Is virtual clinic follow-up of hip and knee joint replacement acceptable to patients and clinicians? A sequential mixed methods evaluation

A review of questionnaires used for the assessment of telemedicine

INTRODUCTION

Telemedicine is the exchange of medical information from one site to another via electronic communications with the goal of improving a patient's clinical health status. Prior studies have identified the absence of a standardized assessment tool for evaluating telemedicine encounters. This study aims to collect and to analyze questionnaires used for the assessment of audiovisual telemedicine encounters from a patient perspective and aims to identify reasons driving the use of self-developed questionnaires.

METHODS

We conducted a systematic search in PubMed for studies that used survey questionnaires to assess synchronous audiovisual telemedicine encounters from 2016 to 2021. We categorized questionnaires used into validated and non-validated types, and for each of them, collected questions, response format, author, year, specialty, and country of publication.

RESULTS AND DISCUSSION

We analyzed a total of 71 articles. We found that only 16 studies used three validated questionnaires. The remaining 55 studies used non-validated questionnaires. Non-validated questionnaires had a high variability in length and used Likert scales, binary responses, multiple choice, and open-ended answers. We found only eight studies in which the authors gave a reason for resorting to designing their own questionnaires. This review reveals insufficient standardized survey questionnaires to be used for the assessment of audiovisual telemedicine encounters. Future research initiatives should focus on developing a standardized and validated instrument well accepted by researchers.

Mobile and Computer-Based Applications for Rehabilitation Monitoring and Self-Management After Knee Arthroplasty: Scoping Review

BACKGROUND

Successful post-knee replacement rehabilitation requires adequate access to health information, social support, and periodic monitoring by a health professional. Mobile health (mHealth) and computer-based technologies are used for rehabilitation and remote monitoring. The extent of technology use and its function in post-knee replacement rehabilitation care in low and middle-income settings are unknown.

OBJECTIVE

To inform future mHealth intervention development, we conducted a scoping review to map the features and functionality of existing technologies and determine users' perspectives on telerehabilitation and technology for self-management.

METHODS

We followed the Joanna Briggs Institute methodology for scoping reviews. We searched the Embase, Medline, PsycINFO via OVID, and Cochrane Central Register of Controlled Trials databases for manuscripts published from 2001 onward. We included original research articles reporting the use of mobile or computer-based technologies by patients, health care providers, researchers, or family members. Studies were divided into the following 3 categories based on the purpose: validation studies, clinical evaluation, and end user feedback. We extracted general information on study design, technology features, proposed function, and perspectives of health care providers and patients. The protocol for this review is accessible in the Open Science Framework.

RESULTS

Of the 5960 articles, 158 that reported from high-income settings contributed to the qualitative summary (64 studies on mHealth or telerehabilitation programs, 28 validation studies, 38 studies describing users' perceptions). The highest numbers of studies were from Europe or the United Kingdom and North America regarding the use of a mobile app with or without wearables and reported mainly in the last decade. No studies were from low and middle-income settings. The primary functions of technology for remote rehabilitation were education to aid recovery and enable regular, appropriate exercises; monitoring progress of pain (n=19), activity (n=20), and exercise adherence (n=30); 1 or 2-way communication with health care professionals to facilitate the continuum of care (n=51); and goal setting (n=23). Assessment of range of motion (n=16) and gait analysis (n=10) were the commonly validated technologies developed to incorporate into a future rehabilitation program. Few studies (n=14) reported end user involvement during the development stage. We summarized the reasons for satisfaction and dissatisfaction among users across various technologies.

CONCLUSIONS

Several existing mobile and computer-based technologies facilitate post-knee replacement rehabilitation care for patients and health care providers. However, they are limited to high-income settings and may not be extrapolated to low-income settings. A systematic needs assessment of patients undergoing knee replacement and health care providers involved in rehabilitation, involving end users at all stages of development and evaluation, with clear reporting of the development and clinical evaluation can make post-knee replacement rehabilitation care in resource-poor settings accessible and cost-effective.

Patients' needs and experiences of telerehabilitation after total hip and knee arthroplasty: A qualitative systematic review and meta-synthesis

Background

The number of patients undergoing joint replacement procedures is continuously increasing. Tele-equipment is progressively being employed for postrehabilitation of total hip and knee replacements. Gaining a comprehensive understanding of the experiences and requirements of patients undergoing total hip and knee arthroplasty who participate in telerehabilitation can contribute to the enhancement of telerehabilitation programs and the overall rehabilitation and care provided to this specific population.

Objective

To explore the needs and experiences of total hip and knee arthroplasty patients with telerehabilitation.

Design

Systematic review and qualitative synthesis.

Methods

Electronic databases PubMed, Web of Science, The Cochrane Library, Embase, CINAHL, Scopus, ProQuest, CNKI, Wanfang Data, VIP, and SinoMed were systematically searched for information on the needs and experiences of telerehabilitation for patients with total hip arthroplasty and total knee arthroplasty in qualitative studies. The search period was from the creation of the database to March 2024. Literature quality was assessed using the 2016 edition of the Australian Joanna Briggs Institute Centre for Evidence-Based Health Care Quality Assessment Criteria for Qualitative Research. A pooled integration approach was used to integrate the findings inductively.

Results

A total of 11 studies were included and 4 themes were identified: the desire to communicate and the need to acquire knowledge; accessible, high-quality rehabilitation services; positive psychological experiences; the dilemmas of participating in telerehabilitation.

Conclusions

This study's findings emphasize that the practical needs and challenges of total hip and knee arthroplasty patients' participation in telerehabilitation should be continuously focused on, and the advantages of telerehabilitation should be continuously strengthened to guarantee the continuity of patients' postoperative rehabilitation and to promote their postoperative recovery.

Decision Aid on Orthopedic Virtual Care: Patient Preferences in Orthopedic Hand Clinic

Introduction: The objectives of this study are to develop a decision aid for orthopedic patients to decide between virtual or in-person care and assess patient preferences for these modalities in hand clinic. Methods: An orthopedic virtual care decision aid was developed alongside orthopedic surgeons and a virtual care expert. Subject participation involved 5 steps: Orientation, Memory, and Concentration Test (OMCT), knowledge pretest, decision aid, postdecision aid questionnaire, and Decisional Conflict Scale (DCS) assessment. Patients presenting to hand clinic were initially provided the OMCT to assess decision-making capacity, with those failing excluded. Subjects were then administered a pretest to assess their understanding of virtual and in-person care. Subsequently, the validated decision aid was provided to patients, after which a postdecision aid questionnaire and DCS assessment were administered. Results: This study enrolled 124 patients. Pre- to postdecision aid knowledge test scores increased by 15.3% (p < 0.0001), and the average patient DCS score was 18.6. After reading the decision aid, 47.6% of patients believed that virtual and in-person care provided similar physician interaction, 46.0% felt little difference in effectiveness between the modalities, and 39.5% had no preference for either. Most patients understood their options (79.8%) and were ready to make a care modality decision (65.4%) following decision aid administration. Conclusion: Significant improvements in knowledge scores, strong DCS scores, and high levels of understanding and decision-making readiness support decision aid validity. Hand patients appear to have no consensus preferences for care modality, emphasizing the need for a decision aid to help determine individual care preferences.

Feasibility testing of a standardised virtual clinic for follow-up of patients after hip and knee arthroplasty

INTRODUCTION

Over 200,000 hip and knee total joint arthroplasties (TJAs) are performed annually in England and Wales. UK guidelines recommend regular follow-up because missed early failure can result in complex revision surgery, which places additional burden on overstretched orthopaedic services. This study evaluated the feasibility and acceptability of an expert, consensus-based, standardised virtual clinic (VC) approach for TJA follow-up.

METHODS

Five UK secondary care orthopaedic centres implemented a standardised VC. Feedback was obtained through patient satisfaction questionnaires and telephone interviews with arthroplasty care practitioners. Key stakeholders subsequently attended an expert discussion forum to achieve consensus on the final VC format and to address obstacles identified during testing.

RESULTS

From 19 June 2018 to 11 December 2018, 561 TJA patients [mean age (SD) 70 (9.4) years, 57.8% female, 69.0% hip TJA, 1-28 years postsurgery (median 5 years)] completed a VC. Of these 561 patients, 82.2% were discharged without attending an outpatient appointment and 46 (8.8%) required early face-to-face consultant review. Patient satisfaction with the VC was high (156/188; 83.0%); over 70% of patients indicated a preference for the VC.

DISCUSSION

This feasibility study suggested significant resource savings, including time spent by consultant orthopaedic surgeons in outpatient clinics, hospital transport and an estimated saving of up to two-thirds of usual clinic-allotted time. The expert discussion forum provided helpful feedback for supporting more efficient implementation of the VC.

CONCLUSIONS

A standardised VC is a feasible alternative to outpatient clinics for the follow-up of hip and knee TJA patients, and is acceptable to key stakeholders, including patients.

Innovations and Implementation of Telemedicine in Surgical Clinics Beyond COVID-19: A Narrative Review

Introduction: Telemedicine has emerged as a powerful tool in the delivery of health care to surgical patients and innovations are developing to address challenges in the technology, enhancing consumer-provider encounters while located remotely. Our study aims at collating and commenting on the published evidence for how current challenges in telemedicine for surgical clinics are met by innovations currently in development. We also comment on the implementation and monitoring strategies for telemedicine. Methods: Databases searched included: PubMed, OVID Medline, Embase, Scopus, Web of Science, and review of reference lists. Key words used were "telemedicine"; "telehealth"; "videoconference"; "outpatient"; and "surgical clinic." For inclusion, articles required to be in English, published between 2000 and 2021, were in an outpatient surgical setting, and if they had a focus during the COVID-19 pandemic. Results: Three hundred forty-five articles were identified and screened, so that 73 articles were included in the review. Almost all articles were from Western countries (n = 69), mostly in surgical journals (n = 39) and from a range of sub-specialties, but pre-dominantly orthopedics (n = 12) and general surgery (n = 9). The majority were original comparative studies, with 31 studies directly comparing telemedicine with in-person appointments and 22 articles focused on implementation during COVID-19. Discussion/Conclusion: Advanced telecommunication technology has enabled telemedicine to become an effective and safe form of health care delivery, with high consumer and provider satisfaction. Innovative protocol and technology developments have addressed the limitations of telemedicine. Sophisticated and familiar medical software integrates with electronic medical records to automate and streamline documentation, consent, and billing processes. Surgical clinics are investing in telehealth workflow co-ordination and information technology support to troubleshoot any technical difficulties as well as education for providers and consumers to address technology illiteracy. As health care services continue to transition their systems to an online network, further research is required to understand the ability and assess the feasibility of telemedicine to fully integrate.

Automatic Identification of Failure in Hip Replacement: An Artificial Intelligence Approach

Background: Total hip arthroplasty (THA) follow-up is conventionally conducted with serial X-ray imaging in order to ensure the early identification of implant failure. The purpose of this study is to develop an automated radiographic failure detection system. Methods: 630 patients with THA were included in the study, two thirds of which needed total or partial revision for prosthetic loosening. The analysis is based on one antero-posterior and one lateral radiographic view obtained from each patient during routine post-surgery follow-up. After pre-processing for proper standardization, images were analyzed through a convolutional neural network (the DenseNet169 network), aiming to predict prosthesis failure. The entire dataset was divided in three subsets: training, validation, and test. These contained transfer learning and fine-tuning algorithms, based on the training dataset, and were implemented to adapt the DenseNet169 network to the specific data and clinical problem. Results: After the training procedures, in the test set, the classification accuracy was 0.97, the sensitivity 0.97, the specificity 0.97, and the ROC AUC was 0.99. Only five images were incorrectly classified. Seventy-four images were classified as failed, and eighty as non-failed with a probability >0.999. Conclusion: The proposed deep learning procedure can detect the loosening of the hip prosthesis with a very high degree of precision.

The Impact of Perioperative Remote Patient Monitoring on Clinical Staff Workflows: Scoping Review

BACKGROUND

Remote patient monitoring (RPM) interventions are being increasingly implemented in health care environments, given their benefits for different stakeholders. However, the effects of these interventions on the workflow of clinical staff are not always considered in RPM research and practice.

OBJECTIVE

This review explored how contemporary RPM interventions affect clinical staff and their workflows in perioperative settings.

METHODS

We conducted a scoping review of recent articles reporting the impact of RPM interventions implemented in perioperative settings on clinical staff and their workflow. The databases accessed were Embase and PubMed. A qualitative analysis was performed to identify the main problems and advantages that RPM brings to staff, in addition to the approaches taken to evaluate the impact of those interventions. Different themes were identified in terms of the challenges of RPM for clinical staff as well as in terms of benefits, risk-reduction strategies, and methods for measuring the impact of these interventions on the workflow of clinical staff.

RESULTS

A total of 1063 papers were found during the initial search, of which 21 (1.98%) met the inclusion criteria. Of the 21 included papers, 15 (71%) focused on evaluating new RPM systems, 4 (19%) focused on existing systems, and 2 (10%) were reviews.

CONCLUSIONS

The reviewed literature shows that the impact on staff work experience is a crucial factor to consider when developing and implementing RPM interventions in perioperative settings. However, we noticed both underdevelopment and lack of standardization in the methods for assessing the impact of these interventions on clinical staff and their workflow. On the basis of the reviewed literature, we recommend the development of more robust methods for evaluating the impact of RPM interventions on staff experience in perioperative care; the adoption of a stronger focus on transition management when introducing these interventions in clinical practice; and the inclusion of longer periods of assessment, including the evaluation of long-term goals.

Virtual phone clinics in orthopaedics: evaluation of clinical application and sustainability

AIMS

Adoption of virtual clinics has been accelerated by the COVID-19 pandemic and they will continue to form an integral part of healthcare delivery. Our objective was to evaluate virtual clinics in orthopaedic practice and determine how to use them effectively and sustainably.

METHODS

We surveyed 100 consecutive patients participating in orthopaedic virtual phone clinic (VPC) at an academic hospital to evaluate patient satisfaction against face-to-face (F2F) consultations and obtain suggestions for improving patient experience, and we surveyed 23 clinicians who conducted orthopaedic VPCs in 2020. Data were correlated with clinic outcomes, reason for consultation, diagnosis, patient age and clinician grade. Consultation duration, clinician-associated costs and reimbursement were analysed. Significance was tested using two-tailed Student's t-test and Fisher's exact test.

RESULTS

Patient satisfaction (out of 5) for VPC was significantly lower than F2F (4.1 vs 4.5, p=0.0003), and a larger proportion of VPC scored <3 compared with F2F (11% vs 2%). Higher VPC scores were associated with appointments for delivering results and where patients felt clinical examination was not needed. Patients suggested introducing video capability, adhering to appointment time and offering the choice of VPC or F2F. Mean clinician satisfaction scores for VPC were 4.3/5 and suggested indications for VPC included: routine surveillance, communication of results, discussing/consenting for surgery and vulnerable patients. Integrating video, providing private rooms and offering patients time intervals for VPC were recommended. Current National Health Service VPC structures uses greater clinician resources and generates lower reimbursement than F2F consultations, resulting in 11.5% reduction in reimbursement.

CONCLUSION

VPC plays a valuable role when clinical evaluation has been performed or considered not necessary. Offering the choice of VPC or F2F, adding video capability and providing a time interval for VPC may reduce resource use and increase satisfaction. We recommend renegotiating VPC tariffs and cost-neutral modifications of clinic structure.

Assessing Orthopedic Patient Preferences for Mandated Virtual Care During the COVID-19 Pandemic and Elective Virtual Care in Non-Pandemic Circumstances

The purpose of this study was to compare orthopedic patient preferences for mandated virtual care during the coronavirus disease 2019 (COVID-19) pandemic and elective virtual care during non-pandemic circumstances. An orthopedic virtual care questionnaire was administered to adult orthopedic patients undergoing their first orthopedic virtual visit between March 15, 2020, and May 18, 2020. The questionnaire had 13 items rated on a 1-to-5 Likert scale ("strongly agree" to "strongly disagree"). Responses were compared using Kruskal-Wallis and nonparametric Wilcoxon rank-sum tests. Patients showed higher preferences for mandated virtual care during the pandemic when compared with elective virtual care during non-pandemic circumstances (2.25±1.31 vs 4.10±1.25, P<.0001) and also preferred virtual visits in other specialties compared with orthopedics (2.17±1.35 vs 2.79±1.42, P<.0001). Patients older than 50 years were more likely to view virtual care as the best option during the pandemic (2.06±1.25 vs 2.48±1.35, P<.0165) and equally as effective as in-person visits in non-pandemic circumstances (2.45±1.36 vs 2.83±1.18, P<.0150). Female patients were more likely to pursue future orthopedic virtual visits (2.61±1.37 vs 3.07±1.45, P<.0203) and view their virtual visit as equally effective as an in-person visit (2.47±1.33 vs 2.87±1.18, P<.0181). Orthopedic patient preference for mandated virtual care during the COVID-19 pandemic seems to be higher than for elective virtual care during non-pandemic circumstances, and older and female patients appear to favor virtual care. [Orthopedics. 2021;44(4):e471-e476.].

Process of Posthospital Care Involving Telemedicine Solutions for Patients after Total Hip Arthroplasty

The importance of telemedicine technologies around the world has been growing for many years, and it turned out to be a particularly important issue for conducting some medical procedures during the SARS-CoV-2 pandemic. It is necessary to create interdisciplinary teams to design and implement improved procedures using telemedicine tools. The aim of the article is to develop original, improved posthospital patient care process after total hip arthroplasty (THA) with the use of telemedicine technologies. In the study, a literature review and empirical research were used. The conducted research resulted in the designing an original posthospital patient care process after THA that uses telematics technologies. Due to the use of analyzed telemedicine technologies, the designed patient care process brings a possibility to increase the patient's safety by monitoring life parameters, allowing for regular, remote contact with specialists and to be supervised remotely. All this may contribute to shortening the convalescence time, reducing the risk of complications, as well as reducing treatment costs. The designed model is ready for further clinical research with the participation of medical staff, patients after THA and patient caregivers.

Automated conversational agents for post-intervention follow-up: a systematic review

BACKGROUND

Advances in natural language processing and other machine learning techniques have led to the development of automated agents (chatbots) that mimic human conversation. These systems have mainly been used in commercial settings, and within medicine, for symptom checking and psychotherapy. The aim of this systematic review was to determine the acceptability and implementation success of chatbots in the follow-up of patients who have undergone a physical healthcare intervention.

METHODS

A systematic review of MEDLINE, MEDLINE In-process, EMBASE, PsychINFO, CINAHL, CENTRAL and the grey literature using a PRISMA-compliant methodology up to September 2020 was conducted. Abstract screening and data extraction were performed in duplicate. Risk of bias and quality assessments were performed for each study.

RESULTS

The search identified 904 studies of which 10 met full inclusion criteria: three randomised control trials, one non-randomised clinical trial and six cohort studies. Chatbots were used for monitoring after the management of cancer, hypertension and asthma, orthopaedic intervention, ureteroscopy and intervention for varicose veins. All chatbots were deployed on mobile devices. A number of metrics were identified and ranged from a 31 per cent chatbot engagement rate to a 97 per cent response rate for system-generated questions. No study examined patient safety.

CONCLUSION

A range of chatbot builds and uses was identified. Further investigation of acceptability, efficacy and mechanistic evaluation in outpatient care pathways may lend support to implementation in routine clinical care.

Remote Musculoskeletal Consultations: A Survey of General Practitioner Registrars' Level of Confidence, Acceptability, and Management

Background and objective The coronavirus disease 2019 (COVID-19) pandemic has accelerated the shift towards remote consultations in the medical field, including musculoskeletal (MSK) appointments. General practitioner (GP) registrars are now routinely conducting many MSK consultations remotely; however, very little is known of their level of confidence and satisfaction regarding this new and evolving scenario, or how this may impact patient management of patients. In this study, we aimed to understand GP registrars' level of confidence and satisfaction with respect to remote MSK consultations, and the perceived impact on patient management. Study design This study involved a cross-sectional online survey of GP registrars in the West Midlands, which was conducted in January 2021. Methods The survey asked for ranked responses to questions comparing face-to-face consulting methods with remote consulting, focusing on confidence, satisfaction, onward investigations, and referral activity. Statistical analysis was performed using the R software version 4.0.3. Results The overall survey response was 21.2% (n=312/1,471). Of the respondents, 85.9% of GP registrars had not received any training to prepare them for remote MSK consultations. GP registrars generally felt that they were more confident when treating patients face-to-face compared to remote consultations (p<0.001). This was true for general MSK complaints as well as specific assessments of the hand, shoulder, spine, hip, knee, and ankle; 36.2% of GP registrars were not satisfied and 51.0% thought that their patients were not satisfied with the current quality of remote MSK consultations. Of note, 77.6% of GP registrars said that they were more likely to request additional investigations, and 75.6% stated that they were more likely to refer patients to a specialist after a remote MSK consultation. Conclusion This study highlights the need for further training to better equip primary care doctors for remote MSK consultations. With tailored training, GP registrars could offer more streamlined remote patient care for MSK complaints.

Cost analysis on virtual clinic follow-up after primary joint arthroplasty

BACKGROUND

As previously reported, a virtual clinic (VC) effectively manages the increasing need to review and monitor patients after primary joint replacement. Such procedure is increasing steadily in number, with more than 200,000 procedures performed annually in the UK. Considering that face-to-face review following routine uncomplicated primary joint arthroplasty is costly and time consuming, guidelines suggest reviewing patients at regular intervals through radiographs and patient-reported outcome measures (PROMs).

METHODS

We reviewed our VC experience in a large teaching hospital. A single surgeon established the VC, and all primary hip and knee replacements over an 18-month period (January 2016 to July 2017) were included in the study. We evaluated all clinical records, PROMs, patient satisfaction, and outcome of VC at one-year follow-up. Additionally, we conducted a safety and cost analysis.

RESULTS

This study included 154 primary joints (70 total knee replacements and 84 total hip replacements) in 148 patients (89 females, 59 males). The mean age at surgery was 65.3 years. Of the patients, 93% completed the postoperative PROMs, whereas <40% completed the PROM during regular clinical follow-up. All the patients had follow-up radiographs. After VC assessment, which included radiographies and PROMs, 59% of the patients were directly discharged. Of the remaining 41% patients who had face-to-face review, one-third were examined for the same arthroplasty issue, and two-thirds were examined for unrelated or other joint problems. Although the postoperative PROM was below the national average, the improvement in PROM (from pre-operative to post-operative scores) was higher than the national average. The cost analysis demonstrated an average cost savings of £10.449 per year and consultant.

CONCLUSIONS

VC follow-up after primary joint replacement is a safe and cost-effective option to manage postoperative follow-up visits and identify those patients who require additional face-to-face reviews and who can be safely discharged. The discharge criteria included satisfactory improvement in PROM scores, review of follow-up radiographs, and no concerns raised by patients. Considering the increasing number of primary joint arthroplasty and the financial pressure on the National Health Service, VC offers an excellent alternative to conventional clinics.

Current and future use of telemedicine in surgical clinics during and beyond COVID-19: A narrative review

Introduction

Telemedicine has emerged as a powerful tool in the delivery of healthcare to surgical patients and enhances clinician-patient encounters during all phases of patient care. Our study aims were: to review the current use and applicability of telemedicine; evaluate its suitability, safety and effectiveness in a surgical outpatient setting, particularly in the era of social distancing restrictions and provide insight into future applications.

Methods

Databases searched included: PubMed, OVID Medline, Embase, Scopus, Web of Science and review of reference lists. Key words used were "telemedicine"; "telehealth"; "videoconference"; "outpatient" and "surgical clinic". For inclusion, articles required to be in English, published between 2000 and 2021, were in an outpatient surgical setting and if they had a focus during the COVID-19 pandemic.

Results

335 articles were identified and screened, so that 63 articles were included in the review. Almost all articles were from Western countries (n = 60), mostly in surgical journals (n = 35) and from a range of sub-specialities, but pre-dominantly orthopaedics (n = 12) and general surgery (n = 7). The majority were original comparative studies where 31 studies directly compared telemedicine to in-person appointments and 14 papers focused on implementation during COVID-19.

Discussion/conclusions

Telemedicine has been safely used across various phases of surgical outpatient care, with its effectiveness evaluated by clinical outcomes, economics and user/provider satisfaction. Telemedicine has multiple accepted benefits including time efficiency, patient/healthcare cost savings and community access, but with reported limitations of clinical uncertainty, technology infrastructure requirements, cybersecurity vulnerabilities and healthcare regulatory restraints. These limitations are being overcome by accelerated implementation during COVID-19 via fast-tracked practice development. Further work is required via development of research protocols to refine the application of emerging telemedicine technologies and their applicability to different surgical sub-specialties.

Effectiveness, Patient Satisfaction, and Cost Reduction of Virtual Joint Replacement Clinic Follow-Up of Hip and Knee Arthroplasty

BACKGROUND

Total hip and knee arthroplasties are increasingly performed operations, and routine follow-up places huge demands on orthopedic services. This study investigates the effectiveness, patients' satisfaction, and cost reduction of Virtual Joint Replacement Clinic (VJRC) follow-up of total hip arthroplasty and total knee arthroplasty patients in a university hospital. VJRC is especially valuable when in-person appointments are not advised or feasible such as during the COVID-19 pandemic.

METHODS

A total of 1749 patients who were invited for VJRC follow-up for knee or hip arthroplasty from January 2017 to December 2018 were included in this retrospective study. Patients were referred to VJRC after their 6-week postoperative review. Routine VJRC postoperative review was undertaken at 1 and 7 years and then 3-yearly thereafter. We evaluated the VJRC patient response rate, acceptability, and outcome. Patient satisfaction was measured in a subgroup of patients using a satisfaction survey. VJRC costs were calculated compared to face-to-face follow-up.

RESULTS

The VJRC had a 92.05% overall response rate. Only 7.22% required further in-person appointments with only 3% being reviewed by an orthopedic consultant. VJRC resulted in an estimated saving of £42,644 per year at our institution. The patients' satisfaction survey showed that 89.29% of the patients were either satisfied or very satisfied with VJRC follow-up.

CONCLUSION

VJRC follow-up for hip and knee arthroplasty patients is an effective alternative to in-person clinic assessment which is accepted by patients, has high patient satisfaction, and can reduce the cost to both health services and patients.

An Overview of Telehealth in Total Joint Arthroplasty

With the increase in technological advances over the years, telehealth services in orthopedic surgery have gained in popularity, yet adoption among surgeons has been slow. With the onset of the COVID-19 pandemic, however, orthopedic surgery practices nationwide have accelerated adaptation to telemedicine. Telehealth can be effectively applied to total joint arthroplasty, with the ability to perform preoperative consultations, postoperative follow-up, and telerehabilitation in a virtual, remote manner with similar outcomes to in-person visits. New technologies that have emerged, such as virtual goniometers, wearable sensors, and app-based patient questionnaires, have improved clinicians' ability to conduct telehealth visits. Benefits of using telehealth include high patient satisfaction, cost-savings, increased access to care, and more efficiency. Notably, some challenges still exist, including widespread accessibility and adaptation of new technologies, inability to conduct an in-person orthopedic physical examination, and regulatory barriers, such as insurance reimbursement, increased medicolegal risk, and privacy and confidentiality concerns. Despite these hurdles, telehealth is here to stay and can be successfully incorporated in any total joint arthroplasty practice with the appropriate adjustments.

The result of the use of remote consultation in orthopaedic and trauma surgery during the COVID-19 pandemic

The COVID pandemic has made telematic consultations a basic tool in daily practice.

Aims

The main objective of the study is to assess the results of the application of telematic consultations to limit the mobility of patients.

The operational objectives are; to propose a consultation plan, to know how attendance limits consultations and to define which pathologies benefit the most from this plan.

Methods

A scheme is proposed with the creation of pre-scheduled clinic to assess suitability and the possibility of carrying them out in a single non face-to-face act.

Results

Phone call to 5619 patients were made with a lack of response of 19%

The cases of 74% of the patients that answered were resolved virtually. There is a difference between units, obtaining a higher answering rate from patients appointed to specific clinic units, OR = 0.60, or to general trauma ones, OR = 0.67. The lowest answering rate was obtained from those derived from the emergency department.

Twenty per cent of the consultations were not accompanied by complementary tests that would have favored the resolution in a single act. The general trauma consultations, OR = 0.34, postoperative control, OR = 0.49, and specific unit ones, OR = 0.40, were the ones that better met this requirement.

Out of the remaining patients, the general trauma consultations, OR = 0.50, and those referred to units, OR = 0.54, were the ones that had a higher resolution rate without in- person consultation.

Conclusions

The cases of 74% of the patients who answered the phone call were resolved virtually.

Cases of 20% of the patients cannot be solved in a single act because they are derived without complementary tests.

Osteosynthesis and postoperative arthroscopic follow-up consultations are the ones that need to be carried out in person the most.

Evaluation of the Feasibility of a Telemedical Examination of the Hip and Pelvis - Early Lessons from the COVID-19 Pandemic

Introduction Due to the current COVID-19 pandemic, the German Health Ministry has issued restrictions applying to the field of orthopaedics and trauma surgery. Besides postponement of elective surgeries, outpatient consultations have been drastically reduced. Parallel to these developments, an increase in telemedical consultations has reflected efforts to provide sufficient patient care. This study aims to evaluate the feasibility of a clinical examination of the hip joint and pelvis by way of a telemedical consultation.

Materials and Methods Twenty-nine patients of a German university clinic were recruited and assessed in both telemedical and conventional examinations. Agreement between the two examinations was then assessed, and connections between the observed agreement and patient-specific factors such as age, BMI and ASA classification were investigated.

Results The inspections agreed closely with a mean Cohenʼs kappa of 0.76 ± 0.37. Palpation showed adequate agreement with a mean Cohenʼs kappa of 0.38 ± 0.19. Function showed good agreement with a mean Cohenʼs kappa of 0.61 ± 0.26 and range of motion showed adequate agreement with a mean Cohenʼs kappa of 0.36 ± 0.19. A significant positive correlation was observed between the number of deviations in the different examinations and age (p = 0.05), and a significant positive correlation was shown between the number of non-feasible examinations and age (p < 0.01), BMI (p < 0.01) and ASA classification score (p < 0.01).

Discussion Inspection and function can be reliably evaluated, whereas the significance of palpation, provocation and measurement of range of motion is limited. The small sample size puts limitations on the significance of a statistically relevant correlation between patient-specific factors such as age, BMI and ASA classification score and valid and successful implementation of a telemedical examination. The authors recommend targeted patient selection. If, however, patients are being evaluated who are very old (> 75 years), obese (BMI > 30) or with multiple comorbidities (ASA 3 and above), caution is advised. Large, prospective studies are needed in the future to fully validate telemedical consultations in the fields of orthopaedics and trauma surgery.

Conclusion A telemedical examination of the hip joint and pelvis can be performed with certain limitations. Patient-specific factors such as age, BMI, and extent of comorbidities appear to have a relevant impact on validity and execution of the examination. Patients with multiple comorbidities (ASA 3 and above), advanced age (> 75 years) or obesity (BMI > 30) should, whenever possible, be examined in a conventional outpatient setting.

Institutional arthroplasty registry: what is the minimum acceptable dataset to be included in your hospital? Recommendations from a single-country national consensus using the Delphi method

PURPOSE

Institutional arthroplasty registries are very popular nowadays; however, very few efforts have been made in order to standardize the information to be collected, thus limiting the possibility of inter-institutional data interpretation. This manuscript reports the results of a single-country consensus designed to define the minimum standardized dataset to be recorded within an institutional arthroplasty registry.

METHODS

A national consensus was carried out among all members of the Colombian Society of Hip and Knee Surgeons using the Delphi method. Eleven questions and answers comprising every potential domain of an institutional registry of hip and knee arthroplasty were defined. According to the methodology, anonymous voting and multiple discussion rounds were performed. Three levels of agreement were defined: Strong consensus: equal to or greater than 80%, weak consensus between 70 and 79.9%, and no consensus below 70%.

RESULTS

All of the questions reached consensus level. The minimum dataset was defined to include demographic and clinical information, intraoperative and implant details, follow-up and early complications, implant survival, and functional outcome scores, as well as the validation model to assess information quality within the database. Currently, this dataset is being implemented voluntarily by the members of our national society.

DISCUSSION

A national consensus is a feasible method to build homogeneous arthroplasty registries. We recommend such an exercise since it establishes the basis to compare and add data between institutions and the joint analysis of said information in a national registry.

Result of the implementation of telematic consultations in orthopaedic surgery and traumatology during COVID-19 laparoscopic surgery

La pandemia COVID ha hecho de las consultas telemáticas una herramienta básica en la práctica diaria. El objetivo principal del estudio es valorar los resultados de la aplicación de consultas telemáticas para limitar la movilidad de los pacientes.

Son objetivos operativos: proponer un plan de consultas, conocer cómo limita la asistencia a las consultas, definir qué patologías se benefician más con este plan.

Material y métodos

Se propone un esquema con la creación de consultas previas a las agendadas para valorar idoneidad y posibilidad de realizarla en acto único no presencial.

Resultados

Se han realizado 5.619 consultas con una falta de respuesta telefónica del 19%. El 74% de los pacientes fueron resueltos de forma virtual. Existe diferencia entre unidades, siendo más probable la respuesta telefónica para las consultas de unidad, OR = 0,60 o de traumatología general, OR = 0,67 y menos para los derivados desde urgencias.

El 20% de las consultas no se acompañaban de pruebas complementarias. Las consultas de traumatología general, OR = 0,34, control postoperatorio, OR = 0,49, y unidades, OR = 0,40, cumplieron mejor este requisito. De los pacientes restantes, las consultas de traumatología general, OR = 0,50, y las derivadas a unidades, OR = 0,54 fueron las que más se resolvieron sin acudir presencialmente.

Conclusiones

Se han resuelto de forma no presencial el 74% de los pacientes que atendieron a la llamada telefónica. El 20% de los pacientes acuden a la visita sin pruebas complementarias. Las consultas de seguimiento de osteosíntesis y postoperatorio de cirugía artroscópica son las que más precisan de ser realizadas de forma presencial.