Conventional Follow-up Versus Mobile Application Home Monitoring for Postoperative Anterior Cruciate Ligament Reconstruction Patients: A Randomized Controlled Trial

Multicomponent supervised tele-rehabilitation versus home-based self-rehabilitation management after anterior cruciate ligament reconstruction: a study protocol for a randomized controlled trial

INTRODUCTION

Our study aims to assess the effectiveness of multicomponent supervised tele-rehabilitation compared to home-based self-rehabilitation management in patients following anterior cruciate ligament reconstruction (ACLR).

METHODS

The current study is designed as a single-center, single-blinded, randomized controlled, two-arm trial. Participants will be randomized and allocated at a 1:1 ratio into either a multicomponent supervised tele-rehabilitation group or a home-based self-rehabilitation group. All participants receive uniform preoperative education through the HJT software. Participants in the intervention group undergo multicomponent supervised tele-rehabilitation, while those in the control group follow a home-based self-rehabilitation program. All the participants were assessed and measured for the included outcomes at the outpatient clinic before the procedure, and in 2, 4, 8, 12, and 24 weeks after ACLR by two assessors. The primary outcome was the percentage of patients who achieve a satisfactory active ROM at the 12 weeks following the ACLR. The satisfactory active ROM was also collected at 2, 4, 8, and 24 weeks after ACLR. The secondary outcomes were active and passive range of motion (ROM), pain, muscle strength, and function results.

REGISTRATION DETAILS

Ethical approval has been obtained from the West China Hospital Ethics Committee (approval number 2023-1929, December 2023). The trial has been registered on ClinicalTrials.gov (registration number NCT06232824, January 2024).

A Novel Digital Health Platform With Health Coaches to Optimize Surgical Patients: Feasibility Study at a Large Academic Health System

BACKGROUND

Pip is a novel digital health platform (DHP) that combines human health coaches (HCs) and technology with patient-facing content. This combination has not been studied in perioperative surgical optimization.

OBJECTIVE

This study's aim was to test the feasibility of the Pip platform for deploying perioperative, digital, patient-facing optimization guidelines to elective surgical patients, assisted by an HC, at predefined intervals in the perioperative journey.

METHODS

We conducted an institutional review board-approved, descriptive, prospective feasibility study of patients scheduled for elective surgery and invited to enroll in Pip from 2.5 to 4 weeks preoperatively through 4 weeks postoperatively at an academic medical center between November 22, 2022, and March 27, 2023. Descriptive primary end points were patient-reported outcomes, including patient satisfaction and engagement, and Pip HC evaluations. Secondary end points included mean or median length of stay (LOS), readmission at 7 and 30 days, and emergency department use within 30 days. Secondary end points were compared between patients who received Pip versus patients who did not receive Pip using stabilized inverse probability of treatment weighting.

RESULTS

A total of 283 patients were invited, of whom 172 (60.8%) enrolled in Pip. Of these, 80.2% (138/172) patients had ≥1 HC session and proceeded to surgery, and 70.3% (97/138) of the enrolled patients engaged with Pip postoperatively. The mean engagement began 27 days before surgery. Pip demonstrated an 82% weekly engagement rate with HCs. Patients attended an average of 6.7 HC sessions. Of those patients that completed surveys (95/138, 68.8%), high satisfaction scores were recorded (mean 4.8/5; n=95). Patients strongly agreed that HCs helped them throughout the perioperative process (mean 4.97/5; n=33). The average net promoter score was 9.7 out of 10. A total of 268 patients in the non-Pip group and 128 patients in the Pip group had appropriate overlapping distributions of stabilized inverse probability of treatment weighting for the analytic sample. The Pip cohort was associated with LOS reduction when compared to the non-Pip cohort (mean 2.4 vs 3.1 days; median 1.9, IQR 1.0-3.1 vs median 3.0, IQR 1.1-3.9 days; mean ratio 0.76; 95% CI 0.62-0.93; P=.009). The Pip cohort experienced a 49% lower risk of 7-day readmission (relative risk [RR] 0.51, 95% CI 0.11-2.31; P=.38) and a 17% lower risk of 30-day readmission (RR 0.83, 95% CI 0.30-2.31; P=.73), though these did not reach statistical significance. Both cohorts had similar 30-day emergency department returns (RR 1.06, 95% CI 0.56-2.01, P=.85).

CONCLUSIONS

Pip is a novel mobile DHP combining human HCs and perioperative optimization content that is feasible to engage patients in their perioperative journey and is associated with reduced hospital LOS. Further studies assessing the impact on clinical and patient-reported outcomes from the use of Pip or similar DHPs HC combinations during the perioperative journey are required.

Not all patient-reported outcome measures are equivalent at two years compared to one year after anterior cruciate ligament reconstruction based on a retrospective analysis

OBJECTIVE

This article aims to assess for clinically important differences in patient-reported outcome measures (PROMs) at one and two years post anterior cruciate ligament reconstruction (ACLR).

METHODS

A retrospective comparison of prospectively collected PROMs for a single cohort who underwent a primary ACLR with or without associated meniscal surgery from 2016 to 2020 was assessed. Six externally validated PROMs were collected preoperatively and at standardized times postoperatively. Descriptive statistics and paired equivalence testing of PROMs at one and two years after surgery was completed using previously published or calculated minimal clinically important differences as upper and lower equivalence limits. A repeated measures analysis of PROMs that were not clinically equivalent at one and two years after surgery was completed to assess for a clinically significant difference. Subgroup analyses based on sex, age and associated meniscal injury were completed.

RESULTS

One-hundred and forty-five participants with a mean age of 28.7 years (standard deviation: 9.9 years) were included in the final analysis. All PROMs were clinically equivalent at two years compared to one year after ACLR except the quality of life and sport and recreation domains of the Knee Injury and Osteoarthritis Outcome Score (KOOS). The quality of life (mean difference (MD):12.3, P ​< ​0.01, effect size (η2): 0.65) and sport and recreation (MD: 8.78, P ​< ​0.01, η2: 0.50) domains of the KOOS were clinically different at two years compared to one year postoperatively. No major differences were found in the subgroup analyses compared to the entire included sample.

CONCLUSION

While most PROMs were equivalent at two years compared to one year after ACLR, the quality of life and sport and recreation domains of the KOOS, which reflect knee performance during higher demand activities, exhibited a clinically significant difference.

LEVEL OF EVIDENCE

IV.

The Effect of Staged Versus Usual Care Physiotherapy on Knee Function Following Anterior Cruciate Ligament Reconstruction

CONTEXT

The long duration and high cost of anterior cruciate ligament reconstruction (ACLR) rehabilitation can pose barriers to completing rehabilitation, the latter stages of which progress to demanding sport-specific exercises critical for a safe return to sport. A staged approach shifting in-person physiotherapy sessions to later months of recovery may ensure patients undergo the sport-specific portion of ACLR rehabilitation. Design/Objective: To compare postoperative outcomes of knee function in patients participating in a staged ACLR physiotherapy program to patients participating in usual care physiotherapy through a randomized controlled trial.

METHODS

One hundred sixty-two patients were randomized to participate in staged (n = 80) or usual care physiotherapy (n = 82) following ACLR and assessed preoperatively and postoperatively at 2 weeks, 6 weeks, 3 months, and 6 months. The staged group completed the ACLR rehabilitation protocol at home for the first 3 months, followed by usual care in-person sessions. The usual care group completed in-person sessions for their entire rehabilitation. Outcome measures included the Lower Extremity Functional Scale, International Knee Documentation Committee Questionnaire, pain, range of motion, strength, and hop testing.

RESULTS

There were no statistically significant between-group differences in measures of knee function at 6 months postoperative. Patients in the usual care group reported significantly higher International Knee Documentation Committee scores at 3 months postoperative (mean difference = 5.8; 95% confidence interval,  1.3 to 10.4; P = .01).

CONCLUSION

A staged approach to ACLR rehabilitation does not appear to impede knee function at 6 months postoperative but may result in worse patient reported outcomes at early follow-ups.

Patient Satisfaction With a Multisite, Multiregional Remote Patient Monitoring Program for Acute and Chronic Condition Management: Survey-Based Analysis

BACKGROUND

Remote patient monitoring (RPM) is an option for continuously managing the care of patients in the comfort of their homes or locations outside hospitals and clinics. Patient engagement with RPM programs is essential for achieving successful outcomes and high quality of care. When relying on technology to facilitate monitoring and shifting disease management to the home environment, it is important to understand the patients' experiences to enable quality improvement.

OBJECTIVE

This study aimed to describe patients' experiences and overall satisfaction with an RPM program for acute and chronic conditions in a multisite, multiregional health care system.

METHODS

Between January 1, 2021, and August 31, 2022, a patient experience survey was delivered via email to all patients enrolled in the RPM program. The survey encompassed 19 questions across 4 categories regarding comfort, equipment, communication, and overall experience, as well as 2 open-ended questions. Descriptive analysis of the survey response data was performed using frequency distribution and percentages.

RESULTS

Surveys were sent to 8535 patients. The survey response rate was 37.16% (3172/8535) and the completion rate was 95.23% (3172/3331). Survey results indicated that 88.97% (2783/3128) of participants agreed or strongly agreed that the program helped them feel comfortable managing their health from home. Furthermore, 93.58% (2873/3070) were satisfied with the RPM program and ready to graduate when meeting the program goals. In addition, patient confidence in this model of care was confirmed by 92.76% (2846/3068) of the participants who would recommend RPM to people with similar conditions. There were no differences in ease of technology use according to age. Those with high school or less education were more likely to agree that the equipment and educational materials helped them feel more informed about their care plans than those with higher education levels.

CONCLUSIONS

This multisite, multiregional RPM program has become a reliable health care delivery model for the management of acute and chronic conditions outside hospitals and clinics. Program participants reported an excellent overall experience and a high level of satisfaction in managing their health from the comfort of their home environment.

Postoperative Rehabilitation after Anterior Cruciate Ligament Reconstruction through Telerehabilitation with Artificial Intelligence Brace during COVID-19 Pandemic

BACKGROUND

Due to the rapid spread of the coronavirus disease-19 (COVID-19), most of the patients expressed a reluctance to undergo postoperative rehabilitation at a rehabilitation clinic. Therefore, in this scenario it was necessary to reshape the crucial role of postoperative rehabilitation of these patients. We conducted a telerehabilitation program based on an artificial intelligence brace (AI brace) which can monitor the progress of rehabilitation through an app and an internet server. Our hypothesis was that home-based telerehabilitation might provide clinical outcomes comparable to face-to-face, hospital-based rehabilitation programs in terms of effectiveness.

METHODS

A retrospective cohort study enrolled patients who received anterior cruciate ligament reconstruction (ACLR) between January and September 2020. Patients were divided into two groups: the tele-AI group received telerehabilitation with an AI brace while the FTF group had face-to-face, hospital-based rehabilitation. Clinical knee functional scores and Tegner Activity Scale (TAS) were assessed and analyzed until 12 months after the operation.

RESULTS

The tele-AI group had higher IKDC scores at 3 months (p = 0.0443) and 6 months (p = 0.0052) after surgery and higher KOOS scores at 1 month (p = 0.0365) and 6 months (p = 0.0375) after surgery. However, no significant difference between the two groups was detected at the end of the follow-up. The tele-AI group had higher TAS than FTF group after 1 year.

CONCLUSIONS

Telerehabilitation after ACLR seems to provide a superior short-term outcome compared to hospital-based rehabilitation during the COVID-19 pandemic.

Readiness for implementation of novel digital health interventions for postoperative monitoring: a systematic review and clinical innovation network analysis

An increasing number of digital health interventions (DHIs) for remote postoperative monitoring have been developed and evaluated. This systematic review identifies DHIs for postoperative monitoring and evaluates their readiness for implementation into routine health care. Studies were defined according to idea, development, exploration, assessment, and long-term follow-up (IDEAL) stages of innovation. A novel clinical innovation network analysis used coauthorship and citations to examine collaboration and progression within the field. 126 DHIs were identified, with 101 (80%) being early stage innovations (IDEAL stage 1 and 2a). None of the DHIs identified had large-scale routine implementation. There is little evidence of collaboration, and there are clear omissions in the evaluation of feasibility, accessibility, and the health-care impact. Use of DHIs for postoperative monitoring remains at an early stage of innovation, with promising but generally low-quality supporting evidence. Comprehensive evaluation within high-quality, large-scale trials and real-world data are required to definitively establish readiness for routine implementation.

Use of an Artificial Intelligence Conversational Agent (Chatbot) for Hip Arthroscopy Patients Following Surgery

Purpose

The purpose of this study was to evaluate the use of an AI conversational agent during the postoperative recovery of patients undergoing elective hip arthroscopy.

Methods

Patients undergoing hip arthroscopy were enrolled in a prospective cohort for their first 6 weeks following surgery. Patients used standard SMS text messaging to interact with an artificial intelligence (AI) chatbot ("Felix") used to initiate automated conversations regarding elements of postoperative recovery. Patient satisfaction was measured at 6 weeks after surgery using a Likert scale survey. Accuracy was determined by measuring the appropriateness of chatbot responses, topic recognition, and examples of confusion. Safety was measured by evaluating the chatbot's responses to any questions with potential medical urgency.

Results

Twenty-six patients were enrolled with a mean age of 36 years, and 58% (n = 15) were male. Overall, 80% of patients (n = 20) rated the helpfulness of Felix as good or excellent. In the postoperative period, 12/25 (48%) patients reported being worried about a complication but were reassured by Felix and, thus, did not seek medical attention. Of a total of 128 independent patient questions, Felix handled 101/128 questions appropriately (79%), either by addressing them independently, or facilitating contact with the care team. Felix was able to adequately answer the patient question independently 31% of the time (n = 40/128). Of 10 patient questions that were thought to potentially represent patient complications, in 3 cases Felix did not adequately address or recognize the health concern-none of these situations resulted in patient harm.

Conclusion

The results of this study demonstrate that the use of a chatbot or conversational agent can enhance the postoperative experience for hip arthroscopy patients, as demonstrated by high levels of patient satisfaction.

Levels of Evidence

Level IV, therapeutic case series.

Postoperative regular use of a self-rehabilitation mobile application for more than two weeks reduces extension deficit and cyclop syndrome after anterior cruciate ligament reconstruction

PURPOSE

To investigate the minimum use that correlates with the best outcomes in term of complications associated with self-directed rehabilitation mobile application and to explore the user profile and usage habits.

METHODS

This was a single-center retrospective study of 356 patients who underwent ACL reconstruction surgery between November 2019 and August 2020. Complications were defined as the presence of an extension deficit ≥ 5° after 6 weeks and/or the presence of cyclops syndrome. The demographics, sports competition level and number of connections were collected by the application.

RESULTS

The complication rate was reduced 4.2-fold with at least 2 weeks of use (2.4% (3/123) (with 0.8% (1/123) of cyclops syndrome) versus 10.8% (23/212) (with 3.3% (7/212) cyclops syndrome), p = .04). The mean duration of use was 20 ± 23 days with a frequency of 2.1 ± 2.3 connections per day. The usage rate was 50% in week 1, 35% in week 2, and 24% in week 3. There was one peak in the abandon rate during the first few days of use and a second peak at Day 10 when physiotherapy sessions started. There were two dips in the abandon rate associated with the follow-up visits at Days 21 and 45. Greater use was found in older patients (p = .0001) and female patients (p = .04).

CONCLUSIONS

When using the application for a minimum of 2 weeks, the risk of complications was reduced 4.2-fold. The typical users of a self-directed rehabilitation application after ACL surgery in this study were women and patients over 30 years of age.

LEVEL OF EVIDENCE

IV, retrospective.

Telemedicine in orthopaedics and trauma surgery during the first year of COVID pandemic: a systematic review

PURPOSE

Prior to the COVID-19 pandemic, telemedicine in orthopaedics and trauma surgery had mostly developed for joint arthroplasty, fracture management, and general pre- and postoperative care including teleradiology. With the corona-outbreak, telemedicine was applied on a broad scale to prevent assemblage and to guarantee access to medical care protecting critical areas. The purpose of the present study was to give an overview of the spectrum of clinical applications and the efficacy of telemedicine in orthopaedic and trauma surgery as published in times of the COVID-19 pandemic.

METHODS

All published studies investigating the application of telemedicine related to orthopaedics and trauma during the COVID-19 pandemic were accessed and screened for suitability. The primary outcome of interest was the efficacy of telemedicine in various clinical applications. The secondary outcome of interest was the spectrum of different applications in which telemedicine applications were investigated.

RESULTS

The literature search resulted in 1047 articles. After the removal of duplicates, 894 articles were screened of which 31 finally met the inclusion criteria. Dimensions that were described by studies in the literature to have positive effects were preoperative patient optimisation, the usefulness of telemedicine to correctly diagnose a condition, conservative treatment, willingness to and feasibility for telemedicine in patients and doctors, and postoperative/post-trauma care improvement. The efficacy of telemedicine applications or interventions thereby strongly varied and seemed to depend on the exact study design and the research question addressed.

CONCLUSION

Various successful applications of telemedicine have already been reported in orthopaedics and trauma surgery, with a strong increase in scientific output during the COVID-19 years 2020-2021. Whether the advantages of such an approach will lead to a relevant implementation of telemedicine in everyday clinical practice should be monitored after the COVID-19 pandemic.

Evaluation of a smartphone application for self-rehabilitation after anterior cruciate ligament reconstruction during a COVID-19 lockdown

BACKGROUND

Rehabilitation after surgery is a crucial process that governs the final functional outcome. The self-rehabilitation smartphone application Doct'up (Healing SAS, Lyon, France) is designed for patients who have had anterior cruciate ligament (ACL) reconstruction surgery. In France in the spring of 2020, the lockdown mandated due to the COVID-19 pandemic prevented patients from seeing their physiotherapists for 2 months. The objective of this study was to compare the clinical outcomes in two groups of patients who underwent ACL reconstruction surgery: in one group, surgery performed before the lockdown was followed by standard in-person physiotherapy while, in the other, surgery was done just before the lockdown and rehabilitation was performed by the patients themselves using the phone application.

HYPOTHESIS

Using a self-rehabilitation smartphone app limits the negative effects of not receiving physiotherapist rehabilitation after ACL reconstruction.

MATERIAL AND METHODS

We performed a case-control study involving the retrospective analysis of prospectively collected data from two groups of patients who had undergone ACL reconstruction surgery. Patients in the App group had surgery just before the 2-month COVID-19-related lockdown that started in France on March 17, 2020,and used only the smartphone app for rehabilitation. The standard-care group was composed of matched controls who had surgery 1 year before the cases and received rehabilitation therapy during in-person physiotherapist visits. The ACL reconstruction technique was the same in the two groups. The primary outcome measure was extension lag 6 weeks after surgery. The secondary outcome measures were extension lag 3 weeks and 6 months after surgery, quadriceps muscle activation, knee extension locking 3 and 6 weeks after surgery, and the 6-month rate of surgical revision for cyclops syndrome.

RESULTS

We included 32 cases managed using only self-rehabilitation guided by the phone app, and we identified 101 matched controls managed using standard care. We found no significant between-group difference in extension lag after 6 weeks: 9.4% (28/32) vs. 4.6% (87/101), p=0.39. After 3 weeks, the App group had a higher proportions of patients with quadriceps activation (94% [30/32] vs. 73% [74/101], p=0.015) and extension control using canes (78.1% [25/32] vs. 40.6% [41/101], p=0.0002). None of the other measured outcomes differed significantly between the two groups (extension lag after 3 weeks: 12.5% [4/32] vs. 13.8% 14/101]; extension lag after 6 months: 3.2% [1/32] vs. 1% [1/101]; quadriceps activation after 6 weeks: 97% [31/32] vs. 99% [100/101]; extension locking with canes after 6 weeks: 96.9% [31/32] vs. 93.1% [94/101]; extension locking without canes after 3 weeks: 53.2% [17/32] vs. 47.5% [48/101]; extension locking without canes after 6 weeks: 93.7% [30/32] vs. 82.2% [83/101]; and surgery for cyclops syndrome (3.1% [1/32] vs. 1% [1/101]).

DISCUSSION

The use of a self-rehabilitation phone app after ACL reconstruction during a COVID-19 lockdown limited the adverse effects of not receiving in-person physiotherapy. The 6-month outcomes were similar to those seen with standard rehabilitation. The study results demonstrate the usefulness of self-rehabilitation after ACL reconstruction surgery. Self-rehabilitation guided by a phone app could be used as a complement to the protocols generally applied by physiotherapists.

LEVEL OF EVIDENCE

IV, single-centre retrospective case-control study.

Disruptions in standard care: anterior cruciate ligament reconstruction outcomes during the SARS-COV2 pandemic

OBJECTIVE

The SARS-COV2 pandemic led to massive disruptions of care for orthopedic patients. Although many elective procedures were put on hold, a cohort of patients who underwent surgery prior to the outbreak of the pandemic were rendered unable to participate in standard post-operative care. The purpose of this study was to determine the methods of post-operative care in arthroscopic anterior cruciate ligament reconstruction patients who received care during an early height of the pandemic to those who received standard of care in the prior year. We aimed to correlate those results with 1-year clinical outcomes in the form of subjective surveys.

METHODS

Retrospective chart review was used to identify patients who underwent primary anterior cruciate ligament reconstruction in February and March of 2020 (case) and 2019 (control) at a single institution. Workman's compensation patients were excluded. Identified patients were asked to report post-operative care received, satisfaction with care, and complete the IKDC and Lysholm outcome measures. Surveys were conducted minimum 1-year post-operative.

RESULTS

236 patients were identified, including 103 in 2020 and 133 in 2019. Follow-up data was collected for 73 patients (70.9%) in 2020 and 97 patients (72.9%) in 2019. Fifty-one COVID cohort patients (69.9%) had at least one clinical visit conducted via telehealth, compared to zero in the control. There were no differences in IKDC (82.8 ± 13.2 vs 85.0 ± 12.0, P = 0.29) and Lysholm (89.2 ± 11.3 vs 89.6 ± 10.8, P = 0.82) between groups. There were no differences in patient satisfaction with the care received (82.9 ± 22.4 vs 81.9 ± 21.8, P = 0.79).

CONCLUSION

Despite disruptions in care, anterior cruciate ligament reconstruction patients have excellent 1-year outcomes during the pandemic. Telehealth follow-up appointments may be appropriate for anterior cruciate ligament reconstruction patients beyond the pandemic and do not seem to adversely affect short-term patient reported outcome measures.

The effect of eConsult on the provision of orthopaedic services in Nunavut

To assess the effect of eConsultation in providing Orthopaedic Surgery specialist service to patients in Nunavut. A cross-sectional study of 161 Orthopaedic Surgery consultations received from primary care providers (PCPs) in Nunavut via the Champlain Building Access to Specialist service through eConsult (BASE^TM) service over the 2-year period from January 2017 to December 2018. Data captured were: reason for consultation, impact of advice on referral, perceived value to the PCPs and time spent. eConsult avoided unnecessary in-person consultation 62% of the time while catching 5% of the referrals that would have otherwise been missed. PCP referral behaviour was modified 48% of the time. 94% of eConsults were rated as valuable to PCPs in their practice and 100% of eConsults resulted in actionable advice. Further, eConsults took an average of 15.4 minutes of specialist time to complete, and the mean time from referral to response was 1.4 days. eConsultation spares unnecessary consultation to Orthopaedic Surgery, catches important referrals that would have otherwise been missed, decreases wait time, and may reduce cost in remote healthcare systems such as Nunavut.

Outcomes With a Mobile Digital Health Platform for Patients Undergoing Spine Surgery: Retrospective Analysis

BACKGROUND

Digital health solutions have been shown to enhance outcomes for individuals with chronic medical illnesses, but few have been validated for surgical patients. The digital health platform ManageMySurgery (MMS) has been validated for spine surgery as a feasible method for patients along their surgical journey through in-app education and completion of patient-reported outcomes surveys.

OBJECTIVE

The aim of this study is to determine the rates of 90-day emergency room (ER) visits, readmissions, and complications in patients undergoing spine surgery using MMS compared to patients using traditional perioperative care alone.

METHODS

Patients undergoing spine surgery at a US-based academic hospital were invited to use MMS perioperatively between December 2017 and September 2021. All patients received standard perioperative care and were classified as MMS users if they logged into the app. Demographic information and 90-day outcomes were acquired via electronic health record review. The odds ratios of having 90-day ER visits, readmissions, mild complications, and severe complications between the MMS and non-MMS groups were estimated using logistic regression models.

RESULTS

A total of 1015 patients were invited, with 679 using MMS. MMS users and nonusers had similar demographics: the average ages were 57.9 (SD 12.5) years and 61.5 (SD 12.7) years, 54.1% (367/679) and 47.3% (159/336) were male, and 90.1% (612/679) and 88.7% (298/336) had commercial or Medicare insurance, respectively. Cervical fusions (559/1015, 55.07%) and single-approach lumbar fusions (231/1015, 22.76%) were the most common procedures for all patients. MMS users had a lower 90-day readmission rate (55/679, 8.1%) than did nonusers (30/336, 8.9%). Mild complications (MMS: 56/679, 8.3%; non-MMS: 32/336, 9.5%) and severe complications (MMS: 66/679, 9.7%; non-MMS: 43/336, 12.8%) were also lower in MMS users. MMS users had a lower 90-day ER visit rate (MMS: 62/679, 9.1%; non-MMS: 45/336, 13.4%). After adjustments were made for age and sex, the odds of having 90-day ER visits for MMS users were 32% lower than those for nonusers, but this difference was not statistically significant (odds ratio 0.68, 95% CI 0.45-1.02; P=.06).

CONCLUSIONS

This is one of the first studies to show differences in acute outcomes for people undergoing spine surgery who use a digital health app. This study found a correlation between MMS use and fewer postsurgical ER visits in a large group of spine surgery patients. A planned randomized controlled trial will provide additional evidence of whether this digital health tool can be used as an intervention to improve patient outcomes.

Patient Preferences Regarding Telemedicine to In-person Consultation: A Questionnaire-Based Survey

INTRODUCTION

Telemedicine has been evolving over the last two decades; however, with the advent of the COVID 19 pandemic, its utility and acceptance have drastically increased. Most studies report increasing acceptability and satisfaction rates. This study aimed to assess patient preferences regarding telemedicine to in-person consultations and to attempt to assess the factors driving these preferences.

MATERIAL AND METHODS

A questionnaire-based cross-sectional study was conducted for patients who had both teleconsultation and in-person consultation in the orthopedic outpatient. After obtaining consent to participate in the study, the patients were divided into broad clinical categories and responses were recorded regarding the treatment of illness by the doctor and opinions regarding telemedicine. Most questions were in yes/no or a Likert-based questionnaire. Mean, median, percentage and proportions were used for statistical analysis of the data.

RESULTS

The study group included 264 patients, with the majority with fractures and dislocations. Most patients (55.7%) were comfortable using the software for teleconsultation, and half the respondents found telemedicine convenient. A large percentage of the study group preferred in-person consultation to teleconsultation (58.7%), and the primary reasons for discontinuing teleconsultation were dissatisfaction during the interaction with the doctor and poor connectivity to telecommunication networks.

CONCLUSION

Telecommunication has high acceptance and satisfaction, but many factors limit its acceptance in developing countries.

Clinical feasibility of the Q1.6 Inguinal Hernia application: a prospective cohort study

PURPOSE

Patient-reported outcomes (PROs) are essential to evaluate inguinal hernia surgery. There is a need for digital and disease-specific PRO measurement. Current measuring instruments (PROMs) have several disadvantages, for example, fixed measuring moments with a chance of recall bias. The Q1.6 Inguinal Hernia application has been developed to overcome these challenges. This pilot study reports the first clinical feasibility results.

METHODS

All surgically treated inguinal hernia patients were eligible for inclusion. The application uses "twitch crowdsourcing"; after unlocking a smartphone or tablet, a single short question is asked. This can easily be repeated multiple times a day/week/month. Questions from validated questionnaires were implemented. The adaptive question engine generates an individualised set of questions. Alerts are generated when a complication is suspected.

RESULTS

A total of 229 patients were given over 50.000 questions of which 92% were answered. Pre- and postoperative patient characteristics and their reported clinical outcomes confirmed a standard inguinal hernia population. Compliance with the application was 91.7% after 14 days, 69.0% after 3 months and 28.8% after one year. After months 3, 6 and 11, respectively, 3.0%, 4.4% and 4.5% of patients reported inguinal pain or discomfort (NRS ≥ 4). Patients were highly satisfied (92.8% preferred the app over standard care).

CONCLUSIONS

This smartphone application shows promising results for clinical practice. It might allow for continuous digital patient-reported outcome measurement using non-intrusive, concise questions. Remote monitoring may become standard postoperative care after (inguinal hernia) surgery. The current application will be further improved and evaluated for cost-effectiveness, safety and validity.

Automated Text-Messaging After Hip Arthroscopy: A Randomized-Controlled Trial of "Post-Op Buddy"

PURPOSE

To assess an automated text-messaging system for patients after hip arthroscopy and its impact at 90 days on the Hip Disability Osteoarthritis Outcome Score Physical Function Short form (HOOS-PS, HOOS-Pain), compliance with rehabilitation guidelines, and patient satisfaction.

METHODS

One hundred twenty-one participants (average age 29 ± 8.7 years, 52% female) undergoing hip arthroscopy at 2 academic institutions were prospectively enrolled and randomized to receive (1) standard perioperative communication or (2) additional automated mobile phone text messages. Inclusion criteria included ability to communicate in written English and access to a mobile phone with text-messaging capability. Patients undergoing revision surgery or simultaneous femoral or acetabular osteotomy were excluded. HOOS-PS and HOOS-Pain were collected preoperatively, and after surgery an automated mobile phone robot sent participants in the therapeutic arm intermittent text messages for 90 days. At 90 days all participants again completed HOOS-PS, HOOS-Pain, and additional survey questions on satisfaction with their experience (10-point scale), communication from the surgical team (10-point scale) and adherence to physical therapy exercises, weight-bearing guidelines, and brace use, The primary outcome assessed was a statistically significant change in HOOS-PS and HOOS-Pain; secondary outcomes included change in satisfaction, communication, and adherence to physical therapy exercises, weightbearing guidelines, or brace use. Wilcoxon rank sum was used to compare HOOS-PS and HOOS-Pain scores at 0 and 90 days. Demographic characteristics and survey variables were compared using Students t test for continuous variables and χ² or Fisher exact test for categorical variables as appropriate.

RESULTS

There were statistically significant and clinically relevant improvements in HOOS-PS and HOOS-Pain in both groups (P < .05). Subjective feedback was strongly positive, with 96% of text message participants reporting they would choose automated messages if it was offered to them again in the future.

CONCLUSIONS

Ninety days of automated text messaging after hip arthroscopy failed to show a significant difference in HOOS-PS (P = .09), HOOS-Pain (P = .13), patient-reported compliance with postoperative guidelines, or satisfaction with support and communication from the surgical team.

LEVEL OF EVIDENCE

I, randomized control trial (RCT).

Arthroscopy Annual Research Awards: Something to Celebrate

With sincere appreciation to the AANA Education Foundation for their generous support, we announce our Annual Awards for the best Clinical Research, Basic Science Research, Resident/Fellow Research, and Systematic Reviews published in 2021, as well as the Most Downloaded and Most Cited papers published 5 years ago. Also, as is customary and as we require of authors, our editors update their annual disclosures of potential conflicts of interest. Finally, we annually update our masthead, thus introducing a new Associate Editor and many new members of the Editorial Board and Social Media Board.

Mobile health technology for remote home monitoring after surgery: a meta-analysis

BACKGROUND

Mobile health (mHealth) technology has been proposed as a method of improving post-discharge surveillance. Little is known about how mHealth has been used to track patients after surgery and whether its use is associated with differences in postoperative recovery.

METHODS

Three databases (PubMed, MEDLINE and the Cochrane Central Registry of Controlled Trials) were searched to identify studies published between January 1999 and February 2021. Mobile health was defined as any smartphone or tablet computer capable of electronically capturing health-related patient information and transmitting these data to the clinical team. Comparable outcomes were pooled via meta-analysis with additional studies compiled via narrative review. The quality of each study was assessed based on Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.

RESULTS

Forty-five articles met inclusion criteria. While the majority of devices were designed to capture general health information, others were specifically adapted to the expected outcomes or potential complications of the index procedure. Exposure to mHealth was associated with fewer emergency department visits (odds ratio 0.42, 95 per cent c.i. 0.23 to 0.79) and readmissions (odds ratio 0.47, 95 per cent c.i. 0.29 to 0.77) as well as accelerated improvements in quality of life after surgery. There were limited data on other postoperative outcomes.

CONCLUSION

Remote home monitoring via mHealth is feasible, adaptable, and may even promote more effective postoperative care. Given the rapid expansion of mHealth, physicians and policymakers need to understand these technologies better so that they can be integrated into high-quality clinical care.

Age Significantly Affects Response Rate to Outcomes Questionnaires Using Mobile Messaging Software

Purpose

To investigate the demographic factors that influence time to respond (TTR), time to completion (TTC), and response rate when using a text messaging-based system and to determine the feasibility and applicability of mobile messaging-based services for collection of patient-reported outcomes among orthopaedic sports medicine patients.

Methods

On the day of surgery, patient mobile phone number was collected and the automated mobile messaging service (MOSIO, Seattle, WA) messaged patients for 10 ``days postoperatively. Patient visual analog scale (VAS) scores were collected 3 times daily, side effects were asked each evening, and Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) Short Form was collected on postoperative day 3 and 7.

Results

A total of 177 patients were enrolled in the study. The overall response rate to the survey questions was 75.0%. For all patients, the average TTR of questions was 35.09 ± 12.57 minutes. The TTC was 2.75 ± 3.56 minutes for PROMIS-PI, 3.51 ± 1.26 minutes for VAS, and 3.80 ± 6.87 for side-effect questions. When patients were stratified into age groups, the youngest group, 16 to 32 years, had the greatest response rate of 85.2% and patients in the 49 to 59 years group had the lowest response rate of 68.4% and 69.1%, respectively (P < .001). There was no significant difference in the TTR or TTC for VAS, PROMIS-PI, or side-effect questions when patients were stratified by age or sex groups (P > .05).

Conclusions

Collectively, all age groups successfully achieved a mean response rate of 75%; however, significantly lower response rates were observed for patients >49 years old. Differences in age and sex did not impact the overall TTR or TTC for VAS, PROMIS-PI, or side-effect questions. Mobile-based applications present as an emerging opportunity to track postoperative outcome scores and reduce clinic survey load.

Level of Evidence

Case series, level of evidence IV.

Self-Rehabilitation Guided by a Mobile Application After Anterior Cruciate Ligament Reconstruction Leads to Improved Early Motion and Less Pain

Purpose

To evaluate the adherence rate and the contribution of self-rehabilitation (SR) guided by a mobile application after anterior cruciate ligament reconstruction (ACLR) in combination with physical therapy sessions on early knee function.

Methods

This study was a retrospective analysis of prospectively collected data from a single health care facility. All patients who underwent ACLR by a single surgeon from December 2019 to September 2020 were included. Two groups were formed and compared based on use of the mobile app: users (>10 days of use) and nonusers (≤10 days of use). Outcomes included physical examination at 3 and 6 weeks postoperatively.

Results

A total of 65 patients were analyzed: 19 in the nonuser group and 46 in the user group. Adherence rate was 91% at 10 days, 71% at 15 days, 62% at 21 days, and 44% at 45 days. At 3 weeks, the user group was 3.86 times [range 1.12 to 13.3] as likely to lock the quadriceps during gait with crutches and was 4.2 times [range 1.2 to 14.3] as likely to be pain free. There was a tendency to have less flexion contracture in the user group (17% versus 32%, P = .32). At 6 weeks, the differences leveled out, but the user group still had slightly better quadriceps locking during gait without crutches (87% versus 79%, P = .46).

Conclusions

SR guided by a mobile app combined with a standard rehabilitation protocol is correlated with better knee function at initial follow-up.

Level of evidence

IV, therapeutic case series.

Telemedicine trends in orthopaedics and trauma during the COVID-19 pandemic: A bibliometric analysis and review

Objectives

In the wake of recent widespread interest in telemedicine during the COVID-19 era, many orthopaedic surgeons may be unfamiliar with clinical examination skills, patients’ safety, data security, and implementation-related concerns in telemedicine. We present a bibliometric analysis and review of the telemedicine-related publications concerning orthopaedics care during the COVID-19 pandemic. Such analysis can help orthopaedic surgeons become acquainted with the recent developments in telemedicine and its usage in regular orthopaedics practice.

Methods

We systematically searched the database of Thomson Reuters Web of Science for telemedicine-related articles in orthopaedics published during the COVID-19 pandemic. The selected articles were analysed for their source journals, corresponding authors, investigating institutions, countries of the corresponding authors, number of citations, study types, levels of evidence, and a qualitative review.

Results

Fifty-nine articles meeting the inclusion criteria were published in 28 journals. Three hundred forty-two authors contributed to these research papers. The United States (US) contributed the most number of articles to the telemedicine-related orthopaedics research during the COVID-19 era. All articles combined had a total of 383 citations and 66.1% were related to the Economic and Decision-making Analyses of telemedicine implementation. By and large, level IV evidence was predominant in our review.

Conclusion

Telemedicine can satisfactorily cover a major proportion of patients' visits to outpatient departments, thus limiting hospitals’ physical workload. Telemedicine has a potential future role in emergency orthopaedics and inpatient care through virtual aids. The issues related to patient privacy, data security, medicolegal, and reimbursement-related aspects need to be addressed through precise national or regional guidelines. Lastly, the orthopaedic physical examination is a weak link in telemedicine and needs to be strengthened.

The Use of Mobile Applications for the Diagnosis and Treatment of Tumors in Orthopaedic Oncology - a Systematic Review

The use of smartphone apps is an essential part of everyday life. Mobile applications offer enormous opportunities for dealing with challenges in public health, and their number increases every day. This paper aims to review the existing literature on mobile applications in orthopaedic oncology and to summarize the current mobile applications for musculoskeletal tumors. A systematic literature review was conducted regarding articles on mobile applications in orthopaedic and trauma surgery. The focus was on identifying mobile applications that can be used in the treatment of patients with musculoskeletal tumors. Two reviewers independently assessed study eligibility, extracted data, and appraised methodological quality. In addition, the Apple App Store and Google Play Store were searched for suitable mobile applications. Ninety-one articles describing a mobile application in orthopaedic and trauma surgery were identified. Three articles focused on a mobile application for musculoskeletal tumors. Additionally, seven mobile applications were available in the App/Play Stores dealing with bone or soft tissue tumors in orthopaedic oncology without corresponding scientific articles. Increasing numbers of mobile applications are being developed in orthopaedic and trauma surgery. Currently, only three scientific articles on mobile applications in orthopaedic oncology are present, yet several more applications are available without scientific medical evaluation. Since mobile applications can facilitate the everyday life of orthopaedic and trauma surgeons, it is worthwhile to be aware of new developments in this field. A regular scientific evaluation of the subject is important in order to classify the significance of these applications.

The Reliability of Remote Patient-Reported Outcome Measures via Mobile Apps to Replace Outpatient Visits After Rotator Cuff Repair Surgery: Repetitive Test-Retest Comparison Study for 1-Year Follow-up

BACKGROUND

With the development of health care-related mobile apps, attempts have been made to implement remote patient-reported outcome measures (PROMs). In order for remote PROMs to be widely used by mobile apps, the results should not be different depending on the location; that is, remote PROM results performed in locations other than hospitals should be able to obtain reliable results equivalent to those performed in hospitals, and this is very important. However, to our knowledge, there are no studies that have assessed the reliability of PROMs using mobile apps according to the location by comparing the results performed remotely from the hospital and performed at the outpatient visits.

OBJECTIVE

The purpose of this study was to evaluate the reliability of remote PROMs using mobile apps compared to PROMs performed during outpatient follow-up visits after arthroscopic shoulder surgery.

METHODS

A total of 174 patients who underwent arthroscopic rotator cuff repair completed questionnaires 2 days before visiting the clinic for the 1-, 2-, 3-, 6-, and 12-month follow-ups (test A). The patients completed the questionnaires at the clinic (test B) using the same mobile app and device for the 1-, 2-, 3-, 6-, and 12-month follow-ups. Test-retest comparisons were performed to analyze the differences and reliability of the PROMs according to the period.

RESULTS

Comparisons of tests A and B showed statistically significant differences at 1, 2, and 3 months (all Ps<.05 except for the ASES function scale at 3-months) but not 6 or 12 months after surgery (all Ps>.05). The intraclass correlation values between the two groups were relatively low at the 1-, 2-, and 3-month follow-ups but were within the reliable range at 6 and 12 months after surgery. The rate of completion of tests A and B using the mobile app was significantly lower in the group older than 70 years than in the other groups for all postoperative periods (P<.001).

CONCLUSIONS

PROMs using mobile apps with different locations differed soon after surgery but were reliably similar after 6 months. The remote PROMs using mobile apps could be used reliably for the patient more than 6 months after surgery. However, it is to be expected that the use of mobile app-based questionnaires is not as useful in the group older than 70 years as in other age groups.

Arthroscopy Annual Awards: The "Old Normal"

With sincere thanks to the Arthroscopy Association of North America Education Foundation for their support, we are pleased to announce the Annual Awards for our best Clinical Research, Basic Science Research, Resident/Fellow Research, and Systematic Reviews published in 2020, as well as the Most Downloaded and Most Cited papers published 5 years ago. We proudly introduce new members of our editorial team, and your editors update their disclosures of potential conflicts of interest.

A Smartphone App With a Digital Care Pathway for Patients Undergoing Spine Surgery: Development and Feasibility Study

BACKGROUND

There is a great unmet clinical need to provide patients undergoing spinal surgery and their caregivers with ongoing, high-quality care before and after surgery in an efficiency-focused health care environment.

OBJECTIVE

The objective of this study is to design, develop, and evaluate the acceptability and feasibility of a novel planning-, outcomes-, and analytics-based smartphone app called ManageMySurgery (MMS) in patients undergoing elective spine surgery (MMS-Spine).

METHODS

The development process of the MMS app was conducted over 2 sequential stages: (1) an evidence-based intervention design with refinement from surgeon and patient feedback and (2) feasibility testing in a clinical pilot study. We developed a novel, mobile-based, Health Insurance Portability and Accountability Act-compliant platform for interventional and surgical procedures. It is a patient-centric mobile health app that streamlines patients' interactions with their care team. MMS divides the patient journey into phases, making it feasible to provide customized care pathways that meet patients' unique needs. Patient-reported outcomes are easily collected and conform to the National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) standard.

RESULTS

We tested the feasibility of the MMS-Spine app with patients undergoing elective spine surgery at a large academic health system. A total of 47 patients undergoing elective spine surgery (26 cervical spine and 21 lumbar spine surgeries) downloaded and used MMS-Spine to navigate their surgical journey, quantify their baseline characteristics and postoperative outcomes, and provide feedback on the utility of the app in preparing for and recovering from their spinal surgery. The median age was 59.0 (range 33-77) years, 22 of the 47 patients (47%) were women, and 26 patients (55%) had commercial insurance. Of the 47 patients, a total of 33 (70%) logged in on an iOS device, 11 (23%) on an Android device, and 3 (6%) on a computer or tablet. A total of 17 of the 47 patients (36%) added a caregiver, of which 7 (41%) logged in. The median number of sign-ins was 2. A total of 38 of 47 patients (81%) completed their baseline preoperative PROMIS-29 outcomes, and 14 patients (30%) completed at least one PROMIS-29 survey during the postoperative period. Of the 24 patients who completed the MMS survey, 21 (88%) said it was helpful during preparation for their procedure, 16 (67%) said it was helpful during the postoperative period, and 23 (96%) said that they would recommend MMS to a friend or family member.

CONCLUSIONS

We used a patient-centered approach based on proven behavior change techniques to develop a comprehensive smartphone app for patients undergoing elective spine surgery. The optimized version of the app is ready for formal testing in a larger randomized clinical study to establish its cost-effectiveness and effect on patients' self-management skills and long-term outcomes.

A Smartphone App With a Digital Care Pathway for Patients Undergoing Spine Surgery: Development and Feasibility Study (Preprint).. [DOI: 10.2196/preprints.21138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

BACKGROUND

There is a great unmet clinical need to provide patients undergoing spinal surgery and their caregivers with ongoing, high-quality care before and after surgery in an efficiency-focused health care environment.

OBJECTIVE

The objective of this study is to design, develop, and evaluate the acceptability and feasibility of a novel planning-, outcomes-, and analytics-based smartphone app called ManageMySurgery (MMS) in patients undergoing elective spine surgery (MMS-Spine).

METHODS

The development process of the MMS app was conducted over 2 sequential stages: (1) an evidence-based intervention design with refinement from surgeon and patient feedback and (2) feasibility testing in a clinical pilot study. We developed a novel, mobile-based, Health Insurance Portability and Accountability Act–compliant platform for interventional and surgical procedures. It is a patient-centric mobile health app that streamlines patients’ interactions with their care team. MMS divides the patient journey into phases, making it feasible to provide customized care pathways that meet patients’ unique needs. Patient-reported outcomes are easily collected and conform to the National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) standard.

RESULTS

We tested the feasibility of the MMS-Spine app with patients undergoing elective spine surgery at a large academic health system. A total of 47 patients undergoing elective spine surgery (26 cervical spine and 21 lumbar spine surgeries) downloaded and used MMS-Spine to navigate their surgical journey, quantify their baseline characteristics and postoperative outcomes, and provide feedback on the utility of the app in preparing for and recovering from their spinal surgery. The median age was 59.0 (range 33-77) years, 22 of the 47 patients (47%) were women, and 26 patients (55%) had commercial insurance. Of the 47 patients, a total of 33 (70%) logged in on an iOS device, 11 (23%) on an Android device, and 3 (6%) on a computer or tablet. A total of 17 of the 47 patients (36%) added a caregiver, of which 7 (41%) logged in. The median number of sign-ins was 2. A total of 38 of 47 patients (81%) completed their baseline preoperative PROMIS-29 outcomes, and 14 patients (30%) completed at least one PROMIS-29 survey during the postoperative period. Of the 24 patients who completed the MMS survey, 21 (88%) said it was helpful during preparation for their procedure, 16 (67%) said it was helpful during the postoperative period, and 23 (96%) said that they would recommend MMS to a friend or family member.

CONCLUSIONS

We used a patient-centered approach based on proven behavior change techniques to develop a comprehensive smartphone app for patients undergoing elective spine surgery. The optimized version of the app is ready for formal testing in a larger randomized clinical study to establish its cost-effectiveness and effect on patients’ self-management skills and long-term outcomes.