Mobile Application Use and Patient Engagement in Total Hip and Knee Arthroplasty

» Mobile applications (MAs) are widely available for use during the perioperative period and are associated with increased adherence to rehabilitation plans, increased satisfaction with care, and considerable cost savings when used appropriately.» MAs offer surgeons and health care stakeholders the ability to collect clinical data and quality metrics that are important to value-based reimbursement models and clinical research.» Patients are willing to use wearable technology to assist with data collection as part of MAs but prefer it to be comfortable, easy to apply, and discreet.» Smart implants have been developed as the next step in MA use and data collection, but concerns exist pertaining to patient privacy and cost.» The ongoing challenge of MA standardization, validation, equity, and cost has persisted as concerns regarding widespread use.

Fixation Strategies for Periprosthetic Fractures With Stable Implants

The fixation of periprosthetic fractures remains challenging and controversial. It is important to achieve consensus opinions regarding the management of stable periprosthetic fractures with internal fixation. Key strategies to optimize surgical decision making and fixation and manage complications following these difficult injuries are addressed.

The Impact of the COVID-19 Pandemic on the Practice of Hip and Knee Arthroplasty

» The COVID-19 global pandemic resulted in unprecedented disruptions in care including massive surgical cancelations, a shift to outpatient surgery, and novel medical risks posed by COVID-19 infection on patients undergoing joint replacement surgery.» Refined patient optimization pathways have facilitated safe, efficient outpatient total joint arthroplasty in patient populations that may not otherwise have been considered eligible.» Rapid innovations emerged to deliver care while minimizing the risk of disease transmission which included the widespread adoption of telemedicine and virtual patient engagement platforms.» The widespread adoption of virtual technology was similarly expanded to resident education and continuing medical activities, which has improved our ability to propagate knowledge and increase access to educational initiatives.» Novel challenges borne of the pandemic include profound personnel shortages and supply chain disruptions that continue to plague efficiencies and quality of care in arthroplasty and require creative, sustainable solutions.

The influence of the COVID-19 pandemic on total hip and knee arthroplasty in Ontario: a population-level analysis

BACKGROUND

The effects of the COVID-19 pandemic on elective orthopedic surgery have yet to be reported at the population level in Canada. We sought to detail the effect of the pandemic on patients who underwent total hip arthroplasty (THA) and total knee arthroplasty (TKA), and on surgeons with respect to surgical volume, wait times and health care quality.

METHOD

We compared patient length of hospital stay, revisions, readmissions and emergency department presentations between pre-pandemic (April 2019 to February 2020) and postpandemic (April 2020 to February 2021) cohorts of patients who underwent inpatient THAs or TKAs. Wait times for THA and TKA in Ontario were similarly collected.

RESULTS

Case volumes for THA and TKA decreased by 30% during the pandemic. There were significantly fewer medically complex cases during this time period (p < 0.001). Length of hospital stay was reduced from 2.2 to 1.8 days (p < 0.001). Patients were less likely to visit the emergency department within 30 days of surgery (p < 0.001). Patients who underwent TKA were also more likely to be discharged directly home (p = 0.025). There was no difference in rate of revision surgery or readmission within 30 days. The proportion of patients meeting the standard benchmark wait time in Ontario was significantly lower (p < 0.001). The corresponding wait time to treatment increased significantly (p < 0.001).

CONCLUSION

The effects of the COVID-19 pandemic on elective THA and TKA case volumes and wait times was significant. Patients having surgery during the pandemic were less medically complex, had shorter length of hospital stays and had significantly less health care utilization.

Hemiarthroplasty for Unstable Intertrochanteric Hip Fractures: A Matched Cohort Study

BACKGROUND

Geriatric intertrochanteric fractures remain a major public health concern due to the considerable disability, morbidity, mortality, and health care costs associated with these injuries. The underlying poor bone quality and unstable nature of these fractures makes them difficult to treat. The main purpose of this study was to evaluate the outcome of hemiarthroplasty for unstable intertrochanteric hip fractures when compared to the traditional treatment options of open reduction internal fixation (ORIF).

METHODS

A retrospective 1:1 matched cohort of 150 patients who had intertrochanteric fractures treated with either hemiarthroplasty or ORIF was developed using a local institutional database. Demographic, perioperative, and postoperative variables were collected with at least 1 year of patient follow-up. Statistical analyses were performed with use of Student's t-tests, chi-square tests, and analysis of variance.

RESULTS

Unstable intertrochanteric fractures treated with ORIF were associated with significantly more blood loss and an increased need for revision surgery. This effect was most pronounced in Arbeitsgemeinschaft für Osteosynthesefragen Orthopaedic Trauma Association classification type 31.A3 fractures, as patients treated with ORIF experienced significantly slower postoperative mobilization, increased blood loss, increased readmission, and revision surgery rates. Hemiarthroplasty was associated with an increased risk of greater trochanter escape, which did not appear to effect outcomes in this subset of patients.

CONCLUSION

Hemiarthroplasty may improve outcomes for patients with unstable intertrochanteric fractures. The benefit of this technique is likely maximized in Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association type 31.A3 fractures. It remains a good option in the hands of experienced surgeons.

Bundled Care in Elective Total Joint Replacement: Payment Models in Sweden, Canada, and the United States: A Critical Analysis Review

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Rising health-care expenditures and payer dissatisfaction with traditional models of reimbursement have driven an interest in alternative payment model initiatives.

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Bundled payments, an alternative payment model, have been introduced for total joint replacement in Sweden, the United States, and Canada to help to curb costs, with varying degrees of success.

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Outpatient total knee arthroplasty and total hip arthroplasty are becoming increasingly common and provide value for patients and payers, but have negatively impacted providers participating in bundled payment models due to considerable losses and decreased reimbursement.

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A fine balance exists between achieving cost savings for payers and enticing participation by providers in bundled payment models.

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The design of each model is key to payer, provider, and patient satisfaction and should feature comprehensive coverage for a full cycle of care whether it is in the inpatient or outpatient setting, is linked to quality and patient-reported outcomes, features appropriate risk adjustment, and sets limits on responsibility for unrelated complications and extreme outlier events.

Appraisal and patient-reported outcomes following total hip arthroplasty: a longitudinal cohort study

Background

Total hip arthroplasty (THA) is a successful procedure that provides pain relief, restores function, and improves quality of life (QOL) for patients with advanced arthritis in their hip joint. To date, little research has examined the role of cognitive appraisal processes in THA outcomes. This study examined the role of cognitive appraisal processes in THA outcomes in the first year post-surgery.

Methods

This longitudinal cohort study collected data at pre-surgery, 6 weeks post-surgery, 3 months post-surgery, and 12 months post-surgery. Adults (n = 189) with a primary diagnosis of osteoarthritis were consecutively recruited from an active THA practice at a Canadian academic teaching hospital. Measures included the Hip Disability and Osteoarthritis Outcome Score (HOOS), the Mental Component Score (MCS) of the Rand-36, and the Brief Appraisal Inventory (BAI). Analysis of Variance examined the association between BAI items and the HOOS or MCS scores. Random effects models investigated appraisal main effects and appraisal-by-time interactions for selected BAI items.

Results

HOOS showed great improvement over the first 12 months after THA, and was mitigated by three appraisal processes in particular: focusing on problems with healthcare or living situation, and preparing one’s family for health changes. MCS was stable and low over time, and the following appraisal processes were implicated by very large effect sizes: not comparing themselves to healthier people, focusing on money problems, preparing their family for their health changes, or trying to shed responsibilities.

Conclusions

Appraisal processes are relevant to health outcomes after THA, with different processes coming into play at different points in the recovery trajectory.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00498-z.

Late-Onset Radial Nerve Palsy in the Setting of Humeral Shaft Hypertrophic Nonunion: A Case Report

CASE

A 67-year-old woman presented 9 months after a closed midshaft humerus fracture with a new onset radial nerve palsy. Radiographs demonstrated a hypertrophic nonunion. Upon exploration, the radial nerve was in continuity and entrapped in fracture callus. It was extricated from the callus, and an open reduction and plate fixation was performed. Full radial nerve function returned by 3 months.

CONCLUSION

We recommend that delayed onset radial nerve palsies be treated on a semiurgent basis with radial nerve exploration and decompression followed by internal fixation to achieve primary bone healing and minimize fracture callus formation.

Articular reductions - how close is close enough? A narrative review

Intra-articular fractures are a unique subset of fractures as they involve a varying extent of damage to cartilage. The impact of this articular fracture causes significant microscopic and macroscopic changes, as well as biomechanical irregularities, which can lead to further cartilage damage, and ultimately cascade down the dreaded path to arthritis. It is generally believed that an anatomic reduction of an articular fracture is the necessary goal of treatment for these injuries, however it yet to be delineated how perfect this reduction has to be. A comprehensive literature review was carried out to create a best available evidence guide to the acceptability of upper extremity and lower extremity articular fracture reductions. Ultimately, a perfect anatomic reduction is the best strategy to minimize abnormal loading and wear patterns, however this should be balanced with the realistic factors of each individual case, such as the level of difficulty, joint involved, surgical timing, and patient activity levels.

Diagnostic Accuracy of Serum, Synovial, and Tissue Testing for Chronic Periprosthetic Joint Infection After Hip and Knee Replacements: A Systematic Review

BACKGROUND

Chronic periprosthetic joint infection (PJI) is a devastating complication that can occur following total joint replacement. Patients with chronic PJI report a substantially lower quality of life and face a higher risk of short-term mortality. Establishing a diagnosis of chronic PJI is challenging because of conflicting guidelines, numerous tests, and limited evidence. Delays in diagnosing PJI are associated with poorer outcomes and morbid revision surgery. The purpose of this systematic review was to compare the diagnostic accuracy of serum, synovial, and tissue-based tests for chronic PJI.

METHODS

This review adheres to the Cochrane Collaboration's diagnostic test accuracy methods for evidence searching and syntheses. A detailed search of MEDLINE, Embase, the Cochrane Library, and the grey literature was performed to identify studies involving the diagnosis of chronic PJI in patients with hip or knee replacement. Eligible studies were assessed for quality and bias using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Meta-analyses were performed on tests with sufficient data points. Summary estimates and hierarchical summary receiver operating characteristic (HSROC) curves were obtained using a bivariate model.

RESULTS

A total of 12,616 citations were identified, and 203 studies met the inclusion criteria. Of these 203 studies, 170 had a high risk of bias. Eighty-three unique PJI diagnostic tests were identified, and 17 underwent meta-analyses. Laboratory-based synovial alpha-defensin tests and leukocyte esterase reagent (LER) strips (2+) had the best performance, followed by white blood-cell (WBC) count, measurement of synovial C-reactive protein (CRP) level, measurement of the polymorphonuclear neutrophil percentage (PMN%), and the alpha-defensin lateral flow test kit (Youden index ranging from 0.78 to 0.94). Tissue-based tests and 3 serum tests (measurement of interleukin-6 [IL-6] level, CRP level, and erythrocyte sedimentation rate [ESR]) had a Youden index between 0.61 to 0.75 but exhibited poorer performance compared with the synovial tests mentioned above.

CONCLUSIONS

The quality of the literature pertaining to chronic PJI diagnostic tests is heterogeneous, and the studies are at a high risk for bias. We believe that greater transparency and more complete reporting in studies of diagnostic test results should be mandated by peer-reviewed journals. The available literature suggests that several synovial fluid-based tests perform well for diagnosing chronic PJI and their use is recommended in the work-up of any suspected case of chronic PJI.

LEVEL OF EVIDENCE

Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Early surgery of multiligament knee injuries may yield better results than delayed surgery: a systematic review

Importance

Multiligament knee injuries are rare, but can lead to significant functional limitations. Surgery has been shown to improve outcomes, however, there remains considerable debate regarding the optimal timing of surgery.

Objective

We aimed to determine whether early surgery in the setting of a multiligamentous knee injury was associated with superior functional outcomes when compared with surgery on a delayed basis.

Evidence review

A comprehensive literature search of the MEDLINE, EMBASE and PubMed databases was conducted up to March 2018. We identified studies with a sample size greater than 10 that included subjects with an injury to at least two of the four major knee ligaments and compared outcomes between early and delayed surgery. We assessed the methodological quality of each included study using the Newstead-Ottawa Scale.

Findings

We identified 11 eligible studies, including a total of 320 patients (195 early and 125 delayed). The mean time to surgery among patients treated early was 11.2 days in comparison to 294.8 days for the delayed group. Early surgery was found to have a statistically significantly higher Lysholm score (p<0.0001) and Meyers rating (p=0.02) when compared with delayed surgery. No statistically significant differences in International Knee Documentation Committee, Tegner Activity Scale, total arc of motion, loss of extension or loss of flexion were demonstrated between early and delayed surgery. Early surgery was noted to have a statistically significantly higher odds of requiring a manipulation under anaesthesia or arthrolysis (p=0.04), however, subsequent subgroup analysis showed no difference between early and delayed surgery when only studies employing an early range of motion protocol were pooled.

Conclusions and relevance

Based on the current body of literature, which primarily consists of level IV evidence, early surgery in the setting of multiligament knee injury may provide better functional outcomes without compromising range of motion when using early postoperative mobilisation protocols. Further studies of higher quality are required to corroborate these findings.

Level of evidence

Level IV, systematic review.