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Liang ZJ, Koh DTS, Soong J, Lee KH, Bin Abd Razak HR. Severity of knee osteoarthritis does not affect clinical outcomes following proximal fibular osteotomy - A systematic review and pooled analysis. J Clin Orthop Trauma 2024; 54:102473. [PMID: 39050652 PMCID: PMC11263641 DOI: 10.1016/j.jcot.2024.102473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 06/05/2024] [Accepted: 06/24/2024] [Indexed: 07/27/2024] Open
Abstract
Background & aims Knee osteoarthritis (KOA) is a progressive degenerative disease of chronic nature. The mainstay of surgical management for KOA would be total knee arthroplasty. Joint preserving options like High Tibial Osteotomy (HTO) and Proximal Fibular Osteotomy (PFO) have been offered as an inexpensive option by knee preservation surgeons. Current literature on PFO outcomes lack of clarity for specific indications for offering PFO based on degree of severity of KOA. Therefore, this systematic review aims to critically evaluate clinical and radiological outcomes of PFO stratified by severity of KOA. Methods PubMed, Scopus, CINAHL and Google Scholar databases were searched. Eligible studies included those published up till August 2023, with 271 studies obtained. After duplicate removal, title-abstract screening, and a full text screen based on inclusion and exclusion criteria, 11 papers were included. 46 papers were further identified from snowballing of 7 existing systematic reviews, with 2 additional papers subsequently included. Results 13 included articles analysed 788 knees. Our study found that indications based on KL grading of KOA do not seem to differ in terms of post-operative clinical outcomes (VAS score) and radiological measures also found that hip knee alignment was improved regardless of KL grading of KOA. Additionally, the most common post-operative complication reported was deep peroneal nerve palsy. Conclusion PFO is a viable knee joint preserving surgery for medial compartment KOA, however given the high risk for complications reported in the literature, surgeons should pay close attention to the neuroanatomical landmarks and techniques to avoid neurovascular injury.
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Affiliation(s)
- Zhen Jonathan Liang
- Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road Level 11, Singapore, 119228, Singapore
- Singapore Knee Preservation Society, Singapore
| | - Don Thong Siang Koh
- Department of Orthopaedic Surgery, Singapore General Hospital, 31 Third Hospital Ave, Singapore, 168753, Singapore
- Singapore Knee Preservation Society, Singapore
| | - Junwei Soong
- Department of Orthopaedic Surgery, Singapore General Hospital, 31 Third Hospital Ave, Singapore, 168753, Singapore
- Singapore Knee Preservation Society, Singapore
| | - Kong Hwee Lee
- Department of Orthopaedic Surgery, Singapore General Hospital, 31 Third Hospital Ave, Singapore, 168753, Singapore
- Singapore Knee Preservation Society, Singapore
| | - Hamid Rahmatullah Bin Abd Razak
- Total Orthopaedic Care & Surgery, Novena Medical Centre, 10 Sinaran Drive, 09-24, 307506, Singapore
- SingHealth Duke-NUS Musculoskeletal Sciences Academic Clinical Programme, Academia Level 4, 20 College Road, Singapore, 169865, Singapore
- Singapore Knee Preservation Society, Singapore
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2
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Bocea BA, Catrina BI, Roman MD, Ion NCI, Fleaca SR, Mohor CI, Raluca AO, Moga SI, Mihaila RG. Incidence of Subclinical Deep Vein Thrombosis after Total Hip and Knee Arthroplasty Is Not Correlated with Number of Tranexamic Acid Doses. J Clin Med 2024; 13:3834. [PMID: 38999401 PMCID: PMC11242633 DOI: 10.3390/jcm13133834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Revised: 06/23/2024] [Accepted: 06/26/2024] [Indexed: 07/14/2024] Open
Abstract
Background: Recent studies increasingly highlight the efficacy of tranexamic acid administration in total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, the optimal dosage of tranexamic acid is still controversial. Methods: The current study analyzes the efficiency of tranexamic acid dosage and the number of administrations in THA and TKA. The objective of this study is to compare the incidence of deep vein thrombosis (DVT) based on the number of dosages. We divided the patients into two groups; one group received a single dosage, and the other group received two dosages. Doppler ultrasound examinations were conducted on the lower limbs of all patients at both six and thirty days postoperatively. The second objective is to compare the decrease in hemoglobin (Hb) in the two groups. Results: The results show that there is no difference in DVT incidence between the patients with different TXA numbers of dosages. There is no statistically significant decrease in Hb between the two groups at day one and day five postoperatively. Day one shows a statistically higher average in the two-dose group, approximately 0.06 g/dL, and day five shows a slightly elevated average in the single-dose group, approximately 0.06 g/dL. Blood transfusion requirements show no significant differences in the groups; one patient in the single-dose tranexamic acid group needed transfusion at day five postoperatively, while two patients in each group required immediate postoperative transfusion. Conclusion: There was no increase in the incidence of deep vein thrombosis among patients receiving two dosages of tranexamic acid.
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Affiliation(s)
- Bogdan-Axente Bocea
- Faculty of Medicine Sibiu, Lucian Blaga University, Str. Lucian Blaga Nr. 2A, 550169 Sibiu, Romania; (B.-A.B.); (N.C.I.I.); (S.R.F.); (C.-I.M.); (A.O.R.); (R.G.M.)
- County Clinical Emergency Hospital, 550245 Sibiu, Romania;
| | - Bianca-Iulia Catrina
- Faculty of Medicine Sibiu, Lucian Blaga University, Str. Lucian Blaga Nr. 2A, 550169 Sibiu, Romania; (B.-A.B.); (N.C.I.I.); (S.R.F.); (C.-I.M.); (A.O.R.); (R.G.M.)
- County Clinical Emergency Hospital, 550245 Sibiu, Romania;
| | - Mihai-Dan Roman
- Faculty of Medicine Sibiu, Lucian Blaga University, Str. Lucian Blaga Nr. 2A, 550169 Sibiu, Romania; (B.-A.B.); (N.C.I.I.); (S.R.F.); (C.-I.M.); (A.O.R.); (R.G.M.)
- County Clinical Emergency Hospital, 550245 Sibiu, Romania;
| | - Nicolas Catalin Ionut Ion
- Faculty of Medicine Sibiu, Lucian Blaga University, Str. Lucian Blaga Nr. 2A, 550169 Sibiu, Romania; (B.-A.B.); (N.C.I.I.); (S.R.F.); (C.-I.M.); (A.O.R.); (R.G.M.)
- County Clinical Emergency Hospital, 550245 Sibiu, Romania;
| | - Sorin Radu Fleaca
- Faculty of Medicine Sibiu, Lucian Blaga University, Str. Lucian Blaga Nr. 2A, 550169 Sibiu, Romania; (B.-A.B.); (N.C.I.I.); (S.R.F.); (C.-I.M.); (A.O.R.); (R.G.M.)
- County Clinical Emergency Hospital, 550245 Sibiu, Romania;
| | - Cosmin-Ioan Mohor
- Faculty of Medicine Sibiu, Lucian Blaga University, Str. Lucian Blaga Nr. 2A, 550169 Sibiu, Romania; (B.-A.B.); (N.C.I.I.); (S.R.F.); (C.-I.M.); (A.O.R.); (R.G.M.)
- County Clinical Emergency Hospital, 550245 Sibiu, Romania;
| | - Antonescu Oana Raluca
- Faculty of Medicine Sibiu, Lucian Blaga University, Str. Lucian Blaga Nr. 2A, 550169 Sibiu, Romania; (B.-A.B.); (N.C.I.I.); (S.R.F.); (C.-I.M.); (A.O.R.); (R.G.M.)
- County Clinical Emergency Hospital, 550245 Sibiu, Romania;
| | | | - Romeo Gabriel Mihaila
- Faculty of Medicine Sibiu, Lucian Blaga University, Str. Lucian Blaga Nr. 2A, 550169 Sibiu, Romania; (B.-A.B.); (N.C.I.I.); (S.R.F.); (C.-I.M.); (A.O.R.); (R.G.M.)
- County Clinical Emergency Hospital, 550245 Sibiu, Romania;
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Hoelen TCA, Heijnens LJM, Jelsma J, van Steenbergen LN, Schotanus MGM, Boonen B, Most J. Socioeconomic Status Affects Patient-Reported Outcome Measures in Total Hip and Knee Arthroplasty: A Retrospective Dutch Registry Study. J Arthroplasty 2024:S0883-5403(24)00325-5. [PMID: 38615972 DOI: 10.1016/j.arth.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/02/2024] [Accepted: 04/04/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND To determine the association between socioeconomic status (SES) and patient-reported outcome measures in a Dutch cohort who have undergone total hip arthroplasty (THA) or total knee arthroplasty (TKA). METHODS A retrospective national registry study of all patients who underwent primary THA or TKA between 2014 and 2020 in the Netherlands was performed. Linear mixed effects regression models were used to assess the association between SES and patient-reported outcome measures for THA and TKA patients separately. The following measures were collected: numeric rating scale for pain, Oxford Hip/Knee Score, Hip/Knee disability and Osteoarthritis Outcome Score, and the EuroQol 5-Dimensions questionnaire. Sex, age, body mass index, American Society of Anesthesiologists classification, Charnley classification, and smoking status were considered as covariates in the models. RESULTS THA patients (n = 97,443) were on average 70 years old with a body mass index of 27.4 kg/m2, and TKA patients (n = 78,811) were on average 69 years old with a body mass index of 29.7 kg/m2. Preoperatively, patients with a lower SES undergoing THA or TKA reported more severe symptoms and lower health-related quality of life. At 1-year follow-up, they also reported lower scores and less improvement over time compared to patients with a higher SES. CONCLUSIONS Patients with lower SES report worse symptoms when admitted for surgery and less improvement after surgery. Future research must address potentially mediating factors of the association between SES and symptom reporting such as access to surgery and rehabilitation, subjectivity in reporting, and patient expectation for THA and TKA outcomes.
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Affiliation(s)
- Thomay-Claire A Hoelen
- Department Orthopedics, Zuyderland Medical Center, Sittard-Geleen, The Netherlands; Department Orthopedics, School of Care and Public Health Research Institute, Faculty of Health, Medicine and Life Science, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Luc J M Heijnens
- Department Orthopedics, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - Jetse Jelsma
- Department Orthopedics, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - Liza N van Steenbergen
- Dutch Arthroplasty Register (Landelijke Registratie Orthopedische Interventies), 's-Hertogenbosch, The Netherlands
| | - Martijn G M Schotanus
- Department Orthopedics, Zuyderland Medical Center, Sittard-Geleen, The Netherlands; Department Orthopedics, School of Care and Public Health Research Institute, Faculty of Health, Medicine and Life Science, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bert Boonen
- Department Orthopedics, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - Jasper Most
- Department Orthopedics, Zuyderland Medical Center, Sittard-Geleen, The Netherlands; Department Epidemiology, School of Care and Public Health Research Institute, Faculty of Health, Medicine and Life Science, Maastricht University Medical Center, Maastricht, The Netherlands
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Ratnakar V, Pawar S, Dwivedi A, Masilamani ABS, Karumuri K, Reddy AVG. Effect of Hypothyroidism on Complications in Patients Undergoing TKA in Indian Population. Indian J Orthop 2023; 57:673-678. [PMID: 37128567 PMCID: PMC10147847 DOI: 10.1007/s43465-023-00841-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 02/02/2023] [Indexed: 05/03/2023]
Abstract
Background The number of hypothyroidism patients undergoing total knee replacement (TKA) in India is increasing. It is assumed that patients with hypothyroidism are more prone to complications following surgery. The aim of this study is to evaluate the impact of hypothyroidism on the complications following TKA. Methods This is a case-control analysis of patients who underwent primary total knee replacement in our hospital from 2017 to 2019. A total of 600 patients were included in the study, of which 300 patients were with hypothyroidism. We compared with a matched cohort of another 300 patients without hypothyroidism as control group. Results A total of 600 patients were analyzed (Hypothyroid group n = 300, Control group n = 300). The medical complications were found to be 6.2% in the hypothyroid group compared to 4% in control group (p = 1.66, odds ratio 0.61). Surgical complications in the hypothyroid group were 3% compared to 0.6% in control group (p = 4.53, odds ratio = 0.21), overall complication rates were not significant statistically when compared between hypothyroid and control group (p = 5.01, odds ratio 0.47). Subgroup analysis of complications of hypothyroid patients with euthyroid status versus uncontrolled hypothyroidism was done and we found no statistical difference in complications. Conclusion The conclusion can be that the rate of hospital stay, surgical site infections and complications were higher in hypothyroid group when compared with control group though statistically not significant.
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Affiliation(s)
- V. Ratnakar
- Orthopaedics Department, KIMS-SUNSHINE Hospitals, PG Road, Secunderabad, 500003 Telangana India
| | - Sawankumar Pawar
- Orthopaedics Department, KIMS-SUNSHINE Hospitals, PG Road, Secunderabad, 500003 Telangana India
| | - Ashutosh Dwivedi
- Orthopaedics Department, KIMS-SUNSHINE Hospitals, PG Road, Secunderabad, 500003 Telangana India
| | - A. B. Suhas Masilamani
- Orthopaedics Department, KIMS-SUNSHINE Hospitals, PG Road, Secunderabad, 500003 Telangana India
| | - Kishore Karumuri
- Orthopaedics Department, KIMS-SUNSHINE Hospitals, PG Road, Secunderabad, 500003 Telangana India
| | - AVGurava Reddy
- Sunshine Hospitals, PG Road, Secunderabad, 500003 Telangana India
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5
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Shen TS, Rodriguez S, LeBrun DG, Yu JS, Gonzalez Della Valle A, Ast MP, Rodriguez JA. Reasons and Risk Factors for Failed Same-Day Discharge After Primary Total Knee Arthroplasty. J Arthroplasty 2023; 38:668-672. [PMID: 36332890 DOI: 10.1016/j.arth.2022.10.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/24/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND As ambulatory total knee arthroplasty (TKA) becomes increasingly common, unplanned admission after surgery presents a challenge for the health care system. Studies evaluating the reasons and risk factors for this occurrence are limited. We sought to evaluate the reasons for unplanned admission after surgery and identify risk factors associated with this occurrence. METHODS Patients registered in an institutional ambulatory joint arthroplasty program who underwent a TKA from 2017-2020 were retrospectively reviewed. The criteria for enrollment include candidates for unilateral TKA between the ages of 18 and 70 years, with a body mass index (BMI) of less than 35, and appropriate social and material support at home. Patients who had certain comorbidities including coronary artery disease, valvular heart disease, and opioid dependence were not eligible. A total of 274 patients who underwent TKA with planned same-day discharge (SDD) were identified in the medical record and reviewed. In this cohort, 140 patients (51.1%) were discharged on the day of surgery and 134 patients (48.9%) required a minimum 1-night admission. Demographics, comorbidities, and perioperative data were collected. Factors associated with failed SDD were identified using multivariate logistic regression. RESULTS The most common reasons for failed SDD were failure to meet ambulation goals (25%) and logistical issues related to a late-day case (19%). Risk factors for failed SDD include general anesthesia (odds ratio (OR) 12.60, P = .047), procedure start time after 11:00 am (OR 5.16, P < .001), highest postoperative pain score >8 (visual analogue scale, OR 5.78, P = .001). Willingness to accept a higher pain threshold before discharge (visual analogue scale 4 to 10) was associated with successful SDD (OR 3.0, P < .001). Age and American Society of Anesthesiologists (ASA) classification were not associated with failed SDD. CONCLUSIONS The most common reasons for failed SDD were related to logistical issues and postoperative mobilization. Risk factors for failed SDD involve case timing and pain control. Modifiable perioperative factors may play an important role in successful SDD after TKA.
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Affiliation(s)
- Tony S Shen
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Samuel Rodriguez
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Drake G LeBrun
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Jonathan S Yu
- Weill Cornell Medicine, Cornell University, New York, New York
| | | | - Michael P Ast
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Jose A Rodriguez
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
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6
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Dong S, Mei F, Li JJ, Xing D. Global Cluster Analysis and Network Visualization in Prosthetic Joint Infection: A Scientometric Mapping. Orthop Surg 2023; 15:1165-1178. [PMID: 36855945 PMCID: PMC10102317 DOI: 10.1111/os.13681] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 11/22/2022] [Accepted: 12/15/2022] [Indexed: 03/02/2023] Open
Abstract
OBJECTIVE Prosthetic joint infection (PJI) is the main reason of failure of total joint arthroplasty (TJA). This study aimed to investigate the global trends and network visualization in research of PJI. METHODS Publications in PJI search during 1980-2022 were extracted from the Science Citation Index-Expanded of Web of Science Core Collection database (WoSCC). The source data was investigated and analyzed by bibliometric methodology. For network visualization, VOS viewer and R software was used to perform bibliographic coupling, co-citation, co-authorship and co-occurrence analysis and to predict the publication trends in PJI research. RESULTS There were 7288 articles included. The number of publications and relative research interests increased gradually per year globally. The USA made the highest contributions in the world and with the highest H-index and the most citations. Journal of Arthroplasty published the highest number of articles in this area. The Mayo Clinic, Thomas Jefferson University (Rothman Institute), Hospital Special Surgery and the Rush University were the most contributive institutions by network visualization. Included studies were divided into four clusters: bacterial pathogenic mechanism and antibacterial drugs study, TJA complications, risk factors and epidemiology of PJI, diagnosis of PJI, and revision surgical management. More articles in PJI could be published over the next few years. CONCLUSION The number of publications about PJI will be increasing dramatically based on the global trends and network visualization. The USA made the highest contributions in PJI. Diagnosis and revision management may be the next hot spots in this field.
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Affiliation(s)
- Shengjie Dong
- Orthopedic Department, Yantaishan Hospital, Yantai, China
| | - Fengyao Mei
- Arthritis Clinic & Research Center, Peking University People's Hospital, Peking University, Beijing, China.,Arthritis Institute, Peking University, Beijing, China
| | - Jiao Jiao Li
- School of Biomedical Engineering, Faculty of Engineering and IT, University of Technology Sydney, Ultimo, Australia
| | - Dan Xing
- Arthritis Clinic & Research Center, Peking University People's Hospital, Peking University, Beijing, China.,Arthritis Institute, Peking University, Beijing, China
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Lindsey C, Dornan GJ, McKelvey K. Integration of collaborative care model ameliorates population level COVID-19 Pandemic-related depressive symptoms among orthopaedic clinic patient population in US major metropolitan area. CURRENT ORTHOPAEDIC PRACTICE 2023. [DOI: 10.1097/bco.0000000000001204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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Yu JS, Sanchez L, Zeitlin J, Sosa B, Sculco P, Premkumar A. Characterization and Potential Relevance of Randomized Controlled Trial Patient Populations in Total Joint Arthroplasty in the United States: A Systematic Review. J Arthroplasty 2022; 37:2473-2479.e1. [PMID: 35750151 DOI: 10.1016/j.arth.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/08/2022] [Accepted: 06/12/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND A substantial number of randomized controlled trial (RCT) studies in total joint arthroplasty (TJA) are published each year in the United States (US). However, it is unknown how closely the demographic and clinical characteristics of these cohorts resemble that of the US patient population undergoing TJA. Thus, the purpose of this systematic review was to evaluate the patient characteristics of published RCTs in TJA in the US and to compare these characteristics against patient cohorts from national patient databases. METHODS RCT studies regarding primary TJA conducted in the US were selected. Key patient demographics were aggregated and compared against demographics characteristics of the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality National Inpatient Sample (NIS) and American College of Surgeons National Surgical Quality Improvement Program patient cohorts. RESULTS One hundred and fifty-three RCTs fulfilled the inclusion criteria and were included. The total number of patients in the 153 RCTs was 24,135 patients. The average age of patients in the TJA RCT cohort was 65 years (53-80) while the NIS cohort was 67 years (18-90) (d = 0.21, effect size = small). The average body mass index of the TJA RCT cohort was 30.8 (18.2-37.6) while the National Surgical Quality Improvement Program cohort was 31.9 (14.1-59.6) (d = 0.18, effect size = small). For TJA, effect sizes for age, body mass index BMI, sex, ethnicity, smoking, and diabetes were all small or very small. CONCLUSION Overall, the US RCT patient cohort for TJA does not differ substantially from the general patient population undergoing TJA in the United States. Differences in demographic and clinical characteristics between the TJA RCT cohort and database cohorts ranged from minimal to small, suggesting that these differences are unlikely to impact clinical outcomes.
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Affiliation(s)
| | | | | | | | - Peter Sculco
- Weill Cornell Medicine, New York, New York; Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
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Laubscher K, Dey R, Nortje M, Held M, Kauta N. Primary hip and knee arthroplasty at district level is safe and may reduce the burden on tertiary care in a low-income setting. BMC Musculoskelet Disord 2022; 23:1014. [PMID: 36434689 PMCID: PMC9701075 DOI: 10.1186/s12891-022-05936-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 10/31/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Arthroplasty procedures in low-income countries are mostly performed at tertiary centers, with waiting lists exceeding 12 to 24 months. Recently, this is further exacerbated by the impact of the Covid Pandemic on elective surgeries. Providing arthroplasty services at other levels of healthcare aims to offset this burden, however there is a marked paucity of literature regarding surgical outcomes. This study aims to provide evidence on the safety of arthroplasty at district level. METHODS Retrospective review of consecutive hip and knee primary arthroplasty cases performed at a District Hospital (DH), and a Tertiary Academic Hospital (TH) in Cape Town, South Africa between 1st January 2015 and 31st December 2018. Patient demographics, hospital length of stay, surgery related readmissions, reoperations, post-operative complications, and mortality rates were compared between cohorts. RESULTS Seven hundred and ninety-five primary arthroplasty surgeries were performed at TH level and 228 at DH level. The average hospital stay was 5.2 ± 2.0 days at DH level and 7.6 ± 7.1 days for TH (p < 0.05). Readmissions within 3 months post-surgery of 1.75% (4 patients) for district and 4.40% (35) for tertiary level (p < 0.05). Reoperation rate of 1 in every 100 patients at the DH and 8.3 in every 100 patients at the TH (p < 0.05). Death rate was 0.4% vs 0.6% at district and tertiary hospitals respectively (p > 0.05). Periprosthetic joint infection (PJI) rate was 0.43% at DH and 2.26% at TH. The percentage of hip dislocation requiring revision was 0% at district and 0.37% at tertiary level. During the study period, 228 patients received their arthroplasty surgery at the DH; these patients would otherwise have remained on the TH waiting list. CONCLUSIONS Hip and Knee Arthroplasty at District health care level is safe and; for the reason that the DH feeds into the TH; providing arthroplasty at district level may help ease the pressure on arthroplasty services at tertiary care facilities in a Southern African context. Adequately trained surgeons should be encouraged to perform these procedures in district hospitals provided there is appropriate patient selection and adherence to strict theatre operating procedures. LEVEL OF EVIDENCE Level III Retrospective cohort study.
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Affiliation(s)
- Kim Laubscher
- grid.413335.30000 0004 0635 1506Orthopaedic Research Unit, Division of Orthopaedic Surgery, Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa ,grid.413335.30000 0004 0635 1506Investigation Performed at Groote Schuur Hospital and Mitchell’s Plain Hospital, Cape Town, South Africa
| | - Roopam Dey
- grid.413335.30000 0004 0635 1506Orthopaedic Research Unit, Division of Orthopaedic Surgery, Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa ,grid.7836.a0000 0004 1937 1151Orthopaedic Biomechanics Lab, Division of Biomedical Engineering, Department of Human Biology, University of Cape Town, Cape Town, South Africa
| | - Marc Nortje
- grid.413335.30000 0004 0635 1506Orthopaedic Research Unit, Division of Orthopaedic Surgery, Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Michael Held
- grid.413335.30000 0004 0635 1506Orthopaedic Research Unit, Division of Orthopaedic Surgery, Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Ntambue Kauta
- grid.413335.30000 0004 0635 1506Orthopaedic Research Unit, Division of Orthopaedic Surgery, Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa ,grid.413335.30000 0004 0635 1506Investigation Performed at Groote Schuur Hospital and Mitchell’s Plain Hospital, Cape Town, South Africa ,Mitchell’s Plain District Hospital, Cape Town, South Africa
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Bailey JG, Miller A, Richardson G, Hogg T, Uppal V. Cost comparison between spinal versus general anesthesia for hip and knee arthroplasty: an incremental cost study. Can J Anaesth 2022; 69:1349-1359. [PMID: 35982355 PMCID: PMC9387885 DOI: 10.1007/s12630-022-02303-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/17/2022] [Accepted: 05/19/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Wait list times for total joint arthroplasties have been growing, particularly in the aftermath of the COVID-19 pandemic. Increasing operating room (OR) efficiency by reducing OR time and associated costs while maintaining quality allows the greatest number of patients to receive care. METHODS We used propensity score matching to compare parallel processing with spinal anesthesia in a block room vs general anesthesia in a retrospective cohort of adult patients undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). We compared perioperative costs, hospital costs, OR time intervals, and complications between the groups with nonparametric tests using an intention-to-treat approach. RESULTS After matching, we included 636 patients (315 TKA; 321 THA). Median [interquartile range (IQR)] perioperative costs were CAD 7,417 [6,521-8,109], and hospital costs were CAD 10,293 [9,344-11,304]. Perioperative costs were not significantly different between groups (pseudo-median difference [MD], CAD -47 (95% confidence interval [CI], -214 to -130; P = 0.60); nor were total hospital costs (MD, CAD -78; 95% CI, -340 to 178; P = 0.57). Anesthesia-controlled time and total intraoperative time were significantly shorter for spinal anesthesia (MD, 14.6 min; 95% CI, 13.4 to 15.9; P < 0.001; MD, 15.9; 95% CI, 11.0 to 20.9; P < 0.001, respectively). There were no significant differences in complications. CONCLUSION Spinal anesthesia in the context of a dedicated block room reduced both anesthesia-controlled time and total OR time. This did not translate into a reduction in incremental cost in the spinal anesthesia group.
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Affiliation(s)
- Jonathan G Bailey
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada.
| | - Ashley Miller
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Glen Richardson
- Division of Orthopedic Surgery, Dalhousie University, Halifax, NS, Canada
| | - Tyler Hogg
- Case Costing, Nova Scotia Health, Halifax, NS, Canada
| | - Vishal Uppal
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
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11
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Ma YP, Shen Q. Impact of being underweight on peri-operative and post-operative outcomes of total knee or hip arthroplasty: A meta-analysis. World J Clin Cases 2022; 10:10967-10983. [PMID: 36338222 PMCID: PMC9631143 DOI: 10.12998/wjcc.v10.i30.10967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/06/2022] [Accepted: 09/16/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Many systematic reviews have focused on assessing the effect of body mass index (BMI) on the outcomes and complications associated with total hip arthroplasty (THA) and total knee arthroplasty (TKA), but primarily dealt with obesity compared to normal weight (NW). None of these reviews attempted to assess the effect of low BMI or underweight (UW) compared to NW in patients undergoing THA or TKA.
AIM This review aims to compare specific operative outcomes such as operation duration, length of hospital stay, and post-operative complications including mortality, infections, deep vein thrombosis, etc. along with re-hospitalization and reoperation rates between UW and NW patients undergoing THA, TKA or both.
METHODS An electronic search was performed in PubMed, Scopus, Excerpta Medica database (EMBASE), Web of Science (WoS), and Cochrane Central Register of Controlled Trials (CENTRAL) along with a manual search. The quality of the studies was assessed using the Newcastle-Ottawa scale for cohort studies. The data were subjected to both qualitative and quantitative analysis.
RESULTS Thirteen retrospective and five prospective cohort studies were included. The quality of included studies was assessed to be good to fair. The length of hospital stay after TKA or THA was found to be significantly higher for UW patients when compared to NW patients, with a mean difference: 0.39 95%CI: [0.06, 0.72], P = 0.02 (in days). Studies presenting both THA and TKA together as total joint arthroplasty showed an increased incidence of mortality in patients treated with THA or TKA alone, Odds ratio: 4.18 95%CI: [2.88, 6.07]. A higher incidence of post-operative complications was also observed in UW patients undergoing THA.
CONCLUSION UW patients undergoing THA or TKA had a higher incidence of post-operative complications and were associated with a higher readmission rate. Moreover, UW patients were associated with an increased incidence of mortality in the studies that reported THA and TKA together.
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Affiliation(s)
- Yun-Ping Ma
- Department of Orthopedics, Huzhou Central Hospital, Affiliated Central Hospital of Huzhou University, Huzhou 313000, Zhejiang Province, China
| | - Qiu Shen
- Department of Orthopedics, Huzhou Central Hospital, Affiliated Central Hospital of Huzhou University, Huzhou 313000, Zhejiang Province, China
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12
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Ekhtiari S, Gazendam A, Saidahmed A, Petruccelli D, Winemaker MJ, de Beer JD, Shah V, Wood TJ. Risk factors for recurrence of periprosthetic joint infection following operative management: a cohort study with average 5-year follow-up. ANNALS OF JOINT 2022; 8:2. [PMID: 38529229 PMCID: PMC10929461 DOI: 10.21037/aoj-22-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 09/08/2022] [Indexed: 03/27/2024]
Abstract
Background Periprosthetic joint infections (PJIs) remain challenging to eradicate even after surgical management, which in most cases involves either debridement, antibiotics and implant retention (DAIR) or single- or two-staged revision. The purpose of this study is to determine predictors of PJI recurrence after operative management for PJI, and to determine differences in recurrence-free survival between DAIR and staged revision. Methods This is a retrospective analysis of prospectively collected data of revision hip and knee arthroplasty surgeries due to PJI between 2011 and 2018 at an academic hospital. Any patient undergoing revision surgery for PJI was included except if the index surgery information was unknown. The primary outcome was confirmed PJI recurrence. Multivariable logistic regression analysis was utilized to determine the relationship between the predictor variables and outcome variable. Log rank testing was used to compare recurrence-free survival between DAIR and staged revision. Results A total of 89 patients (91 joints) underwent revision surgery due to PJI. Younger age and presence of a sinus tract were statistically significant for risk of PJI recurrence. A multivariable logistic regression model including both variables was significant for predicting recurrence of PJI (χ2=10.2, P=0.006). Survival was not significantly different between patients who underwent DAIR versus a staged revision. Conclusions Younger patients and those with a chronic sinus tract are at significantly higher risk of recurrent PJI. This study also demonstrated that PJI can be successfully managed in the majority of cases with DAIR or staged revision.
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Affiliation(s)
- Seper Ekhtiari
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Aaron Gazendam
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Ahmed Saidahmed
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Danielle Petruccelli
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Mitchell J. Winemaker
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Justin D. de Beer
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Vivek Shah
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
| | - Thomas J. Wood
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
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13
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Schwartz CE, Rapkin BD, Sniderman J, Finkelstein JA. Appraisal and patient-reported outcomes following total hip arthroplasty: a longitudinal cohort study. J Patient Rep Outcomes 2022; 6:93. [PMID: 36064834 PMCID: PMC9445109 DOI: 10.1186/s41687-022-00498-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 08/21/2022] [Indexed: 11/10/2022] Open
Abstract
Background Total hip arthroplasty (THA) is a successful procedure that provides pain relief, restores function, and improves quality of life (QOL) for patients with advanced arthritis in their hip joint. To date, little research has examined the role of cognitive appraisal processes in THA outcomes. This study examined the role of cognitive appraisal processes in THA outcomes in the first year post-surgery. Methods This longitudinal cohort study collected data at pre-surgery, 6 weeks post-surgery, 3 months post-surgery, and 12 months post-surgery. Adults (n = 189) with a primary diagnosis of osteoarthritis were consecutively recruited from an active THA practice at a Canadian academic teaching hospital. Measures included the Hip Disability and Osteoarthritis Outcome Score (HOOS), the Mental Component Score (MCS) of the Rand-36, and the Brief Appraisal Inventory (BAI). Analysis of Variance examined the association between BAI items and the HOOS or MCS scores. Random effects models investigated appraisal main effects and appraisal-by-time interactions for selected BAI items. Results HOOS showed great improvement over the first 12 months after THA, and was mitigated by three appraisal processes in particular: focusing on problems with healthcare or living situation, and preparing one’s family for health changes. MCS was stable and low over time, and the following appraisal processes were implicated by very large effect sizes: not comparing themselves to healthier people, focusing on money problems, preparing their family for their health changes, or trying to shed responsibilities. Conclusions Appraisal processes are relevant to health outcomes after THA, with different processes coming into play at different points in the recovery trajectory. Supplementary Information The online version contains supplementary material available at 10.1186/s41687-022-00498-z.
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14
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Involvement of NF-κB/NLRP3 axis in the progression of aseptic loosening of total joint arthroplasties: a review of molecular mechanisms. Naunyn Schmiedebergs Arch Pharmacol 2022; 395:757-767. [PMID: 35377011 DOI: 10.1007/s00210-022-02232-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/11/2022] [Indexed: 10/18/2022]
Abstract
Particulate wear debris can trigger pro-inflammatory bone resorption and result in aseptic loosening. This complication remains major postoperative discomforts and complications for patients who underwent total joint arthroplasty. Recent studies have indicated that wear debris-induced aseptic loosening is associated with the overproduction of pro-inflammatory cytokines. The activation of osteoclasts as a result of inflammatory responses is associated with osteolysis. Moreover, stimulation of inflammatory signaling pathways such as the NF-κB/NLRP3 axis results in the production of pro-inflammatory cytokines. In this review, we first summarized the potential inflammatory mechanisms of wear particle-induced peri-implant osteolysis. Then, the therapeutic approaches, e.g., biological inhibitors, herbal products, and stem cells or their derivatives, with the ability to suppress the inflammatory responses, mainly NF-κB/NLRP3 signaling pathways, were discussed. Based on the results, activation of macrophages following inflammatory stimuli, overproduction of pro-inflammatory cytokines, and subsequent differentiation of osteoclasts in the presence of wear particles lead to bone resorption. The activation of NF-κB/NLRP3 signaling pathways within the macrophages stimulates the production of pro-inflammatory cytokines, e.g., IL-1β, IL-6, and TNF-α. According to in vitro and in vivo studies, novel therapeutics significantly promoted osteogenesis, suppressed osteoclastogenesis, and diminished particle-mediated bone resorption. Conclusively, these findings offer that suppressing pro-inflammatory cytokines by regulating both NF-κB and NLRP3 inflammasome represents a novel approach to attenuate wear-particle-related osteolytic diseases.
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15
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Aquilina CO, Aquilina AL, Webb J, Albur M, Whitehouse MR. Are multiple-use bottles of chlorhexidine solutions at risk of contamination in joint replacement surgery? Ann R Coll Surg Engl 2022; 104:434-436. [PMID: 34939853 PMCID: PMC9158045 DOI: 10.1308/rcsann.2021.0217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Chlorhexidine gluconate 2% w/v in isopropanol 70% solutions in multiple-use bottles is commonly used in surgery as a cost-effective method for skin disinfection. However, multiple-use bottles risk contamination. This study aims to test whether bacterial contamination of multiple-use bottles or their solutions occurs once open and on use between different patients. METHODS Consecutive samples were taken each time a chlorhexidine bottle was used over a 7-day study period. Samples were tested using blood culture, agar plate and mass spectrometry. RESULTS No growth was observed in 52 samples taken from 18 bottles inoculated into blood culture bottles. Four growths on agar plate culture were determined to be contaminants from the sampling process. CONCLUSIONS This study supports the use of multiple-use bottled chlorhexidine solutions as safe and cost-effective in surgical practice.
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Affiliation(s)
| | | | - J Webb
- University of Bristol, UK
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16
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Synovial calprotectin for the diagnosis of periprosthetic joint infection: a diagnostic meta-analysis. J Orthop Surg Res 2022; 17:2. [PMID: 34983582 PMCID: PMC8725344 DOI: 10.1186/s13018-021-02746-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 09/21/2021] [Indexed: 12/04/2022] Open
Abstract
Background Periprosthetic joint infections (PJI) are a rare but severe complication of total joint arthroplasty (TJA). However, the diagnosis of PJI remains difficult. It is one of the research that focuses about diagnosis for PJI for majority researchers to discover a novel biomarker. This meta-analysis tried to evaluate diagnostic value of synovial calprotectin for PJI. Methods This meta-analysis search of the literature was conducted in PubMed, EMBASE, Web of Science, and the Cochrane Library. Literature quality was appraised using Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) based on RevMan (version 5.3). The diagnostic value of calprotectin for PJI was evaluated by calculating sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), diagnostic score and area under SROC (AUC) based on the Stata version 14.0 software. We conduct subgroup analysis according to the study design, cutoff values, the country of study, and gold standard. Results Seven studies were included in this meta-analysis. The pooled sensitivity of synovial calprotectin for the diagnosis of PJI was 0.94 (95% CI, 0.87–0.98), and the specificity was 0.93 (95% CI, 0.87–0.96). The pooled AUC, PLR, and NLR for synovial calprotectin were 0.98 (95% CI, 0.96–0.99), 13.65 (95% CI, 6.89–27.07), and 0.06 (95% CI, 0.02–0.15), respectively. The pooled diagnostic score and DOR were 5.4 (95% CI, 3.96–6.85) and 222.32 (95% CI, 52.52–941.12), respectively. Conclusion In summary, this meta-analysis indicates that synovial calprotectin is a promising biomarker of assistant diagnosis for PJI, as well as recommended test for excluding diagnostic tool. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-021-02746-2.
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17
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Harrison ZL, Pace LR, Brown MN, Beenken KE, Smeltzer MS, Bumgardner JD, Haggard WO, Jennings JA. Staphylococcal infection prevention using antibiotic-loaded mannitol-chitosan paste in a rabbit model of implant-associated osteomyelitis. J Orthop Res 2021; 39:2455-2464. [PMID: 33470467 PMCID: PMC8289950 DOI: 10.1002/jor.24986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 12/08/2020] [Accepted: 01/11/2021] [Indexed: 02/04/2023]
Abstract
Antibiotic-loaded chitosan pastes have shown advantages in the treatment and coverage of complex musculoskeletal defects. We added mannitol, previously shown to increase antibiotic susceptibility of biofilm, to an injectable chitosan/polyethylene glycol paste for delivery of antibiotics. Ground sponges (0.85% acetic acid solution, 1% chitosan, 0% or 2% mannitol, 1% polyethylene glycol) were hydrated using phosphate-buffered saline with 10 mg/ml amikacin and 10 mg/ml vancomycin added to form pastes. We inoculated rabbit radial defects with 105 colony-forming units of Staphylococcus aureus (UAMS-1) and inserted titanium pins into the cortical bone. Groups compared included mannitol blend pastes, non-mannitol blends, antibiotic-loaded bone cement, vancomycin powder, and no treatment controls. We harvested tissue samples and retrieved the pins retrieved at 3 weeks. All antibiotic-loaded groups lowered bacterial growth and colony-forming unit counts in soft and bone tissue and on titanium pins in in vivo studies. The results indicate this biomaterial is capable of eluting active antibiotics at concentrations that reduce bacterial growth on biomaterials and tissue, which, in turn, may prevent biofilm formation. Blends of chitosan and mannitol may be useful in prevention and treatment of osteomyelitis and implant-associated infections.
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Affiliation(s)
- Zoe L. Harrison
- Department of Biomedical Engineering, University of Memphis, Memphis, TN, USA
| | - Leslie R. Pace
- Department of Biomedical Engineering, University of Memphis, Memphis, TN, USA
| | - Madison N. Brown
- Department of Biomedical Engineering, University of Memphis, Memphis, TN, USA
| | - Karen E. Beenken
- Department of Microbiology and Immunology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Mark S. Smeltzer
- Department of Microbiology and Immunology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Joel D. Bumgardner
- Department of Biomedical Engineering, University of Memphis, Memphis, TN, USA
| | - Warren O. Haggard
- Department of Biomedical Engineering, University of Memphis, Memphis, TN, USA
| | - J. Amber Jennings
- Department of Biomedical Engineering, University of Memphis, Memphis, TN, USA
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18
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Alokozai A, Bernstein DN, Samuel LT, Kamath AF. Patient Engagement Approaches in Total Joint Arthroplasty: A Review of Two Decades. J Patient Exp 2021; 8:23743735211036525. [PMID: 34435090 PMCID: PMC8381413 DOI: 10.1177/23743735211036525] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Patient engagement is a comprehensive approach to health care where the physician
inspires confidence in the patient to be involved in their own care. Most
research studies of patient engagement in total joint arthroplasty (TJA) have
come in the past 5 years (2015-2020), with no reviews investigating the
different patient engagement methods in TJA. The primary purpose of this review
is to examine patient engagement methods in TJA. The search identified 31
studies aimed at patient engagement methods in TJA. Based on our review, the
conclusions therein strongly suggest that patient engagement methods in TJA
demonstrate benefits throughout care delivery through tools focused on promoting
involvement in decision making and accessible care delivery (eg, virtual
rehabilitation, remote monitoring). Future work should understand the influence
of social determinants on patient involvement in care, and overall cost (or
savings) of engagement methods to patients and society.
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Affiliation(s)
- Aaron Alokozai
- Tulane University School of
Medicine, New Orleans, LA, USA
| | | | | | - Atul F. Kamath
- Cleveland Clinic Foundation, Cleveland, OH, USA
- Atul F. Kamath, Center for Hip
Preservation, Orthopedic and Rheumatologic Institute, Cleveland Clinic, 9500
Euclid Avenue, Mailcode A41, Cleveland, OH 44195, USA.
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19
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Ekhtiari S, Sefton AK, Wood TJ, Petruccelli DT, Winemaker MJ, de Beer JD. The Changing Characteristics of Arthroplasty Patients: A Retrospective Cohort Study. J Arthroplasty 2021; 36:2418-2423. [PMID: 33846046 DOI: 10.1016/j.arth.2021.02.051] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/16/2021] [Accepted: 02/19/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Total joint arthroplasty (TJA) is among the most common operations performed worldwide, with global volumes on the rise. It is important to understand if the characteristics of this patient population are changing over time for resource allocation and surgical planning. The purpose of this study is to examine how this patient population has changed between 2003 and 2017. METHODS A retrospective review of a prospective TJA database was conducted. Age, gender, body mass index, comorbidities, American Society of Anesthesiologists class, responsible diagnoses, and comorbidities were compared over 5-year intervals between 2003 and 2017. All patients undergoing primary, elective TJA were included. RESULTS Overall, 17,138 TJAs were included. Mean body mass index increased over the study period for total hip arthroplasty (THA; 29.4-30.4 kg/m2, P < .0001) and total knee arthroplasty (TKA; 32.0-3.1 kg/m2, P < .0001) patients. THA patients were significantly younger in more recent years (68.0-66.8 years old, P = .0026); this trend was not observed among TKA patients. Over the study period, a significantly higher proportion of patients were American Society of Anesthesiologists class III/IV for THA (50.5%-72.3%) and TKA (57.5%-80.7%) (P < .00001). Prevalence of common comorbidities did not change significantly. CONCLUSION The key findings of this retrospective analysis of a large prospective database are that patients undergoing TJA are becoming younger and more obese. It is unclear whether patients are becoming more medically complex. These trends paint a concerning picture of a population that is increasingly complex, and may require a greater allocation of resources in the future. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Seper Ekhtiari
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Andrew K Sefton
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Department of Orthopaedic Surgery, Dubbo Base Hospital, Dubbo, New South Wales, Australia; Department of Orthopaedic Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Thomas J Wood
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Danielle T Petruccelli
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Mitchell J Winemaker
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Justin D de Beer
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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20
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Patient Factors That Matter in Predicting Hip Arthroplasty Outcomes: A Machine-Learning Approach. J Arthroplasty 2021; 36:2024-2032. [PMID: 33558044 DOI: 10.1016/j.arth.2020.12.038] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/09/2020] [Accepted: 12/22/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Despite the success of total hip arthroplasty (THA), approximately 10%-15% of patients will be dissatisfied with their outcome. Identifying patients at risk of not achieving meaningful gains postoperatively is critical to pre-surgical counseling and clinical decision support. Machine learning has shown promise in creating predictive models. This study used a machine-learning model to identify patient-specific variables that predict the postoperative functional outcome in THA. METHODS A prospective longitudinal cohort of 160 consecutive patients undergoing total hip replacement for the treatment of degenerative arthritis completed self-reported measures preoperatively and at 3 months postoperatively. Using four types of independent variables (patient demographics, patient-reported health, cognitive appraisal processes and surgical approach), a machine-learning model utilizing Least Absolute Shrinkage Selection Operator (LASSO) was constructed to predict postoperative Hip Disability and Osteoarthritis Outcome Score (HOOS) at 3 months. RESULTS The most predictive independent variables of postoperative HOOS were cognitive appraisal processes. Variables that predicted a worse HOOS consisted of frequent thoughts of work (β = -0.34), frequent comparison to healthier peers (β = -0.26), increased body mass index (β = -0.17), increased medical comorbidities (β = -0.19), and the anterior surgical approach (β = -0.15). Variables that predicted a better HOOS consisted of employment at the time of surgery (β = 0.17), and thoughts related to family interaction (β = 0.12), trying not to complain (β = 0.13), and helping others (β = 0.22). CONCLUSIONS This clinical prediction model in THA revealed that the factors most predictive of outcome were cognitive appraisal processes, demonstrating their importance to outcome-based research. LEVEL OF EVIDENCE Prognostic Level 1.
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21
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Premkumar A, Kolin DA, Farley KX, Wilson JM, McLawhorn AS, Cross MB, Sculco PK. Projected Economic Burden of Periprosthetic Joint Infection of the Hip and Knee in the United States. J Arthroplasty 2021; 36:1484-1489.e3. [PMID: 33422392 DOI: 10.1016/j.arth.2020.12.005] [Citation(s) in RCA: 266] [Impact Index Per Article: 88.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/23/2020] [Accepted: 12/02/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In addition to the significant morbidity and mortality associated with periprosthetic joint infection (PJI), the cost of treating PJI is substantial. Prior high-quality national estimates of the economic burden of PJI utilize data up to 2009 to project PJI growth in the United States through 2020. Now in the year 2020, it is appropriate to evaluate these past projections and incorporate the latest available data to better understand the current scale and burden of PJI in the United States. METHODS The Nationwide Inpatient Sample (2002-2017) was used to identify rates and associated inpatient costs for primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) and PJI-related revision TKA and THA. Poisson regression was utilized to model past growth and project future rates and cost of PJI of the hip and knee. RESULTS Using the most recent data, the combined annual hospital costs related to PJI of the hip and knee were estimated to be $1.85 billion by 2030. This includes $753.4 million for THA PJI and $1.1 billion for TKA PJI, in that year. Increases in PJI costs are mainly attributable to increases in volume. Although the growth in incidence of primary THA and TKA has slowed in recent years, the incidence of PJI and the cost per case of PJI remained relatively constant from 2002 to 2017. DISCUSSION Understanding the current and potential future financial burden of PJI for surgeons, patients, and healthcare systems is essential. There is an urgent need for efficacious preventive strategies in reducing rates of PJI after THA and TKA.
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Affiliation(s)
- Ajay Premkumar
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | | | | | - Jacob M Wilson
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA
| | | | - Michael B Cross
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Peter K Sculco
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
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22
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Floyd SB, Oostdyk A, Cozad M, Brooks JM, Siffri P, Burnikel B. Assessing the Patient-Perceived Monetary Value of Patient-Reported Outcome Improvement for Patients With Chronic Knee Conditions. J Patient Cent Res Rev 2021; 8:98-106. [PMID: 33898641 PMCID: PMC8060045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023] Open
Abstract
PURPOSE The high cost of orthopaedic care has attracted criticism in the current value-based health care environment. The objective of this work was to assess the properties of a willingness to pay (WTP)-based approach to estimate the monetary value that patients place on health improvements in chronic knee conditions following orthopaedic treatment. METHODS A sample of patients with a chronic knee condition were surveyed between January and May of 2018 at a large orthopaedic practice. Each patient provided their WTP for restoration to ideal knee health and completed the Single Assessment Numerical Evaluation (SANE) to describe their baseline knee state. Average WTP was calculated for the total sample and stratified by income, age, and baseline SANE (for which 0 is the worst and 100 is the best) levels. The patient-perceived monetary value of each unit of SANE improvement was assessed. RESULTS The study sample included 86 patients seeking orthopaedic care for a chronic knee condition. Mean baseline SANE score was 45.5 (standard deviation: 25.0). Mean WTP to obtain ideal knee function from baseline was $18,704 (standard deviation: $18,040). For the full sample, patients valued a 1-unit improvement in SANE score at $291.1 (β: 291.1; P<0.05). The amount of money patients were willing to pay to achieve ideal knee function varied with age, income, and baseline knee state. CONCLUSIONS Patients appear to highly value improvement in chronic knee conditions. Willingness-to-pay survey results appear to track expected variation in patient outcome valuation by income and baseline knee condition and could be a valuable approach to assess value-based care in orthopaedics.
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Affiliation(s)
- Sarah B Floyd
- Department of Public Health Sciences, Clemson University, Clemson, SC
- Center for Effectiveness Research in Orthopaedics, Columbia, SC
| | - Alicia Oostdyk
- Center for Effectiveness Research in Orthopaedics, Columbia, SC
- Department of Health Services Policy and Management, University of South Carolina, Columbia, SC
| | - Melanie Cozad
- Center for Effectiveness Research in Orthopaedics, Columbia, SC
- Department of Health Services Policy and Management, University of South Carolina, Columbia, SC
| | - John M Brooks
- Center for Effectiveness Research in Orthopaedics, Columbia, SC
- Department of Health Services Policy and Management, University of South Carolina, Columbia, SC
| | - Paul Siffri
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, SC
| | - Brian Burnikel
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, SC
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23
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Oosting E, Kapitein PJC, de Vries SV, Breedveld E. Predicting short stay total hip arthroplasty by use of the timed up and go-test. BMC Musculoskelet Disord 2021; 22:361. [PMID: 33863323 PMCID: PMC8052837 DOI: 10.1186/s12891-021-04240-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 04/05/2021] [Indexed: 11/10/2022] Open
Abstract
Background One of the most important steps before implementing short stay total hip arthroplasty (THA) is establishing patient criteria. Most existing criteria are mainly based on medical condition, but as physical functioning is associated with outcome after THA, we aim to evaluate the added value of a measure of physical functioning to predict short-stay THA. Methods We used retrospective data of 1559 patients who underwent an anterior THA procedure. Logistic regression analyses were performed to study the predictive value of preoperative variables among which preoperative physical functioning by use of the Timed Up and Go test (TUG) for short stay THA (< 36 h). The receiver operating characteristic (ROC) curve and Youden Index were used to define a cutoff point for TUG associated with short stay THA. Results TUG was significantly associated with LOS (OR 0.84, 95%CI 0.82–0.87) as analyzed by univariate regression analysis. In multivariate regression, a model with the TUG had a better performance with an AUC of 0.77 (95%CI 0.74–0.79) and a R2 of 0.27 compared to the basic model (AUC 0.75, 95%CI 0.73–0.77, R2 0.24). Patients with a preoperative TUG less than 9.7 s had an OR of 4.01 (95%CI 3.19–5.05) of being discharged within 36 h. Conclusions Performance based physical functioning, measured by the TUG, is associated with short stay THA. This knowledge will help in the decision-making process for the planning and expectations in short stay THA protocols with the advantage that the TUG is a simple and fast instrument to be carried out.
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Affiliation(s)
- Ellen Oosting
- Department of Orthopedics, Hospital Gelderse Vallei, Willy Brandtlaan, 10 6716 RP, Ede, the Netherlands. .,Department of Physiotherapy, Hospital Gelderse Vallei, Ede, the Netherlands.
| | - Paul J C Kapitein
- Department of Orthopedics, Hospital Gelderse Vallei, Willy Brandtlaan, 10 6716 RP, Ede, the Netherlands
| | - Suzan V de Vries
- Department of Physiotherapy, Hospital Gelderse Vallei, Ede, the Netherlands
| | - Ellen Breedveld
- Department of Physiotherapy, Hospital Gelderse Vallei, Ede, the Netherlands
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Jayakumar P, Moore MG, Furlough KA, Uhler LM, Andrawis JP, Koenig KM, Aksan N, Rathouz PJ, Bozic KJ. Comparison of an Artificial Intelligence-Enabled Patient Decision Aid vs Educational Material on Decision Quality, Shared Decision-Making, Patient Experience, and Functional Outcomes in Adults With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2037107. [PMID: 33599773 PMCID: PMC7893500 DOI: 10.1001/jamanetworkopen.2020.37107] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Decision aids can help inform appropriate selection of total knee replacement (TKR) for advanced knee osteoarthritis (OA). However, few decision aids combine patient education, preference assessment, and artificial intelligence (AI) using patient-reported outcome measurement data to generate personalized estimations of outcomes to augment shared decision-making (SDM). OBJECTIVE To assess the effect of an AI-enabled patient decision aid that includes education, preference assessment, and personalized outcome estimations (using patient-reported outcome measurements) on decision quality, patient experience, functional outcomes, and process-level outcomes among individuals with advanced knee OA considering TKR in comparison with education only. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial at a single US academic orthopedic practice included 129 new adult patients presenting for OA-related knee pain from March 2019 to January 2020. Data were analyzed from April to May 2020. INTERVENTION Patients were randomized into a group that received a decision aid including patient education, preference assessment, and personalized outcome estimations (intervention group) or a group receiving educational material only (control group) alongside usual care. MAIN OUTCOMES AND MEASURES The primary outcome was decision quality, measured using the Knee OA Decision Quality Instrument (K-DQI). Secondary outcomes were collaborative decision-making (assessed using the CollaboRATE survey), patient satisfaction with consultation (using a numerical rating scale), Knee Injury and Osteoarthritis Outcome Score Joint Replacement (KOOS JR) score, consultation time, TKR rate, and treatment concordance. RESULTS A total of 69 patients in the intervention group (46 [67%] women) and 60 patients in the control group (37 [62%] women) were included in the analysis. The intervention group showed better decisional quality (K-DQI mean difference, 20.0%; SE, 3.02; 95% CI, 14.2%-26.1%; P < .001), collaborative decision-making (CollaboRATE, 8 of 69 [12%] vs 28 of 60 [47%] patients below median; P < .001), satisfaction (numerical rating scale, 9 of 65 [14%] vs 19 of 58 [33%] patients below median; P = .01), and improved functional outcomes at 4 to 6 months (mean [SE] KOOS JR, 4.9 [2.24] points higher in intervention group; 95% CI, 0.8-9.0 points; P = .02). The intervention did not significantly affect consultation time (mean [SE] difference, 2.23 [2.18] minutes; P = .31), TKR rates (16 of 69 [23%] vs 7 of 60 [12%] patients; P = .11), or treatment concordance (58 of 69 [84%] vs 44 of 60 [73%] patients; P = .19). CONCLUSIONS AND RELEVANCE In this randomized clinical trial, an AI-enabled decision aid significantly improved decision quality, level of SDM, satisfaction, and physical limitations without significantly impacting consultation times, TKR rates, or treatment concordance in patients with knee OA considering TKR. Decision aids using a personalized, data-driven approach can enhance SDM in the management of knee OA. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03956004.
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Affiliation(s)
| | - Meredith G. Moore
- Dell Medical School at the University of Texas at Austin, Austin
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Kenneth A. Furlough
- Dell Medical School at the University of Texas at Austin, Austin
- Chicago Medical School, North Chicago, Illinois
| | - Lauren M. Uhler
- Dell Medical School at the University of Texas at Austin, Austin
| | - John P. Andrawis
- Dell Medical School at the University of Texas at Austin, Austin
- Harbor-UCLA Medical Center, West Carson, California
| | - Karl M. Koenig
- Dell Medical School at the University of Texas at Austin, Austin
| | - Nazan Aksan
- Dell Medical School at the University of Texas at Austin, Austin
| | - Paul J. Rathouz
- Dell Medical School at the University of Texas at Austin, Austin
| | - Kevin J. Bozic
- Dell Medical School at the University of Texas at Austin, Austin
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25
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Smith TJ, Siddiqi A, Forte SA, Judice A, Sculco PK, Vigdorchik JM, Schwarzkopf R, Springer BD. Periprosthetic Fractures Through Tracking Pin Sites Following Computer Navigated and Robotic Total and Unicompartmental Knee Arthroplasty: A Systematic Review. JBJS Rev 2021; 9:e20.00091. [PMID: 33502139 DOI: 10.2106/jbjs.rvw.20.00091] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Use of computer-assisted navigation (CAN) and robotic-assisted (RA) surgery in total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) both necessitate the use of tracking pins rigidly fixed to the femur and tibia. Although periprosthetic fractures through tracking pin sites are rare, there is a paucity of literature on this potential complication. Therefore, the purpose of this study was to perform a systematic review of the current literature to assess the incidence and clinical outcomes of periprosthetic fractures through tracking pin sites following CAN and RA TKA and UKA. METHODS A systematic review was performed following PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines using the PubMed, MEDLINE, and Cochrane databases in April 2020. Studies were assessed for the presence of pin site fractures, fracture characteristics, and clinical outcomes. RESULTS Seventeen clinical studies (5 case series, 1 cohort study, and 11 case reports) involving 29 pin-related fractures were included for review. The overall incidence ranged from 0.06% to 4.8%. The mean time from index arthroplasty to fracture was 9.5 weeks (range, 0 to 40 weeks). The majority of fractures occurred in the femoral diaphysis (59%). Nineteen fractures (66%) were displaced and 10 (34%) were nondisplaced or occult. The majority of cases were atraumatic in nature or involved minor trauma and were typically preceded by persistent leg pain. A transcortical pin trajectory, large pin diameter (>4 mm), diaphyseal fixation, multiple placement attempts, and the use of non-self-drilling, non-self-tapping pins were the most commonly reported risk factors for pin-related periprosthetic fractures following CAN or RA TKA. CONCLUSIONS Surgeons should maintain a high index of suspicion for pin-related fractures in patients with ongoing leg or thigh pain after CAN or RA TKA in order to avoid fracture displacement and additional morbidity. As CAN and RA TKA have unique complication risks, the debate regarding the value of technology-assisted TKA and its cost-effectiveness continues. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Tyler J Smith
- Department of Orthopedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Ahmed Siddiqi
- Department of Orthopedics, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Salvador A Forte
- Department of Orthopedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Anthony Judice
- Department of Orthopedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Peter K Sculco
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | | | - Ran Schwarzkopf
- Department of Orthopedics, New York University Langone Medical Center, New York, NY
| | - Bryan D Springer
- Department of Orthopedics, Atrium Musculoskeletal Institute, OrthoCarolina Hip and Knee Center, Charlotte, North Carolina
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Pharr ZK, Rider CM, Bell JW, Wilde JH, Westbrooks TJ, Toy PC. Outpatient Hip Safety in an Ambulatory Surgery Center Is Independent of Approach. J Arthroplasty 2021; 36:231-235. [PMID: 32826145 DOI: 10.1016/j.arth.2020.07.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/28/2020] [Accepted: 07/27/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND There are few data comparing the direct anterior approach (DAA) and posterior approach (PA) for total hip arthroplasty (THA) in the outpatient setting. The purpose of this study is to compare 90-day complications between the 2 approaches. We hypothesized that they would be equally safe and effective. METHODS Retrospective review identified 432 THAs (346 DAA, 86 PA) performed at a single ambulatory surgery center (ASC). Outcomes compared included demographics, comorbidities, preoperative and discharge pain scores (visual analog scale [VAS]), overall time spent in the ASC, overnight stay, emergency room visits, admission, reoperation, and complications within a 90-day period. RESULTS There were no differences in mean preoperative VAS (DAA 4.7, PA 4.5), mean discharge VAS (DAA 0.8, PA 0.7), overall time spent in the ASC (DAA 9.0 hours, PA 9.3 hours), total number of overnight stays (DAA 0.9%, PA 1.2%), emergency room visits (DAA 1.7%, PA 1.2%), admissions (DAA 1.4%, PA 1.2%), reoperations (DAA 1.4%, PA 1.2%), or complications (DAA 3.5%, PA 2.3%). CONCLUSION There were no differences in the safety outcomes, and overall there were few complications in the 90-day period, regardless of the surgeon's preferred approach. This study indicates both DAA and PA are equally safe for THA in the outpatient setting, and the choice of surgical approach should be based on patient and surgeon preference.
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Affiliation(s)
- Zachary K Pharr
- University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, Memphis TN
| | - Carson M Rider
- University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, Memphis TN
| | - Jack W Bell
- University of Tennessee Health Science Center, College of Medicine, Memphis, TN
| | - James H Wilde
- University of Tennessee Health Science Center, College of Medicine, Memphis, TN
| | | | - Patrick C Toy
- University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, Memphis TN
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Ashraf M, Purudappa PP, Sakthivelnathan V, Sambandam S, Mounsamy V. Proximal fibular osteotomy: Systematic review on its outcomes. World J Orthop 2020; 11:499-506. [PMID: 33269216 PMCID: PMC7672796 DOI: 10.5312/wjo.v11.i11.499] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 08/25/2020] [Accepted: 09/22/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The morbidity and burden of knee osteoarthritis affecting millions of lives worldwide has created a constant pursuit in finding the ideal treatment for knee osteoarthritis. There has been a paradigm shift in the surgical treatment of osteoarthritis ever since the initial description of Volkmann’s tibial osteotomy. This review focuses on one such recent procedure, the proximal fibular osteotomy (PFO) for medial compartment knee osteoarthritis. This review encompasses the history, evidence, risk factors, outcomes and technical considerations of PFO.
AIM To understand the evidence and its techniques, and whether this could be an alternative solution to the problem of knee osteoarthritis in the developing world.
METHODS The phrases “proximal fibular osteotomy” and “knee osteoarthritis” were searched (date of search December 20, 2019) on PubMed to identify articles evaluating the biomechanical and clinical outcomes of PFO in patients with knee osteoarthritis. A total of 258 were retrieved. After reviewing the summary of the texts, 22 articles written in English were marked for abstract review. Articles that were case studies or cadaver experiments were excluded. The abstracts of the remaining articles were read, and only those that focused on the history, outcomes of case studies and technical considerations of PFO were included in the review. A total of 12 articles were included in this review.
RESULTS At least six studies reported improvement in the visual analogue scale(VAS) from the average preoperative VAS score [6.32, 95% confidence interval (CI) = (4.05, 8.59)] to average postoperative VAS score [1.23, 95%CI: (-1.20, 3.71)], which was statistically significant. Similarly, the American Knee Society Score (KSS) functional score improved from an average preoperative KSS functional score [43.11, 95%CI: (37.83, 48.38)] to postoperative KSS functional score [66.145, 95%CI: (61.94, 70.35)], which was statistically significant. The femorotibial angle improved by around 7º, and the hip knee ankle angle improved by around 6º.
CONCLUSION With the existing data, it seems that PFO is a viable option for treating medial joint osteoarthritis in selected patients. Long term outcome studies and progression of disease pathology are some of the important parameters that need to be addressed by use of multicenter randomized controlled trials.
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Affiliation(s)
- Munis Ashraf
- Department of Orthopedic Surgery, Yenepoya Medical College Hospital, Mangalore 575108, India
| | | | | | | | - Varatharaj Mounsamy
- Department of Orthopedic Surgery, Dallas VA Medical center, Dallas, TX 75216, United States
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28
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Reilly CA, Doughty HP, Werth PM, Rockwell CW, Sparks MB, Jevsevar DS. Creating a Value Dashboard for Orthopaedic Surgical Procedures. J Bone Joint Surg Am 2020; 102:1849-1856. [PMID: 32694400 DOI: 10.2106/jbjs.20.00270] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Value-based health-care delivery is a framework for restructuring our health-care systems with the goal of providing better outcomes for patients at lower cost. Value is determined by patient health outcomes per dollar spent on health services. We sought to develop a value dashboard that could be used to easily track and improve the value of total hip and knee arthroplasty (THA and TKA). METHODS We created a value dashboard for TKAs and THAs at our institution. Value was defined as quality of outcomes per dollar spent. The dashboard for each procedure displayed the average value by surgeon, compared with institutional averages for physical function scores and cost. Quality metrics were determined by weighted surgeon ranking using a modified Delphi process and included both clinical and patient-reported outcomes, as measured by the mean change in the Patient-Reported Outcomes Measurement Information System Global-10 (PROMIS-10) physical function score, mean change in the Hip disability and Osteoarthritis Outcome Score-Joint Replacement (HOOS-JR) or the Knee injury and Osteoarthritis Outcome Score-Joint Replacement (KOOS-JR), mean change in the modified Single Assessment Numeric Evaluation (SANE) score, complication rate, periprosthetic joint infection (PJI) rate, and 30-day readmission rate. Average direct costs per surgeon were used. Data from January 2017 through April 2018 were included to ensure 1-year follow-up. RESULTS Six surgeons were included in the value dashboard for TKA, and 5 were included in the THA dashboard. The value for TKA by surgeon ranged from 7% below to 12% above the institutional benchmark. The value for THA by surgeon ranged from 12% below to 7% above the institutional benchmark. CONCLUSIONS The proposed dashboard utilizes value in a health-care framework and could be used for comparing and improving value for THA and TKA. This dashboard successfully combined patient outcome metrics and direct costs of surgical procedures. Future studies should focus on involving patients in this process and using national data to create benchmarks, which could provide a more accurate representation of value than using institutional averages.
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Affiliation(s)
- Clifford A Reilly
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Hayden P Doughty
- Department of Orthopaedics, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Paul M Werth
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.,Department of Psychology, Saint Louis University, St. Louis, Missouri
| | - Connor W Rockwell
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Michael B Sparks
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.,Department of Orthopaedics, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - David S Jevsevar
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.,Department of Orthopaedics, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
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Sedentary Behavior in Older Patients before and after Total Hip Arthroplasty: A Prospective Cohort Study. Healthcare (Basel) 2020; 8:healthcare8030346. [PMID: 32962075 PMCID: PMC7551946 DOI: 10.3390/healthcare8030346] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/03/2020] [Accepted: 09/16/2020] [Indexed: 01/22/2023] Open
Abstract
Objective: To compare the habitual sedentary behavior (SB) and physical activity (PA) of older hip osteoarthritis patients before and after elective arthroplasty. Methods: SB, PA and joint-specific disability of 16 patients (68.9 ± 6.8 years) were assessed by accelerometry and questionnaires before and 9 months after arthroplasty. Results: All patients reported substantial postoperative improvements of their joint-related complaints (p ≤ 0.001). Accelerometry showed changes in neither daily SB (10–60 min sedentary bouts, p ≥ 0.569) nor in PA (steps, time in mild-to-vigorous activity and energy expenditure, p ≥ 0.255). Correlation analyses revealed that patients with severe preoperative disability showed a decrease in sedentary time, which was the opposite in patients with mild preoperative disability. Conclusion: SB and PA do not necessarily change after arthroplasty in older orthopedic patients. Even longer bouts of uninterrupted sitting, which are detrimental to health, do not decrease. Preoperative patient education is recommended to foster behavioral changes following elective arthroplasty.
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Jayakumar P, Bozic KJ. Advanced decision-making using patient-reported outcome measures in total joint replacement. J Orthop Res 2020; 38:1414-1422. [PMID: 31994752 DOI: 10.1002/jor.24614] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 01/21/2020] [Indexed: 02/04/2023]
Abstract
Up to one-third of total joint replacement (TJR) procedures may be performed inappropriately in a subset of patients who remain dissatisfied with their outcomes, stressing the importance of shared decision-making. Patient-reported outcome measures capture physical, emotional, and social aspects of health and wellbeing from the patient's perspective. Powerful computer systems capable of performing highly sophisticated analysis using different types of data, including patient-derived data, such as patient-reported outcomes, may eliminate guess work, generating impactful metrics to better inform the decision-making process. We have created a shared decision-making tool which generates personalized predictions of risks and benefits from TJR based on patient-reported outcomes as well as clinical and demographic data. We present the protocol for a randomized controlled trial designed to assess the impact of this tool on decision quality, level of shared decision-making, and patient and process outcomes. We also discuss current concepts in this field and highlight opportunities leveraging patient-reported data and artificial intelligence for decision support across the care continuum.
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Affiliation(s)
- Prakash Jayakumar
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Kevin J Bozic
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, Texas
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31
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Gausden EB, Premkumar A, Bostrom MP. International Collaboration in Total Joint Arthroplasty: A Framework for Establishing Meaningful International Alliances. Orthop Clin North Am 2020; 51:161-168. [PMID: 32138854 DOI: 10.1016/j.ocl.2019.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Despite the increase in utilization of total joint arthroplasty (TJA) throughout high-income countries, there is a lack of access to basic surgical care, including TJA, in low- and middle-income countries (LMICs). Multiple strategies, including short-term surgical trips, establishment of local TJA centers, and education-based international academic collaborations, have been used to bridge the gap in access to quality TJA. The authors review the obstacles to providing TJA in LMICs, the outcomes of the 3 strategies in use to bridge gaps, and a framework for the establishment and maintenance of meaningful international collaborations.
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Affiliation(s)
- Elizabeth B Gausden
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
| | - Ajay Premkumar
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Mathias P Bostrom
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
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Access to Elective Orthopaedic Surgery After the Affordable Care Act Medicaid Expansion: The New York State Experience. J Am Acad Orthop Surg 2020; 28:e158-e163. [PMID: 31365357 DOI: 10.5435/jaaos-d-18-00062] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND As part of the Patient Protection and Affordable Care Act, states were given the option of expanding Medicaid coverage to include adults younger than age 65 years with income at or below 138% of the federal poverty level. Although this expansion was intended to provide health care coverage to an estimated 20 million Americans, several studies have shown increased coverage does not equate to increased access to care by specialty providers. METHODS We queried the New York Statewide Planning and Research Cooperative System database and identified all patients who underwent the 10 most common elective orthopaedic surgeries from January 1, 2012, through March 31, 2016. Medicaid monthly enrollment for the 4-year study period was obtained from NY Department of Health Medicaid Managed Care Enrollment Reports. RESULTS Our query identified 700,159 patients who underwent the investigated orthopaedic surgeries. Of these, 60,786 were Medicaid recipients. During the 4-year study period, Medicaid enrollment and the number of procedures reimbursed by Medicaid increased significantly (P < 0.001 for both). CONCLUSIONS Affordable Care Act-supported Medicaid expansion was associated with an increase in Medicaid enrollment and a concomitant increase in the utilization of orthopaedic surgery by Medicaid beneficiaries in New York State.
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Svinøy OE, Bergland A, Risberg MA, Pripp AH, Hilde G. Better before-better after: efficacy of prehabilitation for older patients with osteoarthritis awaiting total hip replacement-a study protocol for a randomised controlled trial in South-Eastern Norway. BMJ Open 2019; 9:e031626. [PMID: 31892650 PMCID: PMC6955471 DOI: 10.1136/bmjopen-2019-031626] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 12/02/2019] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Health professions need to prepare for the increase of older patients with osteoarthritis requiring health services including those requiring total joint arthroplasty (TJA). The primary objective of this study is to assess the effect of a tailored prehabilitation programme of older patients awaiting primary surgery for total hip replacement on physical function measured by walking speed within 1 week after intervention as well as 6 weeks and 3 months after TJA surgery. METHODS AND ANALYSIS This is a single-blinded randomised controlled trial. The participants are 70 years or older, scheduled for primary total hip replacement due to late stage osteoarthritis. The intervention group will receive patient education and exercise for 6-12 weeks. The control group will receive care as usual. The primary outcome is gait speed. Secondary outcomes are lower body strength, mobility, aerobic capacity, activity of daily living, length of stay at the hospital, referral to an inpatient rehabilitation clinic, pain, quality of life and cost-effectiveness. Estimated sample size is 150 participants randomised into the two arms. The data will be analysed following the intention-to-treat principle with methods for repeated measurements. ETHICS AND DISSEMINATION The project proposal has been approved by The Regional Committee for Medical Research Ethics in South Norway (ref no. 2018/503). The results will be published in peer-reviewed articles. TRIAL REGISTRATION NUMBER NCT03602105.
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Affiliation(s)
- Odd-Einar Svinøy
- Faculty of Health Sciences, Department of Physiotherapy, Oslo Metropolitan University, Oslo, Norway
| | - Astrid Bergland
- Faculty of Health Sciences, Department of Physiotherapy, Oslo Metropolitan University, Oslo, Norway
| | - May Arna Risberg
- Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
- Division of Orthopedic Surgery, Department of Reserach, Oslo University Hospital, Oslo, Norway
| | - Are Hugo Pripp
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Gunvor Hilde
- Faculty of Health Sciences, Department of Physiotherapy, Oslo Metropolitan University, Oslo, Norway
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Clinical practices for primary hip and knee arthroplasties in Spain: A national study. ACTA ACUST UNITED AC 2019. [DOI: 10.1016/j.recote.2019.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Molko S, Dasí-Sola M, Marco F, Combalia A. Clinical practices for primary hip and knee arthroplasties in Spain: A national study. Rev Esp Cir Ortop Traumatol (Engl Ed) 2019; 63:408-415. [PMID: 31558430 DOI: 10.1016/j.recot.2019.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 06/17/2019] [Accepted: 06/25/2019] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE Primary hip and knee arthroplasties are some of the most frequent surgical procedures in the Spanish Healthcare System. This study was carried out with the aim of identifying the current clinical practices held in the territory for such processes, as well as future trends. MATERIAL AND METHODS In May 2017 a set of 40 questions regarding the practices, indicators, coordination, concerns and tendencies were sent to 289 Heads of Orthopaedic Services from all over Spain. RESULTS Responses were received from 141 hospitals. The mean length of stay varied from 2,6 to 12,6days. Mobilization is initiated from the first post-operative hours in 4% of hospitals, until 48h after surgery in 16% of hospitals. There is no unique standard for the use of drains, urinary catheter or fasting time. In addition, different surgical approaches, implant types, analgesia and blood management protocols can coexist within the same hospital. In 87% of cases, there are no formal channel paths for interdisciplinary coordination. Fast-track surgery has been incorporated into the practice of 36% of hospitals, while 66% of hospitals consider that by applying it they could achieve an earlier patient recovery. In 56% of those surveyed, surgeon concerns are focused on infection management and its prevention, which is expected to have a high impact in the future of arthroplasties, together with pain management. CONCLUSION The study shows a high variability in practices among centers in processes, clinical protocols and interdisciplinary coordination, which have an effect on results and process indicators.
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Affiliation(s)
| | | | - F Marco
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, España
| | - A Combalia
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Clínic, Instituto de Investigación August Pi i Sunyer - IDIBAPS, Universidad de Barcelona, Barcelona, España.
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Nouri F, Coole C, Narayanasamy M, Baker P, Khan S, Drummond A. Managing Employees Undergoing Total Hip and Knee Replacement: Experiences of Workplace Representatives. JOURNAL OF OCCUPATIONAL REHABILITATION 2019; 29:451-461. [PMID: 30132175 PMCID: PMC6531398 DOI: 10.1007/s10926-018-9805-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Introduction There is little research on return to work (RTW) from a workplace perspective following hip and knee replacement (THR/TKR) despite employers and other workplace personnel having a key role. Our aim was to explore the experiences of individuals in the workplace in managing employees undergoing THR/TKR. Methods Employers and other workplace representatives from a cross-section of employment sectors and sizes, with experience of managing employees undergoing THR/TKR in the previous 12 months, were recruited. Interviewees included small business owners, line managers, colleagues, human resources managers and occupational health advisers. Semi-structured, qualitative interviews were conducted and data were analysed thematically. Results Twenty-five individuals were interviewed. The main themes identified were accommodating the employee, and barriers and facilitators to RTW. Accommodations included changes to the work environment, amended duties, altered hours, changed roles and colleague support. Perceived barriers and facilitators to RTW included the role of GPs and occupational health, surgical issues, characteristics of the work environment and of employees. Conclusions Employers are motivated to effect supported RTW for employees undergoing THR/TKR but have insufficient guidance. Strategies are required to signpost employers to existing RTW advice, and to develop recommendations specific to lower limb arthroplasty. Communication between medical practitioners and employers should be facilitated in order to enhance the RTW experience of individuals undergoing THR/TKR.
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Affiliation(s)
- Fiona Nouri
- School of Health Sciences, Medical School, Queens Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK.
| | - Carol Coole
- School of Health Sciences, Medical School, Queens Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Melanie Narayanasamy
- School of Health Sciences, Medical School, Queens Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Paul Baker
- South Tees NHS Hospitals Trust, James Cook University Hospital, Middlesbrough, TS3 4BW, UK
| | - Sayeed Khan
- The Buckingham Centre, Collingwood Health, 30 Bradford Road, Slough, SL1 4PG, UK
| | - Avril Drummond
- School of Health Sciences, Medical School, Queens Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
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Churchill L, Pollock M, Lebedeva Y, Pasic N, Bryant D, Howard J, Lanting B, Laliberte Rudman D. Optimizing outpatient total hip arthroplasty: perspectives of key stakeholders. Can J Surg 2019; 61:370-376. [PMID: 30265638 DOI: 10.1503/cjs.016117] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Advances in surgical techniques combined with multimodal analgesia and early rehabilitation have potentiated early mobilization in patients undergoing total hip arthroplasty (THA). Given an increasing push from patients to accelerate recovery and health care budgetary limitations, there has been growing interest in the implementation of outpatient THA in selected patients. Understanding the patient and primary caregiver experience of outpatient THA is important to optimize care. We aimed to gain insight into patient and caregiver perspectives regarding the perceived advantages and disadvantages of same-day discharge to identify areas of care that can be improved. METHOD Using a qualitative descriptive approach, we conducted in-depth semistructured interviews with patient-primary caregiver dyads who experienced same-day discharge or standard care after primary THA with the direct anterior approach in 2016-2017. Two members of the research team coded the data independently, implementing a thematic and content analysis. RESULTS Twenty-eight participants (16 same-day discharge, 12 standard care) were included. Both groups experienced high levels of satisfaction with their care pathway. Concerns and challenges identified in both groups pertained to mobility, pain, self-care and caregiver support. Challenges and concerns unique to same-day discharge were identified regarding expectations for recovery, medications and their impact on mobility, the timing of postoperative education and the availability of formal care. CONCLUSION Outpatient THA can be implemented with high patient and caregiver satisfaction. Preoperative education, clarification of recovery processes and expectations, and proactively addressing concerns related to caregiving are important.
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Affiliation(s)
- Laura Churchill
- From Western University, London, Ont. (Churchill, Pollock, Lebedeva); the School of Physical Therapy, Western University, London, Ont. (Bryant); the Division of Orthopaedic Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont. (Howard, Lanting, Pasic); and the School of Occupational Therapy, Western University, London, Ont. (Laliberte Rudman)
| | - Michael Pollock
- From Western University, London, Ont. (Churchill, Pollock, Lebedeva); the School of Physical Therapy, Western University, London, Ont. (Bryant); the Division of Orthopaedic Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont. (Howard, Lanting, Pasic); and the School of Occupational Therapy, Western University, London, Ont. (Laliberte Rudman)
| | - Yekaterina Lebedeva
- From Western University, London, Ont. (Churchill, Pollock, Lebedeva); the School of Physical Therapy, Western University, London, Ont. (Bryant); the Division of Orthopaedic Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont. (Howard, Lanting, Pasic); and the School of Occupational Therapy, Western University, London, Ont. (Laliberte Rudman)
| | - Nicholas Pasic
- From Western University, London, Ont. (Churchill, Pollock, Lebedeva); the School of Physical Therapy, Western University, London, Ont. (Bryant); the Division of Orthopaedic Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont. (Howard, Lanting, Pasic); and the School of Occupational Therapy, Western University, London, Ont. (Laliberte Rudman)
| | - Dianne Bryant
- From Western University, London, Ont. (Churchill, Pollock, Lebedeva); the School of Physical Therapy, Western University, London, Ont. (Bryant); the Division of Orthopaedic Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont. (Howard, Lanting, Pasic); and the School of Occupational Therapy, Western University, London, Ont. (Laliberte Rudman)
| | - James Howard
- From Western University, London, Ont. (Churchill, Pollock, Lebedeva); the School of Physical Therapy, Western University, London, Ont. (Bryant); the Division of Orthopaedic Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont. (Howard, Lanting, Pasic); and the School of Occupational Therapy, Western University, London, Ont. (Laliberte Rudman)
| | - Brent Lanting
- From Western University, London, Ont. (Churchill, Pollock, Lebedeva); the School of Physical Therapy, Western University, London, Ont. (Bryant); the Division of Orthopaedic Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont. (Howard, Lanting, Pasic); and the School of Occupational Therapy, Western University, London, Ont. (Laliberte Rudman)
| | - Debbie Laliberte Rudman
- From Western University, London, Ont. (Churchill, Pollock, Lebedeva); the School of Physical Therapy, Western University, London, Ont. (Bryant); the Division of Orthopaedic Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont. (Howard, Lanting, Pasic); and the School of Occupational Therapy, Western University, London, Ont. (Laliberte Rudman)
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Sodhi N, Dalton SE, Garbarino LJ, Gold PA, Piuzzi NS, Newman JM, Khlopas A, Sultan AA, Chughtai M, Mont MA. Not all primary total hip arthroplasties are equal-so is there a difference in reimbursement? ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:74. [PMID: 30963069 DOI: 10.21037/atm.2018.08.14] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Relative value units (RVUs) are a physician reimbursement model based on the effort required, or value, in providing a procedure or service for a patient. Procedures such as conversion total hip arthroplasties (THAs) can be compared to primary THAs, but many studies have revealed increased difficulties in conversion cases. Despite the increased time and effort for conversion THA, it is unknown if this is reflected in the RVU compensation model. Therefore, the purpose of this study was to compare the: (I) mean operative times; (II) mean RVUs; (III) RVU/minute for primary and conversion THAs; and (IV) perform an individualized idealized surgeon annual cost difference analysis. Methods A total of 103,702 primary THA patients were identified using CPT code 27130 and 2,986 conversion THA patients were identified using CPT code 27132 using the National Surgical Quality Improvement Program (NSQIP) database. The mean RVUs, operative times (minutes), and RVU/minute were calculated and compared. An annualize cost analysis of dollar amounts per case, day, and the year was also performed. Results The mean operative times for the primary and conversion THA cohorts were 94 vs. 146 minutes (P<0.001) and mean RVUs were 21.24 vs. 25.68 (P<0.001). Interestingly, the mean RVU per minute was higher for the primary THA compared to the conversion THA groups (0.26 vs. 0.21, P<0.001). Annualized cost analysis revealed a potential $173,529 difference from performing primary vs. conversion THAs. Conclusions Even though conversion THA can be considered to a more complex and demanding procedure, based on RVUs per minute of surgery, orthopaedic surgeons are reimbursed better for primary THA cases. This data could be used by orthopaedic surgeons to administer their practices better to yield the highest return on time.
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Affiliation(s)
- Nipun Sodhi
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Sarah E Dalton
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Luke J Garbarino
- Department of Orthopaedic Surgery, Long Island Jewish Hospital, Northwell Health, Great Neck, NY, USA
| | - Peter A Gold
- Department of Orthopaedic Surgery, Long Island Jewish Hospital, Northwell Health, Great Neck, NY, USA
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA.,Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Jared M Newman
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York, NY, USA
| | - Anton Khlopas
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Assem A Sultan
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Morad Chughtai
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Michael A Mont
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA.,Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
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Sodhi N, Dalton SE, Gold PA, Garbarino LJ, Anis HK, Newman JM, Mahmood B, Khlopas A, Sultan AA, Piuzzi NS, Mont MA. A comparison of relative value units in revision hip versus revision knee arthroplasty. J Orthop 2018; 16:45-48. [PMID: 30662237 DOI: 10.1016/j.jor.2018.12.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 12/09/2018] [Indexed: 01/16/2023] Open
Abstract
The purpose of this study was to compare the: 1) RVUs; 2) lengths-of-surgery; 3) RVU per minute between revision hip (THA) and knee (TKA) arthroplasties; and 4) perform an annualized surgeon cost analysis. Using the ACS-NSQIP from 2008 to 2015, 8081 revision TKAs, 7233 THAs were compared. Revision THA had greater mean RVUs (30.27 vs. 27.10 RVUs, p < 0.001), operative times (152 vs. 149 min, p < 0.001), and RVU/minute (0.3 vs. 0.2 RVUs per minute, p < 0.001). Cost analysis yielded and annual $89,922.73 difference. Revision THA, therefore, is reimbursed at a significantly higher "hourly rate," when compared to revision TKA.
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Affiliation(s)
- Nipun Sodhi
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, 10075, USA
| | - Sarah E Dalton
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Peter A Gold
- Department of Orthopaedic Surgery, Long Island Jewish Hospital, Northwell Health, Great Neck, NY, 11021, USA
| | - Luke J Garbarino
- Department of Orthopaedic Surgery, Long Island Jewish Hospital, Northwell Health, Great Neck, NY, 11021, USA
| | - Hiba K Anis
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Jared M Newman
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Bilal Mahmood
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Anton Khlopas
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Assem A Sultan
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Michael A Mont
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, 10075, USA.,Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
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Premkumar A, Morse K, Levack AE, Bostrom MP, Carli AV. Periprosthetic Joint Infection in Patients with Inflammatory Joint Disease: Prevention and Diagnosis. Curr Rheumatol Rep 2018; 20:68. [PMID: 30203376 DOI: 10.1007/s11926-018-0777-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Periprosthetic joint infection (PJI) is a devastating complication that can occur following total joint arthroplasty (TJA), causing significant morbidity and often requiring revision surgery. This goal of this manuscript is to review the current evidence for the prevention and diagnosis of PJI in patients with inflammatory arthritis. RECENT FINDINGS Patients with inflammatory arthritis have a higher risk of PJI after TJA; however, there are several preventive, diagnostic, and therapeutic measures that can be optimized to lower the burden of PJI in this population. This manuscript will review the current evidence and clinical practice recommendations that support specific features of preoperative evaluation, perioperative medication management, and surgical planning in inflammatory arthritis patients undergoing TJA. Evidence and recommendations for the diagnosis of PJI in this patient population will also be reviewed. Despite increased research efforts directed towards PJI, specific approaches directed at the inflammatory arthritis patient population remain surprisingly limited. Optimization strategies such as adequately managing disease-modifying medications, treating preoperative anemia, encouraging smoking cessation, and improving weight management are strongly encouraged before entering the perioperative period. If PJI does occur in the inflammatory arthritis patient, establishing the diagnosis is challenging, since guidelines were created from investigations of PJI in primarily patients without inflammatory arthritis. Future prospective research is required to better guide clinicians in preventing and diagnosing PJI in inflammatory arthritis patients undergoing TJA.
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Affiliation(s)
- Ajay Premkumar
- Department of Academic Training, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Kyle Morse
- Department of Academic Training, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Ashley E Levack
- Department of Academic Training, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
| | - Mathias P Bostrom
- Department of Academic Training, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Alberto V Carli
- Department of Academic Training, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
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Oh C, Slover JD, Bosco JA, Iorio R, Gold HT. Time Trends in Characteristics of Patients Undergoing Primary Total Hip and Knee Arthroplasty in California, 2007-2010. J Arthroplasty 2018; 33:2376-2380. [PMID: 29605148 DOI: 10.1016/j.arth.2018.02.079] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 02/19/2018] [Accepted: 02/20/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND As the number of total hip and knee arthroplasty cases increases, it is important to understand the burden of factors that impact patient outcomes of these procedures. This article examined the time trends in key demographics, clinical characteristics, comorbidity burden (Deyo-Charlson Comorbidity Index [CCI]), and presence of depression in patients undergoing primary total hip arthroplasty and total knee arthroplasty using population-based, all-payer inpatient database, California Healthcare Cost and Utilization Project, from 2007 to 2010. METHODS Chi-square tests and analysis of variance were used. Multivariate logistic regression analyses were also performed to compare the prevalence of depression in 2007 to later years. RESULTS In the primary total hip arthroplasty cohort, the prevalence of depression significantly increased by 20%, mean age decreased by 0.4 years, mean length of stay (LOS) decreased by 0.5 days, and having a CCI score of ≥3 increased by 30% (P value < .001 for all) over the study period. Similarly, in the primary total knee arthroplasty cohort, the prevalence of depression increased by 23%, the mean age decreased by 0.4 years, mean LOS decreased by 0.4 days, and the prevalence of CCI score of ≥3 increased by 35% (P value < .001 for all). CONCLUSION Despite the younger age of the joint arthroplasty population over time, we found increased prevalence of depression and comorbidity scores but shorter LOS. Further study is needed to determine the impact of the changing demographics of the total joint population and the best strategies to optimize their outcome with these procedures.
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Affiliation(s)
- Cheongeun Oh
- Department of Population Health, NYU School of Medicine, New York, New York
| | - James D Slover
- Department of Orthopaedic Surgery, NYU School of Medicine, New York, New York
| | - Joseph A Bosco
- Department of Orthopaedic Surgery, NYU School of Medicine, New York, New York
| | - Richard Iorio
- Department of Orthopaedic Surgery, NYU School of Medicine, New York, New York
| | - Heather T Gold
- Department of Population Health, NYU School of Medicine, New York, New York; Department of Orthopaedic Surgery, NYU School of Medicine, New York, New York
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Godziuk K, Prado CM, Woodhouse LJ, Forhan M. The impact of sarcopenic obesity on knee and hip osteoarthritis: a scoping review. BMC Musculoskelet Disord 2018; 19:271. [PMID: 30055599 PMCID: PMC6064616 DOI: 10.1186/s12891-018-2175-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 07/10/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The progressive, debilitating nature of knee and hip osteoarthritis can result in severe, persistent pain and disability, potentially leading to a need for total joint arthroplasty (TJA) in end-stage osteoarthritis. TJA in adults with obesity is associated with increased surgical risk and prolonged recovery, yet classifying obesity only using body mass index (BMI) precludes distinction of obesity phenotypes and their impact on surgical risk and recovery. The sarcopenic obesity phenotype, characterized by high adiposity and low skeletal muscle mass, is associated with higher infection rates, poorer function, and slower recovery after surgery in other clinical populations, but not thoroughly investigated in osteoarthritis. The rising prevalence and impact of this phenotype demands further attention in osteoarthritis treatment models of care, particularly as osteoarthritis-related pain, disability, and current treatment practices may inadvertently be influencing its development. METHODS A scoping review was used to examine the extent of evidence of sarcopenic obesity in adults with hip or knee osteoarthritis. Medline, CINAHL, Web of Science and EMBASE were systematically searched from inception to December 2017 with keywords and subject headings related to obesity, sarcopenia and osteoarthritis. RESULTS Eleven studies met inclusion criteria, with indications that muscle weakness, low skeletal muscle mass or sarcopenia are present alongside obesity in this population, potentially impacting therapeutic outcomes, and TJA surgical risk and recovery. CONCLUSIONS Consideration of sarcopenic obesity should be included in osteoarthritis patient assessments.
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Affiliation(s)
- Kristine Godziuk
- Faculty of Rehabilitation Medicine, University of Alberta, 8205 – 114 Street, 2-64 Corbett Hall, Edmonton, AB T6G 2G4 Canada
| | - Carla M. Prado
- Division of Human Nutrition, Faculty of Agricultural, Life and Environmental Sciences, University of Alberta, Edmonton, AB Canada
| | - Linda J. Woodhouse
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB Canada
| | - Mary Forhan
- Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB Canada
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Hypothyroidism Increases 90-Day Complications and Costs Following Primary Total Knee Arthroplasty. J Arthroplasty 2018; 33:1003-1007. [PMID: 29174407 PMCID: PMC6383647 DOI: 10.1016/j.arth.2017.10.053] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 10/19/2017] [Accepted: 10/29/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Thyroid disease is common and often remains undetected in the US population. Thyroid hormone has an array of metabolic, immunologic, and musculoskeletal functions crucial to well-being. The influence of thyroid disease on perioperative outcomes following primary total knee arthroplasty (TKA) is poorly understood. We hypothesized that hypothyroidism was associated with a higher risk of postoperative complications and 90-day costs following primary TKA. METHODS The Medicare standard analytical files were queried using International Classification of Disease codes between 2005 and 2014 to identify patients undergoing primary TKA. Patients with a diagnosis of hypothyroidism were matched by age and gender on a 1:1 ratio. Ninety-day postoperative complication rates, day of surgery, and 90-day global period charges and reimbursements were compared between matched cohorts. RESULTS A total of 2,369,594 primary TKAs were identified between 2005 and 2014. After age and gender matching, each cohort consisted of 98,555 patients. Hypothyroidism was associated with greater odds of postoperative complications compared to matched controls (odds ratio 1.367, 95% confidence interval 1.322-1.413). The 90-day incidence of multiple postoperative medical and surgical complications, including periprosthetic joint infection, was higher among patients with hypothyroidism. Day of surgery and 90-day episode of care costs were significantly higher in the hypothyroidism cohort. CONCLUSION This study demonstrated an increased risk of multiple postoperative complications and higher costs among patients with hypothyroidism following primary TKA. Surgeons should counsel patients on these findings and seek preoperative optimization strategies to reduce these risks and lower costs in this patient population.
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Boylan M, Suchman K, Vigdorchik J, Slover J, Bosco J. Technology-Assisted Hip and Knee Arthroplasties: An Analysis of Utilization Trends. J Arthroplasty 2018; 33:1019-1023. [PMID: 29290333 DOI: 10.1016/j.arth.2017.11.033] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 10/26/2017] [Accepted: 11/18/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Robotic and computer navigation technology is available to surgeons for use in hip and knee arthroplasties to increase the precision of component placement. However, they do add significant costs to these procedures, and the long-term clinical outcomes and value of technology assistance for joint replacement remain unclear. METHODS We identified 321,522 patients in Medicare Severity Diagnosis Related Groups 469 and 470 who underwent primary total hip arthroplasty (N = 133,472) or primary total or unicompartmental knee arthroplasty (N = 188,050) between 2008 and 2015 in the New York Statewide Planning and Research Cooperative System (SPARCS). RESULTS Among all total joint arthroplasties performed during this period, technology assistance was used in 5.1% of cases. Technology assistance was more common for knee (7.3%) than hip (1.9%) arthroplasty (P < .001). The proportion of cases using technology assistance grew each year, increasing from 2.8% (knee 4.3% and hip 0.5%) in 2008 to 8.6% (knee 11.6% and hip 5.2%) in 2015 (P trend <.001). The proportion of hospitals and surgeons using robotic assistance also increased during the study period, increasing from 16.2% of hospitals and 6.2% of surgeons in 2008 to 29.2% of hospitals and 17.1% of surgeons in 2015 (P trend <.001 for both). Technology was more likely to be used for patients with private insurance (5.9%) compared with Medicare (4.7%, P < .001) or Medicaid (2.2%, P < .001), and for patients at high-volume (6.9%, P < .001) or very high-volume (6.1%, P < .001) as compared with low-volume (2.7%) hospitals. CONCLUSION Technology assistance has become increasingly used by orthopedic surgeons for hip and knee arthroplasties, however, adoption has not been uniform.
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Affiliation(s)
- Matthew Boylan
- Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
| | - Kelly Suchman
- Icahn School of Medicine at Mount Sinai, Mount Sinai Medical Center, New York, New York
| | - Jonathan Vigdorchik
- Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
| | - James Slover
- Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
| | - Joseph Bosco
- Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
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Sodhi N, Piuzzi NS, Khlopas A, Newman JM, Kryzak TJ, Stearns KL, Mont MA. Are We Appropriately Compensated by Relative Value Units for Primary vs Revision Total Hip Arthroplasty? J Arthroplasty 2018; 33:340-344. [PMID: 28993077 DOI: 10.1016/j.arth.2017.09.019] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 08/28/2017] [Accepted: 09/05/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Relative value units (RVUs) are used to evaluate the effort required for providing a service to patients in order to determine compensation. Thus, more complicated cases, like revision arthroplasty cases, should yield a greater compensation. However, there are limited data comparing RVUs to the time required to complete the service. Therefore, the purpose of this study is to compare the (1) mean RVUs, (2) mean operative times, and (3) mean RVU/minute between primary and revision total hip arthroplasty (THA) and (4) perform an individualized idealized surgeon annual cost difference analysis. METHODS A total of 103,702 patients who underwent primary (current procedural terminology code 27130) and 7273 patients who underwent revision THA (current procedural terminology code 27134) were identified using the National Surgical Quality Improvement Program database. Mean RVUs, operative times (minutes), and RVU/minute were calculated and compared using Student t-test. Dollar amount per minute, per case, per day, and year was calculated to find an individualized idealized surgeon annual cost difference. RESULTS The mean RVU was 21.24 ± 0.53 (range, 20.72-21.79) for primary and 30.27 ± 0.03 (range, 30.13-30.28) for revision THA (P < .001). The mean operative time for primary THA was 94 ± 38 minutes (range, 30-480 minutes) and 152 ± 75 minutes (range, 30-475 minutes) for revision THA (P < .001). The mean RVU/minute was 0.260 ± 0.10 (range, 0.04-0.73) for primary and 0.249 ± 0.12 (range, 0.06-1.0) for revision cases (P < .001). The dollar amounts calculated for primary vs revision THA were as follows: per minute ($9.33 vs $8.93), per case ($877.12 vs $1358.32), per day ($6139.84 vs $5433.26), and a projected $113,052.28 annual cost difference for an individual surgeon. CONCLUSION Maximizing the RVU/minute provides the greatest "hourly rate." The RVU/minute for primary (0.260) being significantly greater than revision THA (0.249) and an annualized $113,052.28 cost difference reveal that although revision THAs are more complex cases requiring longer operative time, greater technical skill, and aftercare, compensation per time is not greater.
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Affiliation(s)
- Nipun Sodhi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Anton Khlopas
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Jared M Newman
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York
| | - Thomas J Kryzak
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Kim L Stearns
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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Swenson ER, Bastian ND, Nembhard HB, Davis Iii CM. Reducing cost drivers in total joint arthroplasty: understanding patient readmission risk and supply cost. Health Syst (Basingstoke) 2017; 7:135-147. [PMID: 31214344 DOI: 10.1080/20476965.2017.1397237] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 10/03/2017] [Accepted: 10/15/2017] [Indexed: 10/28/2022] Open
Abstract
Introduction: Understanding and planning for the factors that impact supply cost and unplanned readmission risk for total joint arthroplasty (TJA) patients is helpful for hospitals at financial risk under bundled payments. Readmission and operating room supply costs are two of the biggest expenses. Methods: Logistic and linear regressions are used to measure the impacts of TJA patient attributes on readmission risk and supply costs, respectively. Results: Patients' health market segment and the number/type of comorbidity impacts 30/90-day readmission rates. Surgeon implant preference and type of surgery impact supply costs. Discharge location and two of the five health market segments increase the odds of 30-day readmission. Arrhythmia and lymphoma are the primary comorbidities that impact the odds of readmission at 90 days. Conclusions: Preoperatively identifying TJA patients likely to have large supply costs and higher readmission risk allows hospitals to invest in low-cost interventions to reduce risk and improve healthcare value.
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Affiliation(s)
- Eric R Swenson
- Center for Health Organization Transformation, Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park, PA, USA
| | - Nathaniel D Bastian
- Center for Health Organization Transformation, Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park, PA, USA
| | - Harriet B Nembhard
- Center for Health Organization Transformation, Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park, PA, USA
| | - Charles M Davis Iii
- Penn State Hershey Medical Center, Bone and Joint Institute, Hershey, PA, USA
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Al Thaher Y, Perni S, Prokopovich P. Nano-carrier based drug delivery systems for sustained antimicrobial agent release from orthopaedic cementous material. Adv Colloid Interface Sci 2017; 249:234-247. [PMID: 28477865 DOI: 10.1016/j.cis.2017.04.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 04/25/2017] [Accepted: 04/26/2017] [Indexed: 12/22/2022]
Abstract
Total joint replacement (TJR), such as hip and knee replacement, is a popular procedure worldwide. Prosthetic joint infections (PJI) after this procedure have been widely reported, where treatment of such infections is complex with high cost and prolonged hospital stay. In cemented arthroplasties, the use of antibiotic loaded bone cement (ALBC) is a standard practice for the prophylaxis and treatment of PJI. Recently, the development of bacterial resistance by pathogenic microorganisms against most commonly used antibiotics increased the interest in alternative approaches for antimicrobial delivery systems such as nanotechnology. This review summarizes the efforts made to improve the antimicrobial properties of PMMA bone cements using nanotechnology based antibiotic and non-antibiotic delivery systems to overcome drawbacks of ALBC in the prophylaxis and treatment of PJIs after hip and knee replacement.
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Affiliation(s)
- Yazan Al Thaher
- School of Pharmacy and Pharmaceutical Science, Cardiff University, Cardiff, UK
| | - Stefano Perni
- School of Pharmacy and Pharmaceutical Science, Cardiff University, Cardiff, UK
| | - Polina Prokopovich
- School of Pharmacy and Pharmaceutical Science, Cardiff University, Cardiff, UK.
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Sibia US, Turcotte JJ, MacDonald JH, King PJ. The Cost of Unnecessary Hospital Days for Medicare Joint Arthroplasty Patients Discharging to Skilled Nursing Facilities. J Arthroplasty 2017; 32:2655-2657. [PMID: 28455180 DOI: 10.1016/j.arth.2017.03.058] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 03/13/2017] [Accepted: 03/24/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The 72-hour Medicare mandate (3-night stay rule) requires a 3-day inpatient stay for patients discharging to skilled nursing facilities (SNFs). Studies show that 48%-64% of Medicare total joint arthroplasty (TJA) patients are safe for discharge to SNFs on postoperative day (POD) #2. The purpose of this study was to extrapolate the financial impact of the 3-night stay rule. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried for all primary TJAs performed in 2015. Discharge destination was recorded. Institutional cost accounting examined costs for patients discharging on POD #2 vs POD #3. RESULTS A total of 42,423 TJAs (14,395 total hip arthroplasties [THAs] and 28,028 total knee arthroplasties [TKAs]) were performed in patients over the age of 65 years. Of these patients, 5252 THAs (36.5%) and 12,022 TKAs (42.9%) were discharged from the hospital on POD #3, with 2404 THAs (16.7%) and 5083 TKAs (18.1%) being discharged to SNFs. Institutional cost accounting revealed hospital costs for THA were $2014 more, whereas hospital costs for TKA were $1814 more for a 3-day length of stay when compared with a 2-day length of stay (P < .001). The mean charge per day for an SNF was $486. CONCLUSION The National Surgical Quality Improvement Program database is a representative sample of all surgeries performed in the United States. Extrapolating our findings to all Medicare TJAs nationally gives an estimated $63 million in annual savings. Medicare mandated, but potentially medically unnecessary inpatient days at a higher level of care increase the total cost for TJAs. Policies regarding minimum stay requirements before discharge should be re-evaluated.
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Affiliation(s)
- Udai S Sibia
- Center for Joint Replacement, Anne Arundel Medical Center, Annapolis, Maryland
| | - Justin J Turcotte
- Department of Surgery, Anne Arundel Medical Center, Annapolis, Maryland
| | - James H MacDonald
- Center for Joint Replacement, Anne Arundel Medical Center, Annapolis, Maryland
| | - Paul J King
- Center for Joint Replacement, Anne Arundel Medical Center, Annapolis, Maryland
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McLawhorn AS, Buller LT. Bundled Payments in Total Joint Replacement: Keeping Our Care Affordable and High in Quality. Curr Rev Musculoskelet Med 2017; 10:370-377. [PMID: 28741101 PMCID: PMC5577424 DOI: 10.1007/s12178-017-9423-6] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review was to evaluate the literature regarding bundle payment reimbursement models for total joint arthroplasty (TJA). RECENT FINDINGS From an economic standpoint, TJA are cost-effective, but they represent a substantial expense to the Centers for Medicare & Medicaid Services (CMS). Historically, fee-for-service payment models resulted in highly variable cost and quality. CMS introduced Bundled Payments for Care Improvement (BPCI) in 2012 and subsequently the Comprehensive Care for Joint Replacement (CJR) reimbursement model in 2016 to improve the value of TJA from the perspectives of both CMS and patients, by improving quality via cost control. Early results of bundled payments are promising, but preserving access to care for patients with high comorbidity burdens and those requiring more complex care is a lingering concern. Hospitals, regardless of current participation in bundled payments, should develop care pathways for TJA to maximize efficiency and patient safety.
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Affiliation(s)
- Alexander S. McLawhorn
- Adult Reconstruction & Joint Replacement, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Leonard T. Buller
- Department of Orthopedic Surgery, University of Miami/Jackson Memorial Hospital, Miami, FL USA
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Jones CA, Martin RS, Westby MD, Beaupre LA. Total joint arthroplasty: practice variation of physiotherapy across the continuum of care in Alberta. BMC Health Serv Res 2016; 16:627. [PMID: 27809849 PMCID: PMC5095989 DOI: 10.1186/s12913-016-1873-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 10/21/2016] [Indexed: 12/27/2022] Open
Abstract
Background Comprehensive and timely rehabilitation for total joint arthroplasty (TJA) is needed to maximize recovery from this elective surgical procedure for hip and knee arthritis. Administrative data do not capture the variation of treatment for rehabilitation across the continuum of care for TJA, so we conducted a survey for physiotherapists to report practice for TJA across the continuum of care. The primary objective was to describe the reported practice of physiotherapy for TJA across the continuum of care within the context of a provincial TJA clinical pathway and highlight possible gaps in care. Method A cross-sectional on-line survey was accessible to licensed physiotherapists in Alberta, Canada for 11 weeks. Physiotherapists who treated at least five patients with TJA annually were asked to complete the survey. The survey consisted of 58 questions grouped into pre-operative, acute care and post-acute rehabilitation. Variation of practice was described in terms of number, duration and type of visits along with goals of care and program delivery methods. Results Of the 80 respondents, 26 (33 %) stated they worked in small centres or rural settings in Alberta with the remaining respondents working in two large urban sites. The primary treatment goal differed for each phase across the continuum of care in that pre-operative phase was directed at improving muscle strength, functional activities were commonly reported for acute care, and post-acute phase was directed at improving joint range-of-motion. Proportionally, more physiotherapists from rural areas treated patients in out-patient hospital departments (59 %), whereas a higher proportion in urban physiotherapists saw patients in private clinics (48 %). Across the continuum of care, treatment was primarily delivered on an individual basis rather than in a group format. Conclusions Variation of practice reported with pre-and post-operative care in the community will stimulate dialogue within the profession as to what is the minimal standard of care to provide patients undergoing TJA. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1873-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- C Allyson Jones
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, T6G 2G4, Canada.
| | - Ruben San Martin
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, T6G 2G4, Canada
| | - Marie D Westby
- School of Public Health, University of Alberta, Edmonton, Alberta, T6G 1C9, Canada
| | - Lauren A Beaupre
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, T6G 2G4, Canada
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