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Tubin N, Brouget-Murray J, Bureau A, Morris J, Azad M, Abdelbary H, Grammatopoulos G, Garceau S. Fellowship Training in Arthroplasty Improves Treatment Success of Debridement, Antibiotics, and Implant Retention for Periprosthetic Knee Infections. Arthroplast Today 2024; 27:101378. [PMID: 38933043 PMCID: PMC11200284 DOI: 10.1016/j.artd.2024.101378] [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: 06/14/2023] [Revised: 02/19/2024] [Accepted: 03/12/2024] [Indexed: 06/28/2024] Open
Abstract
Background Debridement, antibiotics, and implant retention (DAIR) is a well-accepted surgical strategy for periprosthetic joint infection (PJI) following total knee arthroplasty (TKA). DAIR in TKA may be incorrectly thought of as a "simple" procedure not requiring formal specialized training in arthroplasty. Currently, there are no studies comparing the risk of treatment failure based on surgeon fellowship training. Methods A retrospective review was performed of consecutive patients who underwent DAIR for TKA PJI at our institution. Two cohorts were created based on whether DAIR was performed by an arthroplasty fellowship-trained (FT) surgeon or nonarthroplasty fellowship-trained (NoFT) surgeon. Primary outcome was treatment failure following DAIR at a minimum of 1 year postoperatively. Treatment failure was based on the Tier 1 International Consensus Meeting definition of infection control. Secondary outcomes were also recorded including death during the totality of PJI treatment. Results A total of 112 patients were identified (FT = 68, NoFT = 44). At a mean follow-up of 7.3 years [standard deviation = 3.9], 73 patients (59.8%) failed treatment. Fellowship training in arthroplasty significantly improved treatment success rates (FT, 35/68 [51.5%]; NoFT, 10/44 [22.7%]; odds ratio 2.5 [95% confidence interval 1.1 to 5.9; P = .002]). Survivorship also differed significantly between the cohorts; at timepoints of 1.5 months, 5 months, 30 months, and 180 months, survivorship of the FT cohort was 79.4%, 67.6%, 54.4%, and 50.7%, respectively, compared with a survivorship of 65.9%, 52.3%, 25%, and 22.7% in the NoFT cohort (P = .002). Conclusions TKA PJI treated with DAIR should not be considered a simple procedure. Improved treatment success may be associated with subspecialty fellowship training in arthroplasty. Level of Evidence IV.
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Affiliation(s)
- Nicholas Tubin
- Division of Orthopaedic Surgery, Department of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Jonathan Brouget-Murray
- Division of Orthopaedic Surgery, Department of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Antoine Bureau
- Division of Orthopaedic Surgery, Department of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Jared Morris
- Division of Orthopaedic Surgery, Department of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Marsa Azad
- Division of Orthopaedic Surgery, Department of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON, Canada
- Division of Orthopaedic Surgery, Department of Infectious Diseases, The Ottawa Hospital, Ottawa, ON, Canada
| | - Hesham Abdelbary
- Division of Orthopaedic Surgery, Department of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - George Grammatopoulos
- Division of Orthopaedic Surgery, Department of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Simon Garceau
- Division of Orthopaedic Surgery, Department of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON, Canada
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Wolfstadt JI, Landy DC, Blankstein M, Suleiman LI, Slover JD. Traumaplasty: When and How to Perform Acute Arthroplasty for Fractures Around the Hip in the Elderly Patient. J Arthroplasty 2024:S0883-5403(24)00536-9. [PMID: 38823521 DOI: 10.1016/j.arth.2024.05.064] [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: 12/19/2023] [Revised: 05/13/2024] [Accepted: 05/15/2024] [Indexed: 06/03/2024] Open
Abstract
Acute fractures around the hip are prevalent injuries associated with potentially devastating outcomes. The growing utilization of arthroplasty for femoral neck fractures in the elderly is likely a result of improvements in reoperation rates and postoperative function. Compared to hemiarthroplasty, total hip arthroplasty is associated with a slight functional benefit that is unlikely noticeable for many patients, as well as minimal differences in complications and patient reported outcome measures. However, the evidence supporting cement use in femoral stem fixation is robust. Multiple high power randomized controlled trial-based studies indicate cement fixation brings more predictable outcomes and fewer reoperations. In the setting of acute acetabular fracture, total hip arthroplasty is a favorable approach for elderly patients and fracture patterns associated with increased risk of revision after open reduction and internal fixation. Variations in patient characteristics and fracture patterns demand careful consideration whenever selecting the optimal treatment. In fracture patient populations, comanagement is an important consideration when seeking to reduce complications and promote cost-effective quality care.
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Affiliation(s)
- Jesse I Wolfstadt
- Granovsky Gluskin Division of Orthopedic Surgery, Sinai Health System, University of Toronto, Toronto, Ontario, Canada
| | - David C Landy
- OrthoVirginia and Liberty University, Lynchburg, Virginia
| | - Michael Blankstein
- Department of Orthopaedics and Rehabilitation, University of Vermont, Burlington, Vermont
| | - Linda I Suleiman
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - James D Slover
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, New York
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Ramadanov N, Salzmann M, Voss M, Hable R, Hakam HT, Prill R, Dimitrov D, Becker R. The influence of operation time for hip hemiarthroplasty on complication rates and mortality in patients with femoral neck fracture: a retrospective data analysis. J Orthop Surg Res 2024; 19:311. [PMID: 38802945 PMCID: PMC11129483 DOI: 10.1186/s13018-024-04797-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 05/16/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND The aim of the present study was to investigate the influence of various factors, in particular operation time, on mortality and complication rates in patients with femoral neck fractures who have undergone hip hemiarthroplasty (HHA) and to determine a cut-off value above which mortality and complication rates increase significantly. METHODS Cases of patients with femoral neck fracture treated with HHA between 1 January 2017 and 31 December 2023 were screened for eligibility. Multiple logistic regressions were calculated to determine which factors (patient age, experience of surgeon, patient sex, ASA score, time to surgery, operation time) influenced the incidence of complications and mortality. The exact cut-off value for complications and mortality was determined using the Youden index of the ROC curve (sensitivity vs. specificity) of logistic regression. RESULTS A total of 552 patients were considered eligible for this study. During the 90-day follow-up period after HHA, 50 deaths and 34 complications were recorded, giving a mortality rate of 9.1%, and a complication rate of 6.2%. Of the 34 complications recorded, 32.3% were infections, 14.7% dislocations, 20.7% trochanteric avulsions, 11.8% periprosthetic fractures, 11.8% nerve injuries, and 8.8% deep vein thrombosis. The odds ratio (OR) of a patient experiencing a complication is 2.2% higher for every minute increase in operation time (Exponential Beta - 1 = 0.022; p = 0.0363). The OR of a patient dying is 8.8% higher for each year increase in age (Exponential Beta - 1 = 0.088; p = 0.0007). When surgery was performed by a certified orthopaedic surgeon the mortality rate lowered by 61.5% in comparison to the surgery performed by a trainee (1 - Exponential Beta = 0.594; p = 0.0120). Male patients have a 168.7% higher OR for mortality than female patients (Exponential Beta - 1 = 1.687; p = 0.0017). Patients with an operation time of ≥ 86 min. have a 111.8% higher OR for mortality than patients with an operation time of < 86 min. (Exponential Beta - 1 = 1.118). CONCLUSION This retrospective data analysis found that the risk of a patient experiencing a complication was 2.2% higher for every minute increase in operation time. Patients with an operation time above the cut-off of 86 min had a 111.8% higher risk of mortality than those with an operation time below the cut-off. Other influencing factors that operators should be aware of include patient age, male sex, and operator experience.
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Affiliation(s)
- Nikolai Ramadanov
- Center of Orthopaedics and Traumatology, University Hospital Brandenburg/Havel, Brandenburg Medical School Theodor Fontane, 14770, Brandenburg an der Havel, Germany.
- Faculty of Health Science Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany.
| | - Mikhail Salzmann
- Center of Orthopaedics and Traumatology, University Hospital Brandenburg/Havel, Brandenburg Medical School Theodor Fontane, 14770, Brandenburg an der Havel, Germany
- Faculty of Health Science Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
| | - Maximilian Voss
- Center of Orthopaedics and Traumatology, University Hospital Brandenburg/Havel, Brandenburg Medical School Theodor Fontane, 14770, Brandenburg an der Havel, Germany
- Faculty of Health Science Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
| | - Robert Hable
- Faculty of Applied Computer Science, Deggendorf Institute of Technology, Deggendorf, Germany
| | - Hassan Tarek Hakam
- Center of Orthopaedics and Traumatology, University Hospital Brandenburg/Havel, Brandenburg Medical School Theodor Fontane, 14770, Brandenburg an der Havel, Germany
- Faculty of Health Science Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
| | - Robert Prill
- Center of Orthopaedics and Traumatology, University Hospital Brandenburg/Havel, Brandenburg Medical School Theodor Fontane, 14770, Brandenburg an der Havel, Germany
- Faculty of Health Science Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
| | - Dobromir Dimitrov
- Department of Surgical Propedeutics, Faculty of Medicine, Medical University of Pleven, Pleven, Bulgaria
| | - Roland Becker
- Center of Orthopaedics and Traumatology, University Hospital Brandenburg/Havel, Brandenburg Medical School Theodor Fontane, 14770, Brandenburg an der Havel, Germany
- Faculty of Health Science Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
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Collins LK, Winter JE, Delvadia BP, Cole MW, Sherman WF. Adult Reconstruction Surgeons Manage Patients With Higher Medical Complexities and Still Achieve Comparable Outcomes to Sports Medicine Surgeons Following Total Knee Arthroplasty. Arthroplast Today 2024; 25:101287. [PMID: 38380156 PMCID: PMC10877335 DOI: 10.1016/j.artd.2023.101287] [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: 08/01/2023] [Revised: 10/26/2023] [Accepted: 11/03/2023] [Indexed: 02/22/2024] Open
Abstract
Background Orthopaedic surgeons who are fellowship-trained in adult reconstruction (AR) specialize specifically in total joint arthroplasty, including total knee arthroplasty (TKA). However, TKA procedures are not only performed by AR surgeons. The purpose of this study was to compare the patient demographics and postoperative outcomes of patients who had a TKA procedure performed by an AR surgeon vs a sports medicine (SM) surgeon. Methods A retrospective cohort study was conducted using a national insurance database. Patients who underwent a primary elective TKA procedure by an AR surgeon (n = 56,570) and an SM surgeon (n = 72,888) were identified. Patient demographics, rates of joint complications within 2 years, and medical complications within 90 days postoperatively were compared using multivariable logistic regression. Results Compared to the cohort of patients undergoing TKA by SM surgeons, the patient cohort of AR surgeons had a higher mean Elixhauser comorbidity index (4.2 vs 4.0, P < .001), and had significantly higher rates of several comorbidities. Within 90 days, patients of AR surgeons demonstrated significantly lower rates of acute kidney injury and transfusions. When compared to patients of SM surgeons, patients of AR surgeons demonstrated significantly lower rate of manipulation under anesthesia or lysis of adhesions within 2 years. Rates of all other joint-related complications were statistically comparable between the 2 cohorts. Conclusions As a cohort, AR surgeons perform TKA on a higher-risk cohort of patients compared to sports medicine surgeons. Despite the higher-risk patient population, outcomes of TKA by AR surgeons appear equivalent compared to their SM colleagues.
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Affiliation(s)
- Lacee K. Collins
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Julianna E. Winter
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Bela P. Delvadia
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Matthew W. Cole
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - William F. Sherman
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA, USA
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Yaacobi E, Shachar T, Segal D, Agabaria A, Halima G, Marom O, Ohana N. Unveiling the Economic Toll of Surgical Learning Curve in Elderly Hip Fractures. J Clin Med 2023; 12:4880. [PMID: 37568283 PMCID: PMC10420139 DOI: 10.3390/jcm12154880] [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: 06/24/2023] [Revised: 07/17/2023] [Accepted: 07/18/2023] [Indexed: 08/13/2023] Open
Abstract
Can the financial impact of implant choice during the learning curve of inexperienced surgeons in hip fracture surgery be quantified? Hip fractures in the elderly are a significant medical concern, often requiring surgical interventions performed by orthopedic surgery residents. As healthcare costs rise, exploring cost reduction opportunities within the healthcare system becomes crucial. In this prospective analysis, we examined the financial implications of implant choices encountered by residents during their learning curve in hip fracture surgery. Our study included 278 surgically treated pertrochanteric fractures using the same locking cephalomedullary nail. Data on patients, surgeons (including their experience and seniority), and all implants charged by the hospital were collected. This encompassed documentation of any nail-related equipment that was opened on the operating table and whether it was subsequently used by the end of the procedure. By calculating the number and cost of these implants, we assessed the financial burden associated with suboptimal choices made during the learning curve. Our findings revealed that in 16.18% of surgeries, instances of suboptimal implant utilization occurred, highlighting the complexities of the learning process. Importantly, the rate of these challenges was not influenced by surgeon seniority or patient characteristics. The mean additional cost per surgery was determined to be USD 65.69 ± 157.63 for surgeries with suboptimal implant utilization, compared to USD 56.55 ± 139.13 for surgeries without such challenges. Although there was a trend towards higher implant-related costs in resident-led surgeries, the difference did not reach statistical significance. These findings underscore the feasibility of enabling residents to autonomously perform intramedullary nailing surgeries, even without specialist supervision, while incurring minimal additional expenses during the learning curve. By acknowledging the financial implications associated with the learning curve in the management of hip fractures, we can strive to optimize healthcare costs, thus addressing an important aspect of this issue.
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Affiliation(s)
- Eyal Yaacobi
- Department of Orthopaedic Surgery, Meir Medical Center, Tschernihovski 59 Street, Kfar-Saba 4428164, Israel; (E.Y.); (D.S.); (O.M.)
- Faculty of Medicine, Ramat Aviv, Tel Aviv 69978, Israel
| | - Tal Shachar
- Department of Orthopaedic Surgery, Meir Medical Center, Tschernihovski 59 Street, Kfar-Saba 4428164, Israel; (E.Y.); (D.S.); (O.M.)
- Faculty of Medicine, Ramat Aviv, Tel Aviv 69978, Israel
| | - David Segal
- Department of Orthopaedic Surgery, Meir Medical Center, Tschernihovski 59 Street, Kfar-Saba 4428164, Israel; (E.Y.); (D.S.); (O.M.)
- Faculty of Medicine, Ramat Aviv, Tel Aviv 69978, Israel
| | - Altaieb Agabaria
- Department of Orthopaedic Surgery, Meir Medical Center, Tschernihovski 59 Street, Kfar-Saba 4428164, Israel; (E.Y.); (D.S.); (O.M.)
- Faculty of Medicine, Ramat Aviv, Tel Aviv 69978, Israel
| | - Golan Halima
- Surgical Service Unit, Meir Medical Center, Tschernihovski 59 Street, Kfar-Saba 4428164, Israel
| | - Omer Marom
- Department of Orthopaedic Surgery, Meir Medical Center, Tschernihovski 59 Street, Kfar-Saba 4428164, Israel; (E.Y.); (D.S.); (O.M.)
- Faculty of Medicine, Ramat Aviv, Tel Aviv 69978, Israel
| | - Nissim Ohana
- Department of Orthopaedic Surgery, Meir Medical Center, Tschernihovski 59 Street, Kfar-Saba 4428164, Israel; (E.Y.); (D.S.); (O.M.)
- Faculty of Medicine, Ramat Aviv, Tel Aviv 69978, Israel
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Messina JC, Magnuson JA, Melnic CM, Frisch NB, Krueger CA, Grosso MJ. Total Hip Arthroplasty Learning Curves Based on Approach for New Fellowship-trained Surgeons. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202307000-00003. [PMID: 37410811 PMCID: PMC10328697 DOI: 10.5435/jaaosglobal-d-23-00094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/07/2023] [Indexed: 07/08/2023]
Abstract
INTRODUCTION There is concern that the direct anterior (DA) approach is associated with a steeper learning curve than the posterolateral (PL) approach in total hip arthroplasty (THA). The purpose of this study was to investigate if the learning curve is similar for newly trained arthroplasty fellowship-trained surgeons using the DA and PL approaches. METHODS The first 100 primary THA cases of six DA and PL fellowship-trained arthroplasty surgeons were identified and divided into 50 case cohorts. Demographics, indications for surgery, and 90-day Hip Society standardized complications were collected. Variables were analyzed using independent sample t tests, chi-square tests, or Fisher exact tests. RESULTS In total, there were 600 patients, and no notable differences were observed in revision surgeries, surgical complications, and total complications between the DA and PL groups. Both groups had lower revision surgery rates, surgical complications, and total complications during their second 50 cases. Higher revision surgeries, and surgical and total complication rates were observed among all surgeons during the first 50 cases. DISCUSSION AND CONCLUSION No differences were observed in the learning curve when comparing the DA and PL approach. With proper training, early-career surgeons can safely perform THA with similar complication rates regardless of the approach.
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Affiliation(s)
- James C. Messina
- From the Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT (Dr. Messina); Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA (Dr. Magnuson and Dr. Krueger); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Melnic); the Department of Orthopedic Surgery, Ascension Providence Rochester, Rochester, MI (Dr. Frisch); and Connecticut Joint Replacement Institute, Hartford, CT (Dr. Grosso)
| | - Justin A. Magnuson
- From the Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT (Dr. Messina); Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA (Dr. Magnuson and Dr. Krueger); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Melnic); the Department of Orthopedic Surgery, Ascension Providence Rochester, Rochester, MI (Dr. Frisch); and Connecticut Joint Replacement Institute, Hartford, CT (Dr. Grosso)
| | - Christopher M. Melnic
- From the Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT (Dr. Messina); Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA (Dr. Magnuson and Dr. Krueger); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Melnic); the Department of Orthopedic Surgery, Ascension Providence Rochester, Rochester, MI (Dr. Frisch); and Connecticut Joint Replacement Institute, Hartford, CT (Dr. Grosso)
| | - Nicholas B. Frisch
- From the Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT (Dr. Messina); Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA (Dr. Magnuson and Dr. Krueger); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Melnic); the Department of Orthopedic Surgery, Ascension Providence Rochester, Rochester, MI (Dr. Frisch); and Connecticut Joint Replacement Institute, Hartford, CT (Dr. Grosso)
| | - Chad A. Krueger
- From the Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT (Dr. Messina); Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA (Dr. Magnuson and Dr. Krueger); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Melnic); the Department of Orthopedic Surgery, Ascension Providence Rochester, Rochester, MI (Dr. Frisch); and Connecticut Joint Replacement Institute, Hartford, CT (Dr. Grosso)
| | - Matthew J. Grosso
- From the Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT (Dr. Messina); Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA (Dr. Magnuson and Dr. Krueger); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Melnic); the Department of Orthopedic Surgery, Ascension Providence Rochester, Rochester, MI (Dr. Frisch); and Connecticut Joint Replacement Institute, Hartford, CT (Dr. Grosso)
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Domingue G, Warren D, Koval KJ, Riehl JT. Complications of Hip Hemiarthroplasty. Orthopedics 2023; 46:e199-e209. [PMID: 36719411 DOI: 10.3928/01477447-20230125-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Hip hemiarthroplasty is a commonly performed orthopedic surgery, used to treat proximal femur fractures in the elderly population. Although hip hemiarthroplasty is frequently successful in addressing these injuries, complications can occur. Commonly seen complications include dislocation, periprosthetic fracture, acetabular erosion, and leg-length inequality. Less frequently seen complications include neurovascular injury and capsular interposition. This article presents a comprehensive review of the complications associated with the management of hip hemiarthroplasty. [Orthopedics. 2023;46(4):e199-e209.].
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Cao A, Ghanem E, Cichos K, Lichstein P, Chen A. Comparison between Orthopaedic Trauma versus Arthroplasty Fellowship Training on Outcomes of Total Hip Arthroplasty for Femoral Neck Fracture. J Arthroplasty 2023:S0883-5403(23)00354-6. [PMID: 37068569 DOI: 10.1016/j.arth.2023.04.009] [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: 12/05/2022] [Revised: 04/05/2023] [Accepted: 04/08/2023] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND This study aimed to identify differences in patient characteristics, perioperative management methods, and outcomes for total hip arthroplasty (THA) for femoral neck fracture (FNF) when performed by orthopaedic surgeons who have arthroplasty versus orthopaedic trauma training. METHODS This study was a multicenter, retrospective review of 636 patients who underwent THA for FNF between 2010 and 2019. There were 373 patients who underwent THA by an arthroplasty surgeon, and 263 who underwent THA by an orthopaedic trauma surgeon. Comorbidities, management methods, and outcomes were compared between patients operated on by orthopaedic surgeons who had arthroplasty versus trauma training. RESULTS Arthroplasty-trained surgeons had shorter operative times (102 vs 128 minutes, P<0.0001) and utilized tranexamic acid more frequently than trauma-trained surgeons (48.8 vs 18.6%, P<0.0001). Orthopaedic trauma surgeons more frequently utilized an anterior approach. Patients of arthroplasty-trained surgeons had lower rates of complications including pulmonary embolism (1.6 vs 6.5%, P=0.0019) and myocardial infarction (1.6 vs 11.0%, P<0.0001). Similarly, patients of arthroplasty-trained surgeons were discharged faster (5.3 vs 7.9 days, P<0.0001) with greater ambulation capacity (92.2 vs 57.2 feet, P<0.0001). Dislocation, periprosthetic joint infection, and revision were similar between both groups. When adjusted for covariates, there was no difference in 90-day, 1-year, or 2-year mortality. CONCLUSION A THA performed for FNF by arthroplasty surgeons was associated with lower in-hospital morbidities and improved functional statuses at discharge. However, mortalities and complications after discharge were similar between both specialties when adjusted for confounding variables. Optimization of protocols may further improve outcomes for THA for FNF.
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Affiliation(s)
| | - Elie Ghanem
- Department of Orthopaedic Surgery, University of Alabama at Birmingham Hospital, Birmingham, AL, USA; Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
| | - Kyle Cichos
- Department of Orthopaedic Surgery, University of Alabama at Birmingham Hospital, Birmingham, AL, USA; The Hughston Clinic, Columbus, GA, USA; The Hughston Foundation, Columbus, GA, USA
| | | | - Antonia Chen
- Harvard Medical School, Boston, MA, USA; Orthopaedic and Arthritis Center, Brigham and Women's Hospital, Boston, MA, USA
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Coleman JR. The Trauma Fellow's Perspective on Grit and Resilience and Its Role in Wellness. CURRENT TRAUMA REPORTS 2023; 9:1-6. [PMID: 37362904 PMCID: PMC10061407 DOI: 10.1007/s40719-023-00255-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2023] [Indexed: 04/03/2023]
Abstract
Purpose of Review To describe the unique stressors of surgical training and fellowship and how grit and resilience influence trainee wellness. Recent Findings Surgical training is an intense, high-stress experience. For fellows-in-training, unique stressors are associated with this chapter of training, from financial pressors to the stress of job acquisition. Wellness is essential for surgical fellows, not just for the critical need for quality mental health of providers, but also for the patients who are also affected by provider burnout. There are various wellness programs that can be instituted nationally and institutionally to optimize fellow wellness, but one of the most high-yield foci for fellow wellness is focused mentorship, the key to assuring wellness and harnessing grit. Summary Surgical residency and fellowship are prodigiously demanding experiences, which mandate grit and resilience. It is imperative that widespread cultural and institutional changes take place to best support surgical trainees.
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Affiliation(s)
- Julia R. Coleman
- Department of Surgery, The Ohio State University, 410 W 10th Ave, Columbus, OH 43210 USA
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10
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Oliphant BW, Sangji NF, Dolman HS, Scott JW, Hemmila MR. The National Provider Identifier Taxonomy: Does it Align With a Surgeon's Actual Clinical Practice? J Surg Res 2023; 282:254-261. [PMID: 36332304 DOI: 10.1016/j.jss.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/05/2022] [Accepted: 09/15/2022] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The taxonomy code(s) associated with each National Provider Identifier (NPI) entry should characterize the provider's role (e.g., physician) and any specialization (e.g., orthopedic surgery). While the intent of the taxonomy system was to monitor medical appropriateness and the expertise of care provided, this system is now being used by researchers to identify providers and their practices. It is unknown how accurate the taxonomy codes are in describing a provider's true specialization. METHODS Department websites of orthopedic surgery and general surgery from three large academic institutions were queried for practicing surgeons. The surgeon's specialty and subspeciality information listed was compared to the provider's taxonomy code(s) listed on the National Plan and Provider Enumeration System (NPPES). The match rate between these data sources was evaluated based on the specialty, subspecialty, and institution. RESULTS There were 295 surgeons (205 general surgery and 90 orthopedic surgery) and 24 relevant taxonomies (8 orthopedic and 16 general or plastic) for analysis. Of these, 294 surgeons (99%) selected their general specialty taxonomy correctly, while only 189 (64%) correctly chose an appropriate subspecialty. General surgeons correctly chose a subspecialty more often than orthopedic surgeons (70 versus 51%, P = 0.002). The institution did not affect either match rate, however there were some differences noted in subspecialty match rates inside individual departments. CONCLUSIONS In these institutions, the NPI taxonomy is not accurate for describing a surgeon's subspecialty or actual practice. Caution should be taken when utilizing this variable to describe a surgeon's subspecialization as our findings might apply in other groups.
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Affiliation(s)
- Bryant W Oliphant
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI.
| | - Naveen F Sangji
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | - John W Scott
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Mark R Hemmila
- Department of Surgery, University of Michigan, Ann Arbor, MI
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Longo UG, Viganò M, de Girolamo L, Banfi G, Salvatore G, Denaro V. Epidemiology and Management of Proximal Femoral Fractures in Italy between 2001 and 2016 in Older Adults: Analysis of the National Discharge Registry. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16985. [PMID: 36554865 PMCID: PMC9778915 DOI: 10.3390/ijerph192416985] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/12/2022] [Accepted: 12/15/2022] [Indexed: 06/17/2023]
Abstract
This study aims to determine the annual incidence of proximal femoral fractures in Italy in the period between 2001 and 2016 among older adults, and to describe the trends in the clinical management of these cases. Data were retrieved from the National Hospital Discharge records issued by the Italian Ministry of Health and from the Italian Institute for Statistics. The number of hospitalizations increased between 2001 and 2016, while the age-adjusted yearly incidence decreased from 832.2 per 100,000 individuals to 706.2. The median age was 83 years (IQR 78-88) with a large majority of females (76.6%). The type of fracture varied with age in female subjects, with older women more frequently reporting pertrochanteric fractures. Therapeutic strategies for the different types of fracture depended on patients' age. During the study years, improvements in fracture classification and management strategies were observed, with a clear decreasing trend for non-operative solutions. In conclusion, the number of proximal femur fractures in older adults is growing, even if at a lower rate compared to population aging. The Italian surgical practice changed during the study period towards the implementation of the most recent guidelines.
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Affiliation(s)
- Umile Giuseppe Longo
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Rome, Italy
| | - Marco Viganò
- IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161 Milano, Italy
| | - Laura de Girolamo
- IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161 Milano, Italy
| | - Giuseppe Banfi
- IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161 Milano, Italy
| | - Giuseppe Salvatore
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Rome, Italy
| | - Vincenzo Denaro
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Rome, Italy
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DeAngelis RD, Stein MK, Minutillo GT, Mehta NG, Schemitsch EH, Bzovsky S, Sprague S, Bhandari M, Swiontkowski M, Donegan DJ, Mehta S. Subspecialty Fellowship Training Is Not Associated With Better Outcomes in Fixation of Low-Energy Femoral Neck Fractures-An Analysis of the Fixation Using Alternative Implants for the Treatment of Hip Fractures Database. J Orthop Trauma 2022; 36:208-212. [PMID: 34483325 PMCID: PMC8882705 DOI: 10.1097/bot.0000000000002264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/26/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare risk of reoperation for femoral neck fracture patients undergoing fixation with cancellous screws (CSs) or sliding hip screws based on surgeon fellowship (trauma-fellowship-trained vs. non-trauma-fellowship-trained). DESIGN Retrospective review of Fixation using Alternative Implants for the Treatment of Hip fractures data. SETTING Eighty-one centers across 8 countries. PATIENTS/PARTICIPANTS Eight hundred nineteen patients ≥50 years old with low-energy hip fractures requiring surgical fixation. INTERVENTION Patients were randomized to CS or sliding hip screw group in the initial dataset. MAIN OUTCOME MEASUREMENTS The primary outcome was risk of reoperation. Secondary outcomes included death, serious adverse events, radiographic healing, discharge disposition, and use of ambulatory devices postoperatively. RESULTS There was no difference in risk of reoperation between the 2 surgeon groups (P > 0.05). Patients treated by orthopaedic trauma surgeons were more likely to be overweight/obese and have major medical comorbidities (P < 0.05). There was a higher risk of serious adverse events, higher likelihood of radiographic healing, and higher odds of discharge to a facility for patients treated by trauma-fellowship-trained surgeons (P < 0.05). CONCLUSIONS Based on these data, risk of reoperation for low-energy femoral neck fracture fixation is equivalent regardless of fellowship training. The higher likelihood of radiographic healing noted in the trauma-trained group does not seem to have a major clinical implication because it did not affect risk of reoperation between the 2 groups. Patient-specific factors present preinjury, such as body habitus and medical comorbidities, may account for the lower odds of discharge to home and higher risk of postoperative medical complications for patients treated by orthopaedic trauma surgeons. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ryan D. DeAngelis
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Matthew K. Stein
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Gregory T. Minutillo
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Nikhilesh G. Mehta
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Emil H. Schemitsch
- Department of Surgery, University of Western Ontario, London, Ontario, Canada
| | - Sofia Bzovsky
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Sheila Sprague
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Marc Swiontkowski
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, United States
| | - Derek J. Donegan
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Samir Mehta
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, United States
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Nakamura T, Yamakawa T, Hori J, Goto H, Nakagawa A, Takatsu T, Naoki Osamura, Saito A, Keisuke Hagio, Mouri K. Conjoined tendon preserving posterior approach in hemiarthroplasty for femoral neck fractures: A prospective multicenter clinical study of 322 patients. J Orthop Surg (Hong Kong) 2022; 29:23094990211063963. [PMID: 34920684 DOI: 10.1177/23094990211063963] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
PURPOSE The posterior approach is widely used in femoral hemiarthroplasty. The major problem with this approach is the high risk of postoperative dislocation. A modified posterior approach, the conjoined tendon preserving posterior approach (CPP), was developed to reduce postoperative dislocations. The objective of this multicenter study was to evaluate the efficacy and safety of hemiarthroplasty performed using the CPP approach for femoral neck fractures. METHODS A total of 322 patients with femoral neck fracture, from 10 facilities, were prospectively studied. Bipolar hemiarthroplasty using the CPP approach was performed, using the same type of implants. Hip joint movement was not restricted following surgery, regardless of a patient's cognitive status. Final follow-up was performed 9.1 ± 1.5 months after surgery. RESULTS Hemiarthroplasty was undertaken in 320 patients using the CPP approach. The mean age, operative time, and intraoperative blood loss were 83.3 ± 7.4 years, 70.0 ± 22.7 min, and 134.8 ± 107.9 mL, respectively. No postoperative dislocations were observed during the study period. Intraoperative adverse events related to the hip joint included femoral fractures in five patients (1.6%) and trochanteric fractures in four patients (1.3%). Postoperative hip joint adverse events included a periprosthetic fracture in one patient (0.3%), deep infection in two patients (0.6%), and stem subsidence in one patient (0.3%). Postoperative deaths occurred in 23 patients (7.2%). One patient (0.3%) had a severe non-hip adverse event unrelated to surgery that prevented independent living, while five patients (1.6%) had a moderate non-hip adverse event that required treatment. CONCLUSION The CPP approach prevented postoperative dislocation following femoral hemiarthroplasty in elderly patients, with no CPP-associated specific adverse events.
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Affiliation(s)
- Takuya Nakamura
- Department of Orthopedic Surgery, 37113Toyama Prefectural Central Hospital, Toyama, Toyama
| | - Toru Yamakawa
- Department of Orthopedic Surgery, 37071Japanese Red Cross Ise Hospital, Ise, Mie
| | - Junji Hori
- Department of Orthopedic Surgery, 38350Chugoku Rosai Hospital, Kure, Hiroshima
| | - Hisataka Goto
- Department of Orthopedic Surgery, 38454Nagasaki Rosai Hospital, Sasebo, Nagasaki
| | - Akihiko Nakagawa
- Department of Orthopedic Surgery, 373360Holy Spirit Hospital, Nagoya, Aichi
| | - Tetsuro Takatsu
- Department of Orthopedic Surgery, 37079Gifu Prefectural Tajimi Hospital, Tajimi, Gifu
| | - Naoki Osamura
- Department of Orthopedic Surgery, 38081National Hospital Organization Kanazawa Medical Center, Kanazawa, Ishikawa
| | - Atsushi Saito
- Department of Orthopedic Surgery, 200682Center Hospital of the National Center for Global Health and Medicine, Shinjuku, Tokyo
| | - Keisuke Hagio
- Department of Orthopedic Surgery, 38429National Hospital Organization Osaka Minami Medical Center, Kawachinagano City, Osaka
| | - Kanto Mouri
- Department of Orthopedic Surgery, 13771Tokyo Metropolitan Tama Medical Center, Fuchu, Tokyo
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Macdonald H, Brown R, Gronager M, Close J, Fleming T, Whitehouse M. Quality of fracture reduction is associated with patient survival at one year, but not 30 days, following trochanteric hip fracture fixation. A retrospective cohort study. Injury 2022; 53:1160-1163. [PMID: 35058064 DOI: 10.1016/j.injury.2021.12.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 12/17/2021] [Accepted: 12/28/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Few studies have been performed to evaluate the association between technical surgical factors and patient outcomes following hip fracture surgery. We performed a retrospective cohort study of elderly patients who had undergone fixation of trochanteric hip fractures using a sliding hip screw (SHS), with the aim of establishing whether there was a correlation between quality of fracture reduction and mortality at 30 days and one year. PATIENTS AND METHODS A retrospective cohort study was designed. Inclusion criteria were trochanteric (AO 31A1 or 31A2) fractures in patients aged ≥ 65 years, presenting <3 days after injury and fixed using an SHS. Fracture reduction was classified using the Baumgaertner Reduction Quality Criteria (BRQC). A validated predictor of mortality following hip fracture was used to stratify for confounding variables that might affect mortality. Multivariate logistic regression was used to explore the association between fracture reduction and mortality. RESULTS 329 patients were identified (mean age 86, 27% male). 57% had a good reduction, 39% had a fair reduction and 4% had a poor reduction. As reduction grade deteriorated, predicted mortality increased (good reduction: 7.3%; fair reduction: 8.4%; poor reduction: 15.5%). Without adjustment for predicted mortality, there was a significant correlation between decreasing reduction grade and mortality at both time points (30-day: odds ratio 1.95, p = 0.049; one year: odds ratio 1.86, p = 0.003). When adjusted for predicted mortality, only one year mortality remained significant (30 day: odds ratio 1.61, p = 0.173; one year: odds ratio 1.62, p = 0.037). CONCLUSION Some, but not all, of the association between fracture reduction and mortality can be explained by predetermined predictors of a poor outcome. There remains, however, a correlation between poor fracture reduction and mortality at one year. Every effort must be made to achieve an anatomical reduction for these injuries, and trainees must be instructed in methods to achieve this.
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Affiliation(s)
- Hamish Macdonald
- Gloucestershire Hospitals NHS Foundation Trust, Great Western Road, Gloucester GL1 3NN, United Kingdom.
| | - Robyn Brown
- Gloucestershire Hospitals NHS Foundation Trust, Great Western Road, Gloucester GL1 3NN, United Kingdom
| | - Maddison Gronager
- Gloucestershire Hospitals NHS Foundation Trust, Great Western Road, Gloucester GL1 3NN, United Kingdom
| | - James Close
- Gloucestershire Hospitals NHS Foundation Trust, Great Western Road, Gloucester GL1 3NN, United Kingdom
| | - Thomas Fleming
- Gloucestershire Hospitals NHS Foundation Trust, Great Western Road, Gloucester GL1 3NN, United Kingdom
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15
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The case for decreased surgeon-reported complications due to surgical volume and fellowship status in the treatment of geriatric hip fracture: An analysis of the ABOS database. PLoS One 2022; 17:e0263475. [PMID: 35213546 PMCID: PMC8880652 DOI: 10.1371/journal.pone.0263475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 01/19/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction American orthopaedists are increasingly seeking fellowship sub-specialization. One proposed benefit of fellowship training is decrease in complications, however, few studies have investigated the rates of medical and surgical complications for hip fracture patients between orthopedists from different fellowship backgrounds. This study aims to investigate the effect of fellowship training and case volume on medical and surgical outcomes of patient following hip fracture surgical intervention. Methods 1999–2016 American Board of Orthopedic Surgery (ABOS) Part II Examination Case List data were used to assess patients treated by trauma or adult reconstruction fellowship-trained orthopedists versus all-other orthopaedists. Rates of surgeon-reported medical and surgical adverse events were compared between the three surgeon cohorts. Using binary multivariate logistic regression to control of demographic factors, independent factors were evaluated for their effect on surgical complications. Results Data from 73,427 patients were assessed. An increasing number of hip fractures are being treated by trauma fellowship trained surgeons (9.43% in 1999–2004 to 60.92% in 2011–2016). In multivariate analysis, there was no significant difference in type of fellowship, however, surgeons with increased case volume saw significantly decreased odds of complications (16–30 cases: OR = 0.91; 95% CI: 0.85–0.97; p = 0.003; 31+ cases: OR = 0.68; 95% CI: 0.61–0.76; p<0.001). Femoral neck hip fractures were associated with increased odds of surgical complications. Discussion Despite minor differences in incidence of surgical complications between different fellowship trained orthopaedists, there is no major difference in overall risk of surgical complications for hip fracture patients based on fellowship status of early orthopaedic surgeons. However, case volume does significantly decrease the risk of surgical complications among these patients and may stand as a proxy for fellowship training. Fellows required to take hip fracture call as part of their training regardless of fellowship status exhibited decreased complication risk for hip fracture patients, thus highlighting the importance of additional training.
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16
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Association Between COVID-19 and Mortality in Hip Fracture Surgery in the National COVID Cohort Collaborative (N3C): A Retrospective Cohort Study. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202201000-00004. [PMID: 34982060 PMCID: PMC8735795 DOI: 10.5435/jaaosglobal-d-21-00282] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 11/07/2021] [Indexed: 12/27/2022]
Abstract
Background: This study investigated the outcomes of coronavirus disease (COVID-19)-positive patients undergoing hip fracture surgery using a national database. Methods: This is a retrospective cohort study comparing hip fracture surgery outcomes between COVID-19 positive and negative matched cohorts from 46 sites in the United States. Patients aged 65 and older with hip fracture surgery between March 15 and December 31, 2020, were included. The main outcomes were 30-day all-cause mortality and all-cause mortality. Results: In this national study that included 3303 adults with hip fracture surgery, the 30-day mortality was 14.6% with COVID-19-positive versus 3.8% in COVID-19-negative, a notable difference. The all-cause mortality for hip fracture surgery was 27.0% in the COVID-19-positive group during the study period. Dicussion: We found higher incidence of all-cause mortality in patients with versus without diagnosis of COVID-19 after undergoing hip fracture surgery. The mortality in hip fracture surgery in this national analysis was lower than other local and regional reports. The medical community can use this information to guide the management of hip fracture patients with a diagnosis of COVID-19.
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Roberts HJ, Barry J, Nguyen K, Vail T, Kandemir U, Rogers S, Ward D. 2021 John Charnley Award: A protocol-based strategy when using hemiarthroplasty or total hip arthroplasty for femoral neck fractures decreases mortality, length of stay, and complications. Bone Joint J 2021; 103-B:3-8. [PMID: 34192920 DOI: 10.1302/0301-620x.103b7.bjj-2020-2414.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS While interdisciplinary protocols and expedited surgical treatment improve the management of hip fractures in the elderly, the impact of such interventions on patients specifically undergoing arthroplasty for a femoral neck fracture is not clear. We sought to evaluate the efficacy of an interdisciplinary protocol for the management of patients with a femoral neck fracture who are treated with an arthroplasty. METHODS In 2017, our institution introduced a standardized interdisciplinary hip fracture protocol. We retrospectively reviewed adult patients who underwent hemiarthroplasty (HA) or total hip arthroplasty (THA) for femoral neck fracture between July 2012 and March 2020, and compared patient characteristics and outcomes between those treated before and after the introduction of the protocol. RESULTS A total of 157 patients were treated before the introduction of the protocol (35 (22.3%) with a THA), and 114 patients were treated after its introduction (37 (32.5%) with a THA). The demographic details and medical comorbidities were similar in the two groups. Patients treated after the introduction of the protocol had a significantly reduced median time between admission and surgery (22.8 hours (interquartile range (IQR) 18.8 to 27.7) compared with 24.8 hours (IQR 18.4 to 43.3) (p = 0.042), and a trend towards a reduced mean time to surgery (24.1 hours (SD 10.7) compared with 46.5 hours (SD 165.0); p = 0.150), indicating reduction in outliers. Patients treated after the introduction of the protocol had a significantly decreased rate of major complications (4.4% vs 17.2%; p = 0.005), decreased median hospital length of stay in hospital (4.0 days vs 4.8 days; p = 0.008), increased rate of discharge home (26.3% vs 14.7%; p = 0.030), and decreased one-year mortality (14.7% vs 26.3%; p = 0.049). The 90-day readmission rate (18.2% vs 21.7%; p = 0.528) and 30-day mortality (3.7% vs 5.1%; p = 0.767) did not significantly differ. Patients who underwent HA were significantly older than those who underwent THA (82.1 years (SD 10.4) vs 71.1 years (SD 9.5); p < 0.001), more medically complex (mean Charlson Comorbidity Index 6.4 (SD 2.6) vs 4.1 (SD 2.2); p < 0.001), and more likely to develop delirium (8.5% vs 0%; p = 0.024). CONCLUSION The introduction of an interdisciplinary protocol for the management of elderly patients with a femoral neck fracture was associated with reduced time to surgery, length of stay, complications, and one-year mortality. Such interventions are critical in improving outcomes and reducing costs for an ageing population. Cite this article: Bone Joint J 2021;103-B(7 Supple B):3-8.
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Affiliation(s)
- Heather J Roberts
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, USA
| | - Jeffrey Barry
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, USA
| | - Kevin Nguyen
- School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Thomas Vail
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, USA
| | - Utku Kandemir
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, USA
| | - Stephanie Rogers
- Department of Medicine, Division of Geriatrics, University of California San Francisco, San Francisco, California, USA
| | - Derek Ward
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, USA
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Singh V, Simcox T, Aggarwal VK, Schwarzkopf R, Long WJ. Comparative Analysis of Total Knee Arthroplasty Outcomes Between Arthroplasty and Nonarthroplasty Fellowship Trained Surgeons. Arthroplast Today 2021; 8:40-45. [PMID: 33718554 PMCID: PMC7921708 DOI: 10.1016/j.artd.2021.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/25/2020] [Accepted: 01/21/2021] [Indexed: 01/22/2023] Open
Abstract
Background An adult reconstruction (AR) fellowship is designed to provide advanced training for a broad range of primary reconstructive and complex knee revision surgeries. This study aims to identify outcome differences between primary total knee arthroplasty (TKA) performed by AR fellowship-trained surgeons and non-AR (NAR) fellowship-trained surgeons. Material and Methods We retrospectively reviewed 7415 patients who underwent primary TKA from 2016 to 2020. Two cohorts were established based on whether the operation was performed by an AR or NAR fellowship-trained surgeon. Demographic, clinical data, and patient-reported outcome measures were collected at various time-points (preoperatively, 3 months, 1 year). Demographic differences were assessed with chi-square and independent sample t-tests. Primary outcomes were compared using multilinear regressions, controlling for demographic differences. Results AR surgeons performed 5194 (70%) cases while NAR surgeons performed 2221 (30%) cases. Surgical time (minutes) significantly differed between the 2 groups (101.26 vs 111.56; P < .001). Length of stay, 90-day all-cause readmissions, revisions, and all-cause emergency department visits did not statistically differ (P = .079, P = .978, P = .094, and P = .241, respectively). AR surgeons were more likely to discharge their patients home than NAR surgeons (P = .001). NAR group reported lower KOOS, JR scores at 3 months and 1 year (preop: 45.30 vs 45.79, P = .728; 3 months: 64.73 vs 59.47, P < .001; 1 year: 71.66 vs 69.56, P = .234); however, only 3-month scores statistically differed. Veterans RAND-12 Physical and Mental components scores (VR-12 PCS and MCS) were not statistically significant at any time-point between the cohorts. Delta-improvements preoperatively to 1 year in KOOS, JR (26.36 vs 23.77; P < .001) and VR-12 PCS (11.98 vs 10.62; P < .001) scores were significantly higher for the AR cohort but did not exceed the minimal clinically important difference. Conclusion This study demonstrates significantly shorter surgical times and greater improvements in KOOS, JR and VR-12 PCS scores associated with TKAs performed by AR fellowship-trained surgeons. Level III Evidence Retrospective Cohort Study.
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Affiliation(s)
- Vivek Singh
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Trevor Simcox
- NYU Winthrop Hospital, Department of Orthopedic Surgery, Mineola, NY, USA
| | - Vinay K Aggarwal
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Ran Schwarzkopf
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - William J Long
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
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19
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Who Did the Arthroplasty? Hip Fracture Surgery Reoperation Rates are Not Affected by Type of Training-An Analysis of the HEALTH Database. J Orthop Trauma 2020; 34 Suppl 3:S64-S69. [PMID: 33027168 DOI: 10.1097/bot.0000000000001931] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES This study compares outcomes for patients with displaced femoral neck fractures undergoing hemiarthroplasty (HA) or total hip arthroplasty (THA) by surgeons of different fellowship training. DESIGN Retrospective review of HEALTH trial data. SETTING Eighty clinical sites across 10 countries. PATIENTS/PARTICIPANTS One thousand four hundred forty-one patients ≥50 years with low-energy hip fractures requiring surgical intervention. INTERVENTION Patients were randomized to either HA or THA groups in the initial data set. Surgeons' fellowship training was ascertained retrospectively, and outcomes were compared. MAIN OUTCOME MEASUREMENTS The main outcome was an unplanned secondary procedure at 24 months. Secondary outcomes included death, serious adverse events, prosthetic joint infection (PJI), dislocation, discharge disposition, and use of ambulatory devices postoperatively. RESULTS There was a significantly higher risk of PJI in patients treated by surgeons without fellowship training in arthroplasty (P = 0.01), surgeons with unknown fellowship training (P = 0.03), and surgeons with no fellowship training (P = 0.02) than those treated by an arthroplasty-trained surgeon. There were significantly higher odds of being discharged to a facility rather than home in patients who underwent surgery by a surgeon with no fellowship training compared with arthroplasty-fellowship-trained surgeons (P = 0.03). CONCLUSIONS Arthroplasty for hip fracture can be performed by all orthopaedic surgeons with equivalent reoperation rates. Infection prevention strategies and use of "care pathways" by arthroplasty-fellowship-trained surgeons may account for the lower risk of PJI and higher rate of discharge to home. The authors advocate for the use of evidence-based infection prevention initiatives and standardized care pathways in this patient population. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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20
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Mahure SA, Feng JE, Schwarzkopf RM, Long WJ. The Impact of Arthroplasty Fellowship Training on Total Joint Arthroplasty: Comparison of Peri-Operative Metrics between Fellowship-Trained Surgeons and Non-Fellowship-Trained Surgeons. J Arthroplasty 2020; 35:2820-2824. [PMID: 32540307 DOI: 10.1016/j.arth.2020.05.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 05/09/2020] [Accepted: 05/14/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND We sought to identify differences between total joint arthroplasties (TJAs) performed by adult reconstruction fellowship-trained surgeons (FT) than non-fellowship-trained surgeons (NFT). METHODS A single-institution database was utilized to identify patients who underwent elective TJA between 2016 and 2019. RESULTS In total, 16,882 TJAs were identified: 9111 total hip arthroplasties (THAs) and 7771 total knee arthroplasties (TKAs). Patients undergoing THA by FT surgeons were older (63.11 vs 61.84 years, P < .001), more likely to be white, insured by Medicare, and less likely to be active smokers (P < .0001). Both surgical time (90.03 vs 113.1 minutes, P < .0001) and mean length of stay (LOS) (1.85 vs 2.72 days, P < .0001) were significantly shorter for THAs performed by FT surgeons than NFT surgeons. A significantly greater percentage of patients were discharged home after THA by FT surgeons than NFT surgeons (88.7% vs 85.2%, P = .002). FT patients were quicker to mobilize with therapy and required 25% less opioids. TKAs performed by FT surgeons were associated with shorter surgical times (87.4 vs 94.92 minutes, P < .0001), LOS (2.62 vs 2.84 days, P < .0001), and nearly 19% less opioid requirement in the peri-operative period. In addition to higher Activity Measure for Post-Acute Care scores associated with FT surgeons after TKA, a significantly greater percentage of patients were discharged home after TKA by FT surgeons than NFT surgeons (83.97% vs 80.16%, P < .001). CONCLUSION For both THA and TKA, patients had significantly shorter surgical times, LOS, and required less opioids when their procedure was performed by FT surgeons compared to NTF surgeons. Patients who had their TJA performed by a FT surgeon achieved higher Activity Measure for Post-Acute Care scores and were discharged home more often than NFT surgeons. In an era of value-based care, more attention should be paid to the patient outcomes and financial implications associated with arthroplasty fellowship training. LEVEL III EVIDENCE Retrospective Cohort Study.
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Affiliation(s)
- Siddharth A Mahure
- Department of Orthopaedic Surgery, New York University Langone Orthopaedic Hospital, New York, NY
| | - James E Feng
- Department of Orthopaedic Surgery, New York University Langone Orthopaedic Hospital, New York, NY
| | - Ran M Schwarzkopf
- Department of Orthopaedic Surgery, New York University Langone Orthopaedic Hospital, New York, NY
| | - William J Long
- Department of Orthopaedic Surgery, New York University Langone Orthopaedic Hospital, New York, NY
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21
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Abstract
In this article the authors discuss their experience of performing minimally invasive surgery, with emphasis on technique and how to avoid pitfalls. They also discuss the educational literature for learning new techniques and how to shorten the "learning curve."
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Affiliation(s)
- Harvinder Bedi
- Department of Orthopaedic Surgery, Box Hill Hospital, 8 Arnold Street, Box Hill, Melbourne, Victoria 3128, Australia.
| | - Ben Hickey
- Department of Orthopaedic Surgery, Wrexham Maelor Hospital, Croesnewydd Road, Wrexham LL13 7TD, Wales
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Affiliation(s)
- Liang Gao
- Saarland University Medical Center, Homburg, Germany
| | - Zhihua Han
- Shanghai General Hospital, Shanghai, China
| | - Ao Xiong
- Peking University, Shenzhen, China
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