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Mun JS, Parry MW, Tang A, Manikowski JJ, Crinella C, Mercuri JJ. Patient "No-Show" Increases the Risk of 90-Day Complications Following Primary Total Knee Arthroplasty: A Retrospective Cohort Study of 6,776 Patients. J Arthroplasty 2023; 38:2587-2591.e2. [PMID: 37295624 DOI: 10.1016/j.arth.2023.05.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 05/29/2023] [Accepted: 05/31/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Patients who "no-show" (NS) clinical appointments are at a high risk of adverse health outcomes. The objective of this study was to evaluate and characterize the relationship between NS visits prior to primary total knee arthroplasty (TKA) and 90-day complications after TKA. METHODS We retrospectively reviewed 6,776 consecutive patients undergoing primary TKA. Study groups were separated based on whether patients who NS versus always attended their appointment. A NS was defined as an intended appointment that was not canceled or rescheduled ≤2 hours before the appointment in which the patient did not show. Data collected included total number of follow-up appointments prior to surgery, patient demographics, comorbidities, and 90-day postoperative complications. RESULTS Patients who have ≥3 NS appointments had 1.5 times increased odds of a surgical site infection (odds ratio (OR) 1.54, P = .002) compared to always attended patients. Patients who were ≤65 years old (OR: 1.41, P < .001), smokers (OR: 2.01, P < .001), and had a Charlson comorbidity index ≥3 (OR: 4.48, P < .001) were more likely to miss clinical appointments. CONCLUSION Patients who have ≥3 NS appointments prior to TKA had an increased risk for surgical site infection. Sociodemographic factors were associated with higher odds of missing a scheduled clinical appointment. These data suggest that orthopaedic surgeons should consider NS data as an important clinical decision-making tool to assess risk for postoperative complications to minimize complications following TKA.
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Affiliation(s)
- Jeffrey S Mun
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
| | - Matthew W Parry
- Geisinger Musculoskeletal Institute, Division of Adult Reconstruction, Scranton, Pennsylvania
| | - Alex Tang
- Geisinger Musculoskeletal Institute, Division of Adult Reconstruction, Scranton, Pennsylvania
| | - Jesse J Manikowski
- Geisinger Cancer Institute - Center for Oncology Research and Innovation, Danville, Pennsylvania
| | - Cory Crinella
- Geisinger Musculoskeletal Institute, Division of Adult Reconstruction, Scranton, Pennsylvania
| | - John J Mercuri
- Geisinger Musculoskeletal Institute, Division of Adult Reconstruction, Scranton, Pennsylvania
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Luciani AM, Parry M, Udoeyo IF, Suk M, Mercuri JJ, DelSole EM. Physician Perspectives on Telemedicine at an Integrated Health System During the COVID-19 Pandemic. Telemed J E Health 2023; 29:1634-1641. [PMID: 36961394 DOI: 10.1089/tmj.2022.0184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
Introduction: The use of telemedicine (TM) for patient care greatly increased during the COVID pandemic. This study presents data from a single health system regarding physician's perspectives on TM, which could ultimately determine how it is used in the future. Methods: A questionnaire was distributed to physicians throughout the health system. Physicians were divided based on the standard level of patient interaction in each specialty, as well as practice locations and years in practice. Physician perspectives were categorized by their opinions on different aspects of telehealth visits. Results: Of 1,794 physicians, 379 (20.7%) responded to the survey. Psychiatrists used TM significantly more than other groups and project the most future use. Surgeons were least likely to incorporate TM in the future. Ability to perform a physical examination via TM differed significantly by specialty and practice environment, but not by years in practice. Frequency of being able to complete a treatment plan via TM differed significantly by specialty, but not by years in practice or practice environment. Overall, 76.3% of physicians reported feeling "satisfied" with performing TM visits. Satisfaction with TM varied significantly by specialty and practice environment, but not by years in practice. There were no significant differences regarding physician expectations on reimbursement or billing for TM visits based on specialty, age, or practice environment. Conclusions: Discrepancies exist among physicians with respect to their satisfaction and expected future use of TM. Consensus may be difficult to reach regarding reimbursement for these visits, and further work is needed to clarify the optimal practice setting for TM.
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Affiliation(s)
- A Michael Luciani
- Department of Orthopedic Surgery, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Matthew Parry
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Idorenyin F Udoeyo
- Department of Orthopedic Surgery, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Michael Suk
- Department of Orthopedic Surgery, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - John J Mercuri
- Geisinger Community Medical Center, Scranton, Pennsylvania, USA
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Tarwala R, Mercuri JJ, Iorio R, Karkare N. Ethical Considerations in Total Joint Arthroplasty. J Am Acad Orthop Surg 2023; 31:1001-1008. [PMID: 37561941 DOI: 10.5435/jaaos-d-22-00941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 07/03/2023] [Indexed: 08/12/2023] Open
Abstract
Hip and knee arthroplasty surgeries have excellent outcomes and notably improve quality of life. However, ethical issues permeate the practice of adult reconstruction, and as economics and technology evolve, these issues have become increasingly important. This article will review the currently published literature on ethical issues including industry influences, implants and instrumentations, surgical innovation, new technology adoptions, and healthcare policy-relevant issues, including patient cost sharing and bundled care programs. In addition, the direct marketing of implants from the manufacturer to the general public may falsely raise patient expectations concerning the long-term clinical outcome and performance of newer devices in the absence of long-term studies. This article will also focus on relevant contemporary ethical issues that do not necessarily have preexisting published literature or guidelines but, nonetheless, are crucial for adult reconstruction surgeons to address. These issues include access to care and challenges with orthopaedic resident and fellow education. Surgeons must understand the ethical issues that can arise in their clinical practice and how those issues affect patients. Clinicians are tasked with making the best-reasoned judgment possible to optimize their patients' outcomes. Still, the ability to standardize treatment while optimizing individual outcomes for unique patients remains a challenge.
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Affiliation(s)
- Rupesh Tarwala
- From the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY (Tarwala), the Division of Adult Hip and Knee Reconstruction, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Scranton, PA (Mercuri), the Harvard Medical School, Brigham and Women's Hospital, Boston, MA (Iorio), and Lenox Hill Hospital, New York, NY (Karkare)
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Bieganowski T, Buchalter DB, Singh V, Mercuri JJ, Aggarwal VK, Rozell JC, Schwarzkopf R. Bone loss in aseptic revision total knee arthroplasty: management and outcomes. Knee Surg Relat Res 2022; 34:30. [PMID: 35725586 PMCID: PMC9208118 DOI: 10.1186/s43019-022-00158-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 05/21/2022] [Indexed: 12/04/2022] Open
Abstract
Background Although several techniques and implants have been developed to address bone loss in revision total knee arthroplasty (rTKA), management of these defects remains challenging. This review article discusses the indications and management options of bone loss following total knee arthroplasty based on preoperative workup and intraoperative findings. Main text Various imaging modalities are available that can be augmented with intraoperative examination to provide a clear classification of a bony defect. For this reason, the Anderson Orthopaedic Research Institute (AORI) classification is frequently used to guide treatment. The AORI provides a reliable system by which surgeons can classify lesions based on their size and involvement of surrounding structures. AORI type I defects are managed with cement with or without screws as well as impaction bone grafting. For AORI type IIA lesions, wedge or block augmentation is available. For large defects encompassing AORI type IIB and type III defects, bulk allografts, cones, sleeves, and megaprostheses can be used in conjunction with intramedullary stems. Conclusions Treatment of bone loss in rTKA continues to evolve as different techniques and approaches have been validated through short- and mid-term follow-up. Extensive preoperative planning with imaging, accurate intraoperative evaluation of the bone loss, and comprehensive understanding of all the implant options available for the bone loss are paramount to success.
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Tang A, Singh V, Sharan M, Roof MA, Mercuri JJ, Meftah M, Schwarzkopf R. The accuracy of component positioning during revision total hip arthroplasty using 3D optical computer-assisted navigation. Eur J Orthop Surg Traumatol 2022:10.1007/s00590-022-03383-z. [PMID: 36074304 DOI: 10.1007/s00590-022-03383-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 08/28/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Despite the excellent outcomes associated with primary total hip arthroplasty (THA), implant failure and revision continue to burden the healthcare system. The use of computer-assisted navigation (CAN) offers the potential for more accurate placement of hip components during surgery. While intraoperative CAN systems have been shown to improve outcomes in primary THA, their use in the context of revision total hip arthroplasty (rTHA) has not been elucidated. We sought to investigate the validity of using CAN during rTHA. METHODS A retrospective analysis was performed at an academic medical institution identifying all patients who underwent rTHA using CAN from 2016-2019. Patients were 1:1 matched with patients undergoing rTHA without CAN (control) based on demographic data. Cup anteversion, inclination, change in leg length discrepancy (ΔLLD) and change in femoral offset between pre- and post-operative plain weight-bearing radiographic images were measured and compared between both groups. A safety target zone of 15-25° for anteversion and 30-50° for inclination was used as a reference for precision analysis of cup position. RESULTS Eighty-four patients were included: 42 CAN cases and 42 control cases. CAN cases displayed a lower ΔLLD (5.74 ± 7.0 mm vs 9.13 ± 7.9 mm, p = 0.04) and greater anteversion (23.4 ± 8.53° vs 19.76 ± 8.36°, p = 0.0468). There was no statistical difference between the proportion of CAN or control cases that fell within the target safe zone (40% vs 20.9%, p = 0.06). Femoral offset was similar in CAN and control cases (7.63 ± 5.84 mm vs 7.14 ± 4.8 mm, p = 0.68). CONCLUSION Our findings suggest that the use of CAN may improve accuracy in cup placement compared to conventional methodology, but our numbers are underpowered to show a statistical difference. However, with a ΔLLD of ~ 3.4 mm, CAN may be useful in facilitating the successful restoration of pre-operative leg length following rTHA. Therefore, CAN may be a helpful tool for orthopedic surgeons to assist in cup placement and LLD during complex revision cases.
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Affiliation(s)
- Alex Tang
- Department of Orthopedic Surgery, NYU Langone Orthopedic Health, 301 East 17th Street, New York, NY, 10003, USA
- Department of Orthopaedic Surgery, Geisinger Health, Scranton, PA, USA
| | - Vivek Singh
- Department of Orthopedic Surgery, NYU Langone Orthopedic Health, 301 East 17th Street, New York, NY, 10003, USA
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Mohamad Sharan
- Department of Orthopedic Surgery, NYU Langone Orthopedic Health, 301 East 17th Street, New York, NY, 10003, USA
| | - Mackenzie A Roof
- Department of Orthopedic Surgery, NYU Langone Orthopedic Health, 301 East 17th Street, New York, NY, 10003, USA
| | - John J Mercuri
- Department of Orthopaedic Surgery, Geisinger Health, Scranton, PA, USA
| | - Morteza Meftah
- Department of Orthopedic Surgery, NYU Langone Orthopedic Health, 301 East 17th Street, New York, NY, 10003, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Orthopedic Health, 301 East 17th Street, New York, NY, 10003, USA.
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Abstract
Planning for total hip arthroplasty (THA) has traditionally been performed using static supine anteroposterior radiographs of the pelvis. Recent advances in imaging technology and the understanding of human spinopelvic kinematics have made weight-bearing radiography an important adjunct to supine imaging. Hip surgeons can use weight-bearing imaging to optimize THA component position to prevent hip instability and early component wear. The goal of this narrative review is to delineate the fundamentals of spinopelvic kinematics, the benefits of surgical planning using weight-bearing radiography, and the underpinnings of upright full-body stereoradiography as a useful adjunct to traditional supine radiographs.
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Affiliation(s)
- Edward M DelSole
- Division of Spine Surgery, Geisinger Musculoskeletal Institute, Scranton, Pennsylvania
| | - John J Mercuri
- Division of Adult Reconstruction, Geisinger Musculoskeletal Institute, Scranton, Pennsylvania
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Mercuri JJ, Schwarzkopf R. Coronal and Sagittal Balancing of Total Knee Arthroplasty Old Principles and New Technologies. Bull Hosp Jt Dis (2013) 2019; 77:45-52. [PMID: 30865864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The number of total knee arthroplasties performed in the United States is growing, and a leading cause of failure is postoperative knee instability from suboptimal coronal or sagittal balancing. This article reviews native knee anatomy as well as several guiding principles of total knee arthroplasty such as limb axis, femoral referencing, and implant constraint. Next, techniques that can be used by the surgeon to achieve ideal sagittal balance and coronal balance are discussed in detail. Finally, due to the growing use of computer and robotic technologies in knee replacement, the impact of advanced technologies on total knee arthroplasty balancing and alignment is reviewed. An in-depth understanding of these topics will enable surgeons to optimize the outcome of their total knee arthroplasty patients.
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Affiliation(s)
- John J Mercuri
- 1Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, NY
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Affiliation(s)
- John J Mercuri
- 1Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, NY
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Abstract
All orthopedic surgeons face moral dilemmas on a regular basis; however, little has been written about the moral dilemmas that are encountered when providing orthopedic care to pediatric patients and their families. This article aims to provide surgeons with a better understanding of how bioethics and professionalism apply to the care of their pediatric patients. First, several foundational concepts of both bioethics and professionalism are summarized, and definitions are offered for 16 important terms within the disciplines. Next, some of the unique aspects of pediatric orthopedics as a subspecialty are reviewed before engaging in a discussion of 5 common moral dilemmas within the field. Those dilemmas include the following: (1) obtaining informed consent and assent for either surgery or research from pediatric patients and their families; (2) performing cosmetic surgery on pediatric patients; (3) caring for pediatric patients with cognitive or physical impairments; (4) caring for injured pediatric athletes; and (5) meeting the demand for pediatric orthopedic care in the United States. Pertinent considerations are reviewed for each of these 5 moral dilemmas, thereby better preparing surgeons for principled moral decision making in their own practices. Each of these dilemmas is inherently complex with few straightforward answers; however, orthopedic surgeons have an obligation to take the lead and better define these kinds of difficult issues within their field. The lives of pediatric patients and their families will be immeasurably improved as a result.
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DelSole EM, Mercuri JJ, Stachel A, Phillips MS, Zuckerman JD. Risk of hepatitis C virus exposure in orthopedic surgery: is universal screening needed? Am J Orthop (Belle Mead NJ) 2014; 43:E117-E123. [PMID: 24945483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The aging baby boomer generation will soon start using tremendous orthopedic surgical resources. This group has also been identified as a group at high risk for having undiagnosed hepatitis C virus (HCV) infection. We conducted a study to assess the prevalence of HCV among orthopedic surgery patients at our institution-using their demographic data to determine whether they represent a unique cohort at high risk for having undiagnosed HCV. We estimated that we operated on as many as 233 patients with undiagnosed HCV in 2011. A cost-effective, universal preoperative HCV screening program may reduce the risk for occupational exposure in orthopedic surgery and significantly benefit public health by bringing undiagnosed patients to treatment. A robust screening program requires several ethical considerations. By offering routine screening to patients, orthopedic surgeons have an opportunity to maintain intraoperative safety and improve the health of the public.
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Abstract
BACKGROUND Little is known about the moral reasoning utilized by orthopaedic surgery residents when resolving moral dilemmas. METHODS Sixty-three residents in an accredited program took the Defining Issues Test-2, an online examination designed to measure and analyze moral reasoning. Scores approximate how often residents utilize three schemas in their moral reasoning: personal interest, maintaining social norms, and postconventional. Scores were analyzed for differences among years of training, previous literature, and established norms. RESULTS Approximately 9.5% of residents utilized personal interest heavily in their moral reasoning, 27% utilized maintaining norms, and 63.5% utilized postconventional reasoning. There were no significant differences between years of training. The fourth-year (R4) class recorded the highest utilization of principled reasoning, while the fifth-year (R5) class recorded the lowest. The range of principled reasoning scores narrowed from the first year (R1) to R5. The principled reasoning scores of residents were significantly lower than previously reported scores of professional degree-holders and medical students, and empirically lower than previously reported scores of orthopaedic attendings and medical students. CONCLUSIONS Residents utilized principled reasoning less frequently than expected for physicians. It remains unclear as to what factors contributed to high utilization of principled reasoning in the R4 class but low utilization in the R5 class. Our cross-sectional data suggest that each year of training homogenizes toward a class-specific utilization of principled reasoning. It remains unclear why residents utilized principled reasoning less than orthopaedic attendings, medical students, and other professional degree-holders.
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Affiliation(s)
- John J Mercuri
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, 301 East 17th Street, Room 1402, New York, NY 10003, USA
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Affiliation(s)
- Joseph D Zuckerman
- Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, 301 East 17th Street, 14th Floor, New York, NY 10003, USA. joseph.zuckerman@ nyumc.org
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Park JJ, Campbell KA, Mercuri JJ, Tejwani NC. Updates in the management of orthopedic soft-tissue injuries associated with lower extremity trauma. Am J Orthop (Belle Mead NJ) 2012; 41:E27-E35. [PMID: 22482099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Management of traumatic soft-tissue injuries remains a challenging and ever evolving field within orthopedic surgery. The basic principle of addressing life before limb in the initial assessment of critically injured patients has not changed. Although arteriography remains the gold standard for vascular injury screening, computed tomography angiography is being used more often to determine limb viability, and its sensitivity and specificity for detecting vascular lesions are reported to be excellent. Thorough debridement and irrigation with early institution of antibiotics are crucial in preventing infection; debridement should be performed urgently once life-threatening conditions have been addressed. Increasing use of vacuum-assisted closure therapy has created a trend down the reconstructive ladder, with improvements in resulting wound closure. Although the orthoplastics approach and new microsurgical techniques have made limb salvage possible in even the most severely injured extremities, it is important to clearly identify the zone of injury and to inform patients and their families of the outcomes of limb salvage versus amputation. Results from the LEAP (Lower Extremity Assessment Project) trials and similar studies should guide orthopedic surgeons in the management of these complex injuries. Nevertheless, it is important to individualize management plans according to patient factors.
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Affiliation(s)
- Justin J Park
- Division of Orthopaedic Surgery, New York University Hospital for Joint Diseases, New York, USA
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