New technology: safety, efficacy, and learning curves

Effect of mobile application types on stroke rehabilitation: a systematic review

BACKGROUND

Stroke is a significant contributor of worldwide disability and morbidity with substantial economic consequences. Rehabilitation is a vital component of stroke recovery, but inpatient stroke rehabilitation programs can struggle to meet the recommended hours of therapy per day outlined by the Canadian Stroke Best Practices and American Heart Association. Mobile applications (apps) are an emerging technology which may help bridge this deficit, however this area is understudied. The purpose of this study is to review the effect of mobile apps for stroke rehabilitation on stroke impairments and functional outcomes. Specifically, this paper will delve into the impact of varying mobile app types on stroke rehabilitation.

METHODS

This systematic review included 29 studies: 11 randomized control trials and 18 quasi-experimental studies. Data extrapolation mapped 5 mobile app types (therapy apps, education apps, rehab videos, reminders, and a combination of rehab videos with reminders) to stroke deficits (motor paresis, aphasia, neglect), adherence to exercise, activities of daily living (ADLs), quality of life, secondary stroke prevention, and depression and anxiety.

RESULTS

There were multiple studies supporting the use of therapy apps for motor paresis or aphasia, rehab videos for exercise adherence, and reminders for exercise adherence. For permutations involving other app types with stroke deficits or functional outcomes (adherence to exercise, ADLs, quality of life, secondary stroke prevention, depression and anxiety), the results were either non-significant or limited by a paucity of studies.

CONCLUSION

Mobile apps demonstrate potential to assist with stroke recovery and augment face to face rehabilitation, however, development of a mobile app should be carefully planned when targeting specific stroke deficits or functional outcomes. This study found that mobile app types which mimicked principles of effective face-to-face therapy (massed practice, task-specific practice, goal-oriented practice, multisensory stimulation, rhythmic cueing, feedback, social interaction, and constraint-induced therapy) and education (interactivity, feedback, repetition, practice exercises, social learning) had the greatest benefits. Protocol registration PROPSERO (ID CRD42021186534). Registered 21 February 2021.

What Is the Learning Curve for New Technologies in Total Joint Arthroplasty? A Review

PURPOSE OF REVIEW

The adaptation of new technology in joint replacement surgery is often associated with a learning curve, as performance tends to improve with experience. The purpose of this review is to define the learning curve and its relevance to joint replacement surgery in the setting of new technological advances, and to draw analogies with the learning curve of basic surgical training.

RECENT FINDINGS

Assessing a surgeon's learning curve for a new technology is complicated and difficult. With every learning curve, the first patients subjected to the novel technology may be at higher risk for adverse events until the learning curve is overcome and a steady state is reached. While measures of performance can be clear and direct in some professions, learning curves with new technology in total joint arthroplasty have been difficult to quantify. Most attempts measure surgical learning curves via an evaluation of the surgical process or patient outcomes. There are published results of both process (i.e., operative time, accuracy of implant position) and outcome measures (i.e., complication rate, revision rate) utilized as proxy for performance during learning curves. We review the concept of the learning curve in joint replacement surgery, highlighting examples of learning curves with adaptation of new technologies, and conclude with a discussion of dilemmas and challenges.

Can Preoperative 3D Printing Change Surgeon's Operative Plan for Distal Tibia Fracture?

This study aimed to determine if 3D printing can affect surgeon's selection of plate for distal tibia fracture surgery and to find out whether orthopedic surgeons consider this technology necessary and would use it in their practice. A total of 102 orthopedic surgeons were asked to choose anatomically contoured locking plates among 5 most commonly used types for one simple and one complex distal tibia fracture based on X-ray and CT images. Next, they were provided real-size 3D printed models of the same fractures, allowed to apply each of the 5 plates to these models, and asked if they would change their choice of plate. A 10-point numeric rating scale was provided to measure the extent of the help that 3D printing provided on preoperative planning. Finally, we asked the surgeons if they would use 3D printing in their practice. Seventy-four percent of inexperienced surgeons changed their selection of plate after using 3D printed models for the complex fracture. In contrast, only 9% of experienced surgeons changed their selection of plate for the simple fracture. Surgeons rated the extent of usefulness of the 3D models in preoperative planning as a mean of 4.84 ± 2.54 points for the simple fracture and 6.63 ± 2.54 points for the complex fracture. The difference was significant (p < 0.001). Eighty-six percent of inexperienced surgeons wanted to use 3D models for complex fractures. However, only 18% of experienced surgeons wanted to use 3D printed models for simple fractures. The use of a real-size 3D-printed model often changed surgeon's preoperative selection of locking plates, especially when inexperienced surgeons evaluated a complex fracture. However, experienced surgeons did not find 3D models very useful when assessing simple fractures. Future applications of 3D models should focus on training beginners in fracture surgery, especially when complex fractures are concerned.

A Single Femoral Component for All Total Hip Replacements Performed by a Trust? Does This Affect Early Clinical and Radiological Outcomes?

BACKGROUND

Hospitals may be under pressure to implement cost saving strategies regarding prosthesis choice. This may involve the use of components which are not the first preference of individual surgeons, or those they have little experience with. We aim to examine the effect of standardizing the type of femoral stem used in a single trust, and determine whether this is safe practice, particularly in those who have never used this particular stem before.

METHODS

We report results at 2 years of 151 primary total hip arthroplasties performed using a single femoral stem. Data was split into 2 groups: those in which the operating surgeon was previously using this femoral stem, and those who were not. Radiographic outcomes measured were leg length discrepancy, cement mantle grade, and femoral stem alignment. We also report on clinical outcomes, complications, and construct survivability.

RESULTS

No significant differences in clinical outcomes were observed. Cement quality was generally worse in those with no prior use of this stem. Leg length inequality was greater in those previously using the stem (+1.57mm vs 3.83mm), however this did not correlate to clinical outcomes. Alignment was similar between the groups (P=0.464).

CONCLUSION

Our findings suggest that although clinical outcomes are similar at 2 years, radiological differences can be observed even at this early stage in follow up. Choice of components for arthroplasty should remain surgeon led until long term follow up studies can prove otherwise.level of evidence: III.

What Is the Expected Learning Curve in Computer-assisted Navigation for Bone Tumor Resection?

BACKGROUND

Computer navigation during surgery can help oncologic surgeons perform more accurate resections. However, some navigation studies suggest that this tool may result in unique intraoperative problems and increased surgical time. The degree to which these problems might diminish with experience-the learning curve-has not, to our knowledge, been evaluated for navigation-assisted tumor resections.

QUESTIONS/PURPOSES

(1) What intraoperative technical problems were observed during the first 2 years using navigation? (2) What was the mean time for navigation procedures and the time improvement during the learning curve? (3) Have there been any differences in the accuracy of the registration technique that occurred over time? (4) Did navigation achieve the goal of achieving a wide bone margin?

METHODS

All patients who underwent preoperative virtual planning for tumor bone resections and operated on with navigation assistance from 2010 to 2012 were prospectively collected. Two surgeons (GLF, LAA-T) performed the intraoperative navigation assistance. Both surgeons had more than 5 years of experience in orthopaedic oncology with more than 60 oncology cases per year per surgeon. This study includes from the very first patients performed with navigation. Although they did not take any formal training in orthopaedic oncology navigation, both surgeons were trained in navigation for knee prostheses. Between 2010 and 2012, we performed 124 bone tumor resections; of these, 78 (63%) cases were resected using intraoperative navigation assistance. During this period, our general indications for use of navigation included pelvic and sacral tumors and those tumors that were reconstructed with massive bone allografts to obtain precise matching of the host and allograft osteotomies. Seventy-eight patients treated with this technology were included in the study. Technical problems (crashes) and time for the navigation procedure were reported after surgery. Accuracy of the registration technique was defined and the surgical margins of the removed specimen were determined by an experienced bone pathologist after the surgical procedure as intralesional, marginal, or wide margins. To obtain these data, we performed a chart review and review of operative notes.

RESULTS

In four patients (of 78 [5%]), the navigation was not completed as a result of technical problems; all occurred during the first 20 cases of the utilization of this technology. The mean time for navigation procedures during the operation was 31 minutes (range, 11-61 minutes), and the early navigations took more time (the regression analysis shielded R² = 0.35 with p < 0.001). The median registration error was 0.6 mm (range, 0.3-1.1 mm). Registration did not improve over time (the regression analysis slope estimate is -0.014, with R² = 0.026 and p = 0.15). Histological examinations of all specimens showed a wide bone tumor margin in all patients. However, soft tissue margins were wide in 58 cases and marginal in 20.

CONCLUSIONS

We conclude that navigation may be useful in achieving negative bony margins, but we cannot state that it is more effective than other means for achieving this goal. Technical difficulty precluded the use of navigation in 5% of cases in this series. Navigation time decreased with more experience in the procedure but with the numbers available, we did not improve the registration error over time. Given these observations and the increased time and expense of using navigation, larger studies are needed to substantiate the value of this technology for routine use.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Unacceptable failure of the PI2® implant

The PI2® spacer is designed for treatment of trapeziometacarpal (TM) osteoarthritis. However, the shape of this implant has raised concerns about its stability. We retrospectively investigated 45 implants in 41 patients treated for trapeziometacarpal osteoarthritis in our hospital between 2004 and 2009 who underwent trapeziectomy and insertion of a PI2® spacer. Outcome parameters included revision rates and clinical outcomes correlated with implant position and scaphometacarpal distance, assessed using standard radiographs. A total of 12 implants (27%) were removed at a median time of 10 months (interquartile range (IQR), 7-22 months). These included five dislocations and one early infection. Additionally, a further six patients underwent revision due to persistent pain. Three of these had scapho-trapezoid osteoarthritis, two had developed subluxation of the implant, and one did not show any radiographic abnormalities. A review of patient records revealed that 33 implants remained in place at a median time of 29 months (IQR, 20-57). However, of those, only 21 implants (64%) in 17 patients were available for clinical evaluation at a median follow-up of 29 months (IQR, 19-62 months). No significant differences in clinical outcomes including functional results were observed between in-place ( n = 8) and subluxated ( n = 13) implants. Due to the high revision rate (12/45), consistent with other reports in the literature, we have abandoned the use of the PI2® spacer. We recommend the establishment of a registry for evaluation of future implants.

TYPE OF STUDY/LEVEL OF EVIDENCE

Case-series study/level IV.

What is the learning curve for the anterior approach for total hip arthroplasty?

BACKGROUND

There are many factors that may affect the learning curve for total hip arthroplasty (THA) and surgical approach is one of these. There has been renewed interest in the direct anterior approach for THA with variable outcomes reported, but few studies have documented a surgeon's individual learning curve when using this approach.

QUESTIONS/PURPOSES

(1) What was the revision rate for all surgeons adopting the anterior approach for placement of a particular implant? (2) What was the revision rate for surgeons who performed > 100 cases in this fashion? (3) Is there a minimum number of cases required to complete a learning curve for this procedure?

METHODS

The Australian Orthopaedic Association National Joint Replacement Registry prospectively collects data on all primary and revision joint arthroplasty surgery. We analyzed all conventional THAs performed up to December 31, 2013, with a primary diagnosis of osteoarthritis using a specific implant combination and secondarily those associated with surgeons performing more than 100 procedures. Ninety-five percent of these procedures were performed through the direct anterior approach. Procedures using this combination were ordered from earliest (first procedure date) to latest (last procedure date) for each individual surgeon. Using the order number for each surgeon, five operation groups were defined: one to 15 operations, 16 to 30 operations, 31 to 50 operations, 51 to 100 operations, and > 100 operations. The primary outcome measure was time to first revision using Kaplan-Meier estimates of survivorship.

RESULTS

Sixty-eight surgeons performed 5499 THAs using the specified implant combination. The cumulative percent revision at 4 years for all 68 surgeons was 3% (95% confidence interval [CI], 2.5-3.8). For surgeons who had performed over 100 operations, the cumulative revision rate was 3% (95% CI, 2.0-3.5). It was not until surgeons had performed over 50 operations that there was no difference in the cumulative percent revision compared with over 100 operations. The cumulative percent revision for surgeons performing 51 to 100 operations at 4 years was 3% (95% CI, 1.5-5.4) and over 100 operations 2% (95% CI, 1.2-2.7; hazard ratio, 1.40 [95% CI, 0.7-2.7]; p = 0.33).

CONCLUSIONS

There is a learning curve for the anterior approach for THA even when using a prosthesis combination specifically marketed for that approach. We found that 50 or more procedures need to be performed by a surgeon before the rate of revision is no different from performing 100 or more procedures. Surgeons should be aware of this initial higher rate of revision when deciding which approach delivers the best outcome for their patients.