CPT) billing codes of patients undergoing articular cartilage procedures of the knee were searched using the PearlDiver Patient Record Database, a national database of insurance billing records. The CPT codes for chondroplasty, microfracture, osteochondral autograft, osteochondral allograft, and autologous chondrocyte implantation (ACI) were searched.

RESULTS

A total of 163,448 articular cartilage procedures of the knee were identified over a 6-year period. Microfracture and chondroplasty accounted for over 98% of cases. There was no significant change in the incidence of cartilage procedures noted from 2004 (1.27 cases per 10,000 patients) to 2009 (1.53 cases per 10,000 patients) (p = 0.06). All procedures were performed more commonly in males (p < 0.001). This gender difference was smallest in patients undergoing chondroplasty (51 % males and 49% females) and greatest for open osteochondral allograft (61% males and 39% females). Chondroplasty and microfracture were most commonly performed in patients aged 40-59, while all other procedures were performed most frequently in patients <40 years old (p < 0.001).

CONCLUSIONS

Articular cartilage lesions of the knee are most commonly treated with microfracture or chondroplasty in the United States. Chondroplasty and microfracture were most often performed in middle-aged patients, whereas osteochondral autograft, allograft, and ACI were performed in younger patients, and more frequently in males.

LEVEL OF EVIDENCE

Cross-sectional study, Level IV.

Does obesity affect the surgical outcome and complication rates of spinal surgery? A meta-analysis

BACKGROUND

As obesity becomes more prevalent, it becomes more common among patients considering orthopaedic surgery, including spinal surgery. However, there is some controversy regarding whether obesity is associated with complications, failed reconstructions, or reoperations after spinal surgery.

QUESTIONS/PURPOSES

We wished to determine, in patients undergoing spine surgery, whether obesity is associated with (1) surgical site infection, (2) mortality and the need for revision surgery after spinal surgery, and (3) increased surgical time and blood loss.

METHODS

A systematic literature search was performed to collect comparative or controlled studies that evaluated the influence of obesity on the surgical and postoperative outcomes of spinal surgery. Two reviewers independently selected trials, extracted data, and assessed the methodologic quality and quality of evidence. Pooled odds ratios (OR) and mean differences (MD) with 95% CIs were calculated using the fixed-effects model or random-effects model. Data were analyzed using RevMan 5.1. MOOSE criteria were used to ensure this project's validity. Thirty-two studies involving 97,326 patients eventually were included.

RESULTS

Surgical site infection (OR, 2.33; 95% CI, 1.94-2.79), venous thromboembolism (OR, 3.15; 95% CI, 1.92-5.17), mortality (OR, 2.6; 95% CI, 1.50-4.49), revision rate (OR, 1.43; 95% CI, 1.05-1.93) operating time (OR, 14.55; 95% CI, 10.03-19.07), and blood loss (MD, 28.89; 95% CI, 14.20-43.58), were all significantly increased in the obese group.

CONCLUSION

Obesity seemed to be associated with higher risk of surgical site infection and venous thromboembolism, more blood loss, and longer surgical time. Future prospective studies are needed to confirm the relationship between obesity and the outcome of spinal surgery.

Enhanced recovery in total hip replacement: a clinical review

The outcome after total hip replacement has improved with the development of surgical techniques, better pain management and the introduction of enhanced recovery pathways. These pathways require a multidisciplinary team to manage pre-operative education, multimodal pain control and accelerated rehabilitation. The current economic climate and restricted budgets favour brief hospitalisation while minimising costs. This has put considerable pressure on hospitals to combine excellent results, early functional recovery and shorter admissions. In this review we present an evidence-based summary of some common interventions and methods, including pre-operative patient education, pre-emptive analgesia, local infiltration analgesia, pre-operative nutrition, the use of pulsed electromagnetic fields, peri-operative rehabilitation, wound dressings, different surgical techniques, minimally invasive surgery and fast-track joint replacement units.

Heterogeneity in health status and the influence of patient characteristics across patients seeking musculoskeletal orthopaedic care - a cross-sectional study

Background

Health status is an important predictor of patient outcomes. Consequently, identifying patient predictors of health status is essential. In musculoskeletal orthopaedic care, the majority of work examining the association between patient characteristics and health status has been undertaken among hip/knee cohorts. We investigate these associations comparing findings across four musculoskeletal cohorts (hip/knee; foot/ankle; neck/back; elbow/shoulder).

Methods

Patients seeking elective musculoskeletal orthopaedic care were recruited prior to consultation. Questionnaires captured health domain status (bodily pain, physical functioning, and mental and general health) and covariates: demographics; socioeconomic characteristics; and comorbidity. Scores were compared across cohorts. Two path regression analyses were undertaken. First, domain scores were simultaneously examined as dependent variables in the overall sample. Subsequently, the model was assessed stratified by cohort.

Results

1,948 patients: 454 neck/back, 767 hip/knee, 378 shoulder/elbow, 349 foot/ankle. From stratified analyses, significant variability in covariate effects was observed. Worse bodily pain scores were associated with increasing age and female sex among hip/knee, low income among foot/ankle, and overweight/obese for foot/ankle and hip/knee. Worse mental health scores were associated with low income across cohorts except elbow/shoulder, low education within neck/back, and compared to Whites, Blacks had significantly worse scores among foot/ankle, better scores among hip/knee. Worse general health scores were observed for Asians among hip/knee, Blacks among foot/ankle, and South-Asians among elbow/shoulder and neck/back.

Conclusion

The substantial heterogeneity across musculoskeletal cohorts suggests that patient- and cohort-specific approaches to patient counsel and care may be more effective for achieving optimal health and outcomes.

Income and patient-reported outcomes (PROs) after primary total knee arthroplasty

BACKGROUND

To assess whether income is associated with patient-reported outcomes (PROs) after primary total knee arthroplasty (TKA).

METHODS

We used prospectively collected data from the Mayo Clinic Total Joint Registry to assess the association of income with index knee functional improvement, moderate to severe pain and moderate to severe activity limitation at 2-year and 5-year follow-up after primary TKA using multivariable-adjusted logistic regression analyses.

RESULTS

There were 7, 139 primary TKAs at 2 years and 4, 234 at 5 years. In multivariable-adjusted analyses, at 2-year follow-up, compared to income > US$45, 000, lower incomes of ≤ US$35, 000 and > US$35, 000 to 45, 000 were associated (1) significantly with moderate to severe pain with an odds ratio (OR) 0.61 (95% CI 0.40 to 0.94) (P = 0.02) and 0.68 (95% CI 0.49 to 0.94) (P = 0.02); and (2) trended towards significance for moderate to severe activity limitation with OR 0.78 (95% CI 0.60 to 1.02) (P = 0.07) and no significant association with OR 0.96 (95% CI 0.78 to 1.20) (P = 0.75), respectively. At 5 years, odds were not statistically significantly different by income, although numerically they favored lower income. In multivariable-adjusted analyses, overall improvement in knee function was rated as 'better' slightly more often at 2 years by patients with income in the ≤ US$35, 000 range compared to patients with income > US$45, 000, with an OR 1.9 (95% CI 1.0 to 3.6) (P = 0.06).

CONCLUSIONS

We found that patients with lower income had better pain outcomes compared to patients with higher income. There was more improvement in knee function, and a trend towards less overall activity limitation after primary TKA in lower income patients compared to those with higher incomes. Insights into mediators of these relationships need to be investigated to understand how income influences outcomes after TKA.

Clinically important body weight gain following total hip arthroplasty: a cohort study with 5-year follow-up

OBJECTIVE

Literature examining the effects of total hip arthroplasty (THA) on subsequent body weight gain is inconclusive. Determining the extent to which clinically relevant weight gain occurs following THA has important public health implications.

DESIGN

We used multi-variable logistic regression to compare data from one of the largest US-based THA registries to a population-based control sample from the same geographic region. We also identified factors that increased risk of clinically important weight gain specifically among persons undergoing THA. The outcome measure of interest was weight gain of ≥5% of body weight up to 5 years following surgery.

RESULTS

The multi-variable adjusted [age, sex, body mass index (BMI), education, comorbidity and pre-surgical weight change] odds ratio for important weight gain was 1.7 [95% confidence interval (CI), 1.06, 2.6] for a person with THA as compared to the control sample. Additional arthroplasty procedures during the 5-year follow-up further increased odds for important weight gain (OR = 2.0, 95% CI, 1.4, 2.7) relative to the control sample. A patient with THA had increased risk of important post-surgical weight gain of 12% (OR = 1.12, 95% CI, 1.08, 1.16) for every kilogram of pre-operative weight loss.

CONCLUSIONS

While findings should be interpreted with caution because of missing follow-up weight data, patients with THA appear to be at increased risk of clinically important weight gain following surgery as compared to peers. Patients less than 60 years and who have lost a substantial amount of weight prior to surgery appear to be at particularly high risk of important post-surgical weight gain.

Current trends to consider with evidence-based medicine's importance: societal, financial, legal, and clinical research

Evidence-based medicine and its quality work products enter current clinical practice at a time when physicians face a confusing, contradictory, and changing practice environment. Disparate expectations by patients and policy makers; physician conflicts of interest, and an assumption that doctors control the cost of healthcare, contribute to fears that evidence based medicine in general and guidelines and performance measures in particular, will be misused. An integrated framework for developing evidence based tools is presented.