A Patient-Focused Technology-Enabled Program Improves Outcomes in Primary Total Hip and Knee Replacement Surgery

Enhanced recovery after surgery (ERAS) in sacral tumour surgery and comprehensive description of a multidisciplinary program: a prospective study in a specialized hospital in China

PURPOSE

There were fewer data to guide the application of enhanced recovery after surgery (ERAS) theory into sacral tumour surgery. In the present study, we were aiming to describe a multidisciplinary program of ERAS and evaluate the availability in sacral tumour surgery.

METHODS

This was a prospective study of patients with sacral tumour between March 2021 and September 2021 at a single centre. We proposed a multidisciplinary program of ERAS for pre-admission, preoperative, intraoperative, postoperative, and post-discharge clinical care which positively influenced outcomes of patients with sacral tumour. All patients were prospectively assigned into two groups, ERAS group in which patients received ERAS protocols (n = 63), No-ERAS group in which patients had conventional clinical pathways (n = 62). Patient data were collected which included demographics, preoperative preparation, detailed information of surgical procedure, 60-day reoperation rate, 60-day readmission, postoperative length of stay (PLOS), time to first ambulation and flatus after surgery, time to removal of last drainage tube, and visual analogue scale (VAS) score at first ambulation and discharge. Complications referred to ones that occurred within 60 days after surgery. The above parameters were compared between ERAS group and No-ERAS group.

RESULTS

Time to first ambulation after surgery in ERAS group (mean 20.9 h) was significantly shorter than that in No-ERAS group (mean 104.3 ho). Meanwhile, time to first flatus after surgery in ERAS group (mean 26.7 h) was also significantly shorter than that in No-ERAS group (mean 37.3 h). Patients in ERAS group had statistically shorter PLOS (10.7 days) as compared to that in No-ERAS group (13.8 days). In ERAS group, 19 of 63 patients (30.2%) were discharged within seven days after surgery as compared to seven of 62 patients (11.3%) in No-ERAS group. VAS score at first ambulation in ERAS group was not obviously higher than that in No-ERAS group though the time of first ambulation in ERAS group was statistically earlier than one in No-ERAS group. Furthermore, VAS score at discharge in ERAS group was significantly lower than that in No-ERAS group. The rate of postoperative incision necrosis was 6.3% (4/63) in ERAS group and 8.1% (5/62) in No-ERAS group and all of these nine patients underwent reoperation before discharge. The difference was not statistically significant in the wound complication of incision necrosis and 60-day reoperation rate. Only one readmission occurred in No-ERAS group due to the surgical site infection and also there was no significant difference of 60-day readmission rate between these two groups. Furthermore, there was no statistical difference of complications of femoral artery thrombosis and rectal rupture between ERAS group and No-ERAS group.

CONCLUSIONS

Our proposed ERAS pathway for sacral tumour surgery and early walking facilitate safe and prompt discharge. ERAS protocols of sacral tumour surgery could decrease PLOS without significantly increasing postoperative complications, 60-day readmission rate and 60-day reoperation rate. The application of ERAS pathway in the field of sacral tumour surgery should have personalized feature with regard to resection type.

Remote Patient Monitoring Following Total Joint Arthroplasty

This review article presents the current state of remote patient monitoring (RPM) in total joint arthroplasty. RPM refers to the use of telecommunication with wearable and implantable technology to assess and treat patients. Several forms of RPM are discussed including telemedicine, patient engagement platforms, wearable devices, and implantable devices. The benefits to patients and physicians are discussed in the context of postoperative monitoring. Insurance coverage and reimbursement of these technologies are reviewed.

Comparison of a Smartphone App to Manual Knee Range of Motion Measurements

Background

Digital technology has emerged as a useful tool for preoperative and postoperative patient engagement and for remote patient monitoring. Smartphones are equipped with motion-sensing technology, and apps can be designed which use these features to create a simple method for measuring range of motion. The purpose of this study was to determine the accuracy of digital technology in assessing knee range of motion using a smartphone app, compared to traditional goniometric measurements in an office setting.

Methods

Fifty-three (53) patients in a clinical practice were enrolled between October 2019 and March 2020. Three separate measurements were taken during the patient encounter: (1) the surgeon, (2) the app, and (3) the physical therapist. Intraclass correlations were computed to assess the agreement between (1) the surgeon and app and (2) that between the physical therapist and surgeon.

Results

When measuring flexion, the correlation between either the surgeon or therapist with the app was good, whereas the comparison between the surgeon and therapist was moderate. All extension measurement comparisons, between the app, surgeon, and therapist, showed moderate correlation. Limits of agreements showed that 80% of the difference between surgeon and app is within 10 degrees for extension and 11 degrees for flexion. Body mass index did not affect the accuracy of the measurements.

Conclusion

Digital app measurements were comparable to measurements made by either a surgeon or physical therapist with a manual goniometer in the clinical setting and may be beneficial for measuring and monitoring patients’ range of motion remotely.

A Cadaveric Study Addressing the Feasibility of Remote Patient Monitoring Prosthesis for Total Knee Arthroplasty

BACKGROUND

Since the COVID-19 pandemic of 2020, there has been a marked rise in the use of telemedicine to evaluate patients after total knee arthroplasty (TKA). The purpose of our study was to assess a novel stem with an embedded sensor that can remotely and objectively monitor a patient's mobility after TKA.

METHODS

A single anatomically designed knee system was implanted in concert with an interconnected tibial stem extension containing 3D accelerometers, 3D gyroscopes, a power source, and a telemetry transmission capability in 3 cadaveric pelvis to toe specimens. The legs were moved by hand to preset tibial positions at full knee extension, midflexion, flexion, and back to midflexion and extension for a total of 16 trials across 6 knees.

RESULTS

Sensor data were successfully transmitted with good quality of signal to an external base station. Good correlation to the range of motion of the tibia was found (mean error 0.1 degrees; root mean square error 3.8 degrees). The signal from the heel drop tests suggests the sensor could detect heel strike during activities of daily living in vivo and the potential for additional signal processing to analyze vibratory and motion patterns detected by the sensors. A frequency domain analysis of a properly cemented and poorly cemented implant during the heel drop test suggests a difference in accelerometer signal in these implant states.

CONCLUSION

The results confirm signals generated from an embedded TKA sensor can transmit through bone and cement, providing accurate range of motion data and may be capable of detecting changes in prosthesis fixation remotely.

Do Patient Engagement Platforms in Total Joint Arthroplasty Improve Patient-Reported Outcomes?

BACKGROUND

Web-based patient engagement portals are increasing in popularity after total hip and knee arthroplasty (THA and TKA). The literature is mixed regarding patient utilization of these modalities and potential clinical benefit. We sought to determine which demographic factors are associated with increased platform participation and to quantify the impact of a web-based patient portal on patient-reported outcome measures (PROMs).

METHODS

We performed a retrospective analysis of consecutive primary THA (n = 554) and TKA (n = 485) at a single academic institution with minimum follow-up of 12 months. Patients were divided into those who opted-in and those who opted-out of portal use. Global health and joint-specific PROMs were collected preoperatively and postoperatively. Linear mixed effects modeling, bivariate analysis, and logistic regression were utilized.

RESULTS

Of the 1039 included patients, 60.6% (336) THA and 62.7% (304) TKA patients enrolled in the portal. Those who opted-in were younger (P < .001, P < .003), had higher body mass index (P = .024, P = .011), and had a higher household income (P < .001, P < .001) in THA and TKA cohorts, respectively. Portal participation in the TKA but not the THA cohort was associated with significant improvement in physical function (P = .017) and joint-specific function (P = .045). For THA patients who opted-in, increased portal logins were associated with more rapid improvement and higher functional scores (P = .013).

CONCLUSION

There is an inherent difference between patients who opt-in to and those who opt-out of web-based portals. Added resources and support provided by portals may translate to improved PROMs for TKA patients but not THA patients.

Patient Engagement Approaches in Total Joint Arthroplasty: A Review of Two Decades

Patient engagement is a comprehensive approach to health care where the physician inspires confidence in the patient to be involved in their own care. Most research studies of patient engagement in total joint arthroplasty (TJA) have come in the past 5 years (2015-2020), with no reviews investigating the different patient engagement methods in TJA. The primary purpose of this review is to examine patient engagement methods in TJA. The search identified 31 studies aimed at patient engagement methods in TJA. Based on our review, the conclusions therein strongly suggest that patient engagement methods in TJA demonstrate benefits throughout care delivery through tools focused on promoting involvement in decision making and accessible care delivery (eg, virtual rehabilitation, remote monitoring). Future work should understand the influence of social determinants on patient involvement in care, and overall cost (or savings) of engagement methods to patients and society.

Application of Machine Learning Methods on Patient Reported Outcome Measurements for Predicting Outcomes: A Literature Review

The field of patient-centred healthcare has, during recent years, adopted machine learning and data science techniques to support clinical decision making and improve patient outcomes. We conduct a literature review with the aim of summarising the existing methodologies that apply machine learning methods on patient-reported outcome measures datasets for predicting clinical outcomes to support further research and development within the field. We identify 15 articles published within the last decade that employ machine learning methods at various stages of exploiting datasets consisting of patient-reported outcome measures for predicting clinical outcomes, presenting promising research and demonstrating the utility of patient-reported outcome measures data for developmental research, personalised treatment and precision medicine with the help of machine learning-based decision-support systems. Furthermore, we identify and discuss the gaps and challenges, such as inconsistency in reporting the results across different articles, use of different evaluation metrics, legal aspects of using the data, and data unavailability, among others, which can potentially be addressed in future studies.

Impact of Patient Engagement on Tailored Education for Joint Replacement Population Using Technology

Patient engagement and technology use for healthcare are important for optimal care. This study was designed to leverage technology in education among the adult joint population based on their engagement capacity and utilization of technology for care. A convenience sample of 80 patients undergoing joint replacement surgery and followed in the inpatient setting participated. Comparisons were made between an intervention group who completed the Person Engagement Index to measure their engagement capacity and received a technological educational plan based on their score versus those receiving the standard educational plan. The Person Engagement Index psychometrics were sound and indicated high engagement capacity. Overall, the groups did not differ in utilization, satisfaction, and education comprehension; however, the intervention group reported a higher unit mean for the extent they felt ready for discharge and instructions for care at home. Results of this study informed patients' engagement capacity and technology use for pre-/postoperative education for procedure expectations and self-management throughout the joint replacement process and recovery. Future research includes use of technology for engagement capacity and outcomes with other populations, collecting socio-demographic data to determine differences among groups and examining the patient and provider experience and satisfaction with using technology to enhance care and outcomes.

Consensus on pre-operative total knee replacement education and prehabilitation recommendations: a UK-based modified Delphi study

BACKGROUND

Over 90,000 total knee replacement (TKR) procedures are performed annually in the United Kingdom (UK). Patients awaiting TKR face long delays whilst enduring severe pain and functional limitations. Almost 20% of patients who undergo TKR are not satisfied post-operatively. Optimising pre-operative TKR education and prehabilitation could help improve patient outcomes pre- and post-operatively; however, current pre-operative TKR care varies widely. Definitive evidence on the optimal content and delivery of pre-operative TKR care is lacking. This study aimed to develop evidence- and consensus-based recommendations on pre-operative TKR education and prehabilitation.

METHODS

A UK-based, three-round, online modified Delphi study was conducted with a 60-member expert panel. All panellists had experience of TKR services as patients (n = 30) or professionals (n = 30). Round 1 included initial recommendations developed from a mixed methods rapid review. Panellists rated the importance of each item on a five-point Likert scale. Panellists could also suggest additional items in Round 1. Rounds 2 and 3 included all items from Round 1, new items suggested in Round 1 and charts summarising panellists' importance ratings from the preceding round. Free-text responses were analysed using content analysis. Quantitative data were analysed descriptively. All items rated as 'Important' or 'Very important' by at least 70% of all respondents in Round 3 were included in the final set of recommendations.

RESULTS

Fifty-five panellists (92%) (patients n = 26; professionals n = 29) completed Round 3. Eighty-six recommendation items were included in Round 1. Fifteen new items were added in Round 2. Rounds 2 and 3 therefore included 101 items. Seventy-seven of these reached consensus in Round 3. Six items reached consensus amongst patient or professional panellists only in Round 3. The final set of recommendations comprises 34 education topics, 18 education delivery approaches, 10 exercise types, 13 exercise delivery approaches and two other treatments.

CONCLUSIONS

This modified Delphi study developed a comprehensive set of recommendations that represent a useful resource for guiding decision-making on the content and delivery of pre-operative TKR education and prehabilitation. The recommendations will need to be interpreted and reviewed periodically in light of emerging evidence.

Emergency Department Presentation After Total Hip and Knee Arthroplasty: A Systematic Review

BACKGROUND

Recent changes to payment models for elective total joint arthroplasty (TJA) have led to increased interest in postdischarge health care utilization. Although readmission has historically been of primary interest, emergency department (ED) presentation is increasingly a point of focus. The purpose of this review was to summarize the available literature pertaining to ED visits after total hip arthroplasty and total knee arthroplasty.

METHODS

PubMed, MEDLINE, and Embase were searched. Clinical studies reporting rate, reasons, and/or risk factors associated with ED presentation after TJA were included. Pooled return to ED rates were calculated using weighted means.

RESULTS

Twenty-seven studies (n = 1,484,043) were included. After TJA, the mean 30-day and 90-day rates of ED presentation were 8.1% and 10.3%, respectively. Rates were slightly higher in total knee arthroplasty vs total hip arthroplasty patients at 30 days (11.5% vs 6.5%) and 90 days (10.8% vs 9.7%). The most common reasons for ED presentation after TJA were pain (4.6%-35%), medical concerns (5.6%-24.5%), and swelling (1.4%-17.5%). Studies analyzing the timing of ED visits found that most occurred within the first 2 weeks postdischarge. Black race and Medicaid/Medicare insurance coverage were identified as risk factors associated with ED visits.

CONCLUSION

ED visits present a high burden for the health care system, as upward of 1 in 10 patients will return to the ED within 90 days of TJA. Future efforts should be made to develop cost-effective and patient-centered interventions that reduce preventable ED visits after TJA. As well, these rates should be taken into consideration when allocating resources for the care of TJA patients.

Using Patient Engagement Platforms in the Postoperative Management of Patients

PURPOSE OF REVIEW

The purpose of this review is to contextualize the topic of patient engagement in orthopedic surgery. There will be a specific focus on patient engagement platforms and the impact on outcomes and orthopedic clinical workflows.

RECENT FINDINGS

In an attempt to engage patients and optimize the orthopedic perioperative surgical home, patient engagement platforms have emerged in the form of portals, mobile health applications, and chatbots. Collectively, these platforms have improved patient satisfaction scores and outcomes. Patient portals, mobile health applications, and chatbots can engage orthopedic patients and improve the effectiveness of the perioperative orthopedic surgical home. There are specific differences in these applications that should be noted and accounted for. When deciding to incorporate one of these systems into your practice, it is paramount to identify what you are looking to improve upon within your health system and choose a platform accordingly.

Advanced decision-making using patient-reported outcome measures in total joint replacement

Up to one-third of total joint replacement (TJR) procedures may be performed inappropriately in a subset of patients who remain dissatisfied with their outcomes, stressing the importance of shared decision-making. Patient-reported outcome measures capture physical, emotional, and social aspects of health and wellbeing from the patient's perspective. Powerful computer systems capable of performing highly sophisticated analysis using different types of data, including patient-derived data, such as patient-reported outcomes, may eliminate guess work, generating impactful metrics to better inform the decision-making process. We have created a shared decision-making tool which generates personalized predictions of risks and benefits from TJR based on patient-reported outcomes as well as clinical and demographic data. We present the protocol for a randomized controlled trial designed to assess the impact of this tool on decision quality, level of shared decision-making, and patient and process outcomes. We also discuss current concepts in this field and highlight opportunities leveraging patient-reported data and artificial intelligence for decision support across the care continuum.