1
|
George NE. CORR Insights®: Intramedullary Nailing of Intertrochanteric Femoral Fractures in a Level I Trauma Center in Finland: What Complications Can Be Expected? Clin Orthop Relat Res 2024; 482:289-290. [PMID: 37713264 PMCID: PMC10776149 DOI: 10.1097/corr.0000000000002858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 08/16/2023] [Indexed: 09/16/2023]
Affiliation(s)
- Nicole E. George
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD, USA
| |
Collapse
|
2
|
George NE. CORR Insights®: Short-term Complications for Proximal Humerus Fracture Surgery Have Decreased: An Analysis of the National Surgical Quality Improvement Program Database. Clin Orthop Relat Res 2022; 480:2134-2136. [PMID: 36136048 PMCID: PMC9556031 DOI: 10.1097/corr.0000000000002430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 09/07/2022] [Indexed: 01/31/2023]
|
3
|
Mohamed NS, Dávila Castrodad IM, Etcheson JI, George NE, Aitken JS, Kelemen MN, Nace J, Delanois RE. Utilisation of calcium sulphate beads in one-stage aseptic revision total hip arthroplasty. Hip Int 2022; 32:656-660. [PMID: 33241953 DOI: 10.1177/1120700020973973] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) affects many revision total hip arthroplasty (THA) patients, contributing to a concomitant rise in revision costs. Means of decreasing the risk of PJI include the use of antibiotic adjuncts, such as calcium sulphate beads (CSBs). Mixed with antibiotics, the potential benefits of CSBs include dissolvability and antibiotic drug elution. However, information comparing them in aseptic revision is scarce. Therefore, this study investigated CSB utilisation for infection prevention in aseptic revision THA. Specifically, we compared (1) infection rates; (2) lengths of stay; (3) subsequent infection procedures; and (4) final surgical outcome in 1-stage aseptic revision THA patients who did received CSBs to 1-stage aseptic revision THA patients who did not. METHODS A retrospective chart review was performed to identify all patients who underwent an aseptic revision THA between January 2013 and December 2017. Patients who received CSBs (n = 48) were compared to non-CSB patients (n = 58) on the following outcomes: postoperative infections, lengths of stay (LOS), subsequent irrigation and debridements (I+Ds), and final surgical outcome, classified as successful THA reimplantation, retained antibiotic spacer, or Girdlestone procedure. Chi-square and t-testing were used to analyse the variables. RESULTS There was no significant differences found between CSB patients and non-CSB patients in postoperative infections (p = 0.082), LOS (p = 0.179), I+Ds (p = 0.068), and final surgical outcome (p = 0.211). CONCLUSION This study did not find any statistical difference between CSBs and standard of care in infection rates and surgical outcomes. The advantage of these beads for 1-stage aseptic revisions is questionable.
Collapse
Affiliation(s)
- Nequesha S Mohamed
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Iciar M Dávila Castrodad
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Jennifer I Etcheson
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Nicole E George
- Department of Graduate Medical Education, Aultman Hospital, Canton, OH, USA
| | - James S Aitken
- Department of Orthopaedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Margaret N Kelemen
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - James Nace
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| |
Collapse
|
4
|
E George N. CORR Insights®: What Are the Frequency, Related Mortality, and Factors Associated with Bone Cement Implantation Syndrome in Arthroplasty Surgery? Clin Orthop Relat Res 2021; 479:764-766. [PMID: 33570859 PMCID: PMC8083936 DOI: 10.1097/corr.0000000000001658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 01/12/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Nicole E George
- N. E. George, Resident, Aultman Hospital, Graduate Medical Education, Canton, OH, USA
| |
Collapse
|
5
|
Mohamed NS, Remily EA, Wilkie WA, George NE, Nace J, Delanois RE. Modified Allograft Reconstruction of a Disrupted Patella Tendon: A Technical Case Report. JBJS Case Connect 2020; 10:e20.00282. [PMID: 33350620 DOI: 10.2106/jbjs.cc.20.00282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 19-year-old woman with a history of Hoffa fat pad syndrome underwent infrapatellar fat pad synovectomy and subsequently developed extensor mechanism disruption secondary to iatrogenic patellar tendon injury. She received a modified extensor mechanism patella-patellar tendon-tibial tubercle allograft to restore extensor function with satisfactory results at 2-year follow-up. We also review alternative techniques that were considered for her extensor mechanism repair. CONCLUSION The patient demonstrated satisfactory outcomes, similar to other established techniques. This modified extensor mechanism allograft reconstruction may be an effective alternative for patients experiencing acute extensor mechanism disruptions.
Collapse
Affiliation(s)
- Nequesha S Mohamed
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ethan A Remily
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Wayne A Wilkie
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Nicole E George
- Department of Graduate Medical Education, Aultman Hospital, Canton, Ohio
| | - James Nace
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| |
Collapse
|
6
|
Mohamed NS, Dávila Castrodad IM, Gwam CU, Etcheson JI, Passarello AN, George NE, Mahajan AK, Delanois RE. Pain intensity in total hip arthroplasty patients: how communication influences satisfaction. Hip Int 2020; 30:690-694. [PMID: 31122074 DOI: 10.1177/1120700019851783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION An important global measure of health care quality is patient satisfaction. Patient satisfaction partially determines hospital reimbursement for procedures such as total hip arthroplasty (THA). Press Ganey (PG) survey responses assess patient satisfaction, and impact reimbursement. Current efforts to maximise repayment for THA include reducing postoperative pain. The "Pain Management" survey domain is considered a significant factor in patient ratings, but other studies have highlighted staff communication domains as determinants of satisfaction. Therefore, the purpose of this study is to compare PG survey responses to inpatient pain intensity. METHODS We queried the PG database for all patients who underwent a THA between November 2012 and January 2015. This yielded a total of 302 patients. Descriptive statistics were performed to analyse patient-level demographics. A multivariate regression model was constructed utilising pain intensity as the dependent variable. RESULTS Patients rating of "Communication with Doctors" (B = -25.534; p < 0.001) and "Communication about Medicines" (B = -31.49; p = < 0.001) domains were representative of patient pain intensity. No other factors demonstrated a significant relationship to pain intensity. CONCLUSIONS Patient satisfaction continues to be important in care quality. Surrogate markers, such as the PG survey, can guide institutions looking to improve care. Our study revealed scores for "Communication with Doctors" and "Communication about Medicines" best represented true pain intensity levels for THA recipients during the postoperative period. The "Pain Management" domain did not display a relationship to pain intensity. The current method of measuring patient satisfaction should be reassessed to better represent patient responses and outcomes.
Collapse
Affiliation(s)
- Nequesha S Mohamed
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Iciar M Dávila Castrodad
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Chukwuweike U Gwam
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jennifer I Etcheson
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Alexandra N Passarello
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Nicole E George
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Ashwin K Mahajan
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| |
Collapse
|
7
|
Gwam CU, Mohamed NS, Dávila Castrodad IM, George NE, Remily EA, Wilkie WA, Barg V, Gbadamosi WA, Delanois RE. Factors associated with non-home discharge after total knee arthroplasty: Potential for cost savings? Knee 2020; 27:1176-1181. [PMID: 32711879 DOI: 10.1016/j.knee.2020.05.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 05/23/2020] [Accepted: 05/25/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Increasing demand for total knee arthroplasties (TKA) has been targeted by legislation to minimize costs and maximize outcomes. Home discharges reduce costs, and it is important to determine patient variables associated with this discharge disposition. We explored non-modifiable and modifiable factors associated with non-home discharges to determine what patient specific factors require attention. METHODS This retrospective study included 171,903 National Surgical Quality Improvement Program (NSQIP) patients between 2011 and 2016. Patient specific variables and discharge destinations included home, short-term nursing facilities (SNF), not home, and rehabilitation. Chi-squared analyses and analyses of variance (ANOVA) were conducted for categorical and continuous data, respectively. Multinomial regression model was utilized to assess associations between discharge destination and patient specific variables. RESULTS Every year increase above the mean age (66 years) was associated with a nine percent (p < .001) and six percent (p < .001) increased odds for discharge to SNF or rehabilitation, respectively, compared to home discharges. Every 10% increase in BMI from the mean was associated with a 10% increase in discharge to both SNF and rehabilitation (p < .001 for both). CONCLUSION With increasing demands for TKAs and expenditures to Medicare, evaluating factors that impact patient discharge can help optimize costs and outcomes of TKA procedures. Arthroplasty surgeons can benefit by recognizing these correlations and exploring reductions to non-home discharges through pre-operative patient optimization. Future studies should evaluate the economic cost potential associated with optimizing routine home discharge in TKA patients. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Chukwuweike U Gwam
- Department of Orthopedic Surgery, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157, United States of America
| | - Nequesha S Mohamed
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215, United States of America
| | - Iciar M Dávila Castrodad
- Hackensack Meridian School of Medicine at Seton Hall University, Department of Orthopedic Surgery, 340 Kingsland Street, Nutley, NJ 07110, United States of America
| | - Nicole E George
- Aultman Hospital, Dept. of Graduate Medical Education, 2600 6th St. SW, Canton, OH 44710, United States of America
| | - Ethan A Remily
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215, United States of America
| | - Wayne A Wilkie
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215, United States of America
| | - Victoria Barg
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215, United States of America
| | - Wahab A Gbadamosi
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215, United States of America
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215, United States of America.
| |
Collapse
|
8
|
George NE, Gurk-Turner C, Mohamed NS, Wilkie WA, Remily EA, Dávila Castrodad IM, Roadcloud E, Delanois R. Diclofenac Versus Ketorolac for Pain Control After Primary Total Joint Arthroplasty: A Comparative Analysis. Cureus 2020; 12:e7310. [PMID: 32313751 PMCID: PMC7164553 DOI: 10.7759/cureus.7310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 03/17/2020] [Indexed: 11/20/2022] Open
Abstract
Introduction As total hip arthroplasty (THA) and total knee arthroplasty (TKA) transition to outpatient settings, appropriate pain management remains a challenge. Nonsteroidal anti-inflammatory drugs (NSAIDs) may subvert the need for postoperative opioids. This study evaluated: 1) total opioid consumption; 2) postoperative pain intensity; 3) discharge destination; 4) length of stay (LOS); and 5) THA and TKA patients' satisfaction in receiving adjunctive intravenous (IV) diclofenac or ketorolac. Methods In this retrospective cohort study, patients scheduled to undergo primary THA or TKA by a single surgeon between March 2017 and April 2018 were identified. Patients were stratified based on the receipt of IV diclofenac (THA: n = 25; TKA: n = 51) or IV ketorolac (THA: n = 28; TKA: n = 32) in addition to the standard pain management regimen. Student's t-testing and Chi-square were used to analyze continuous and categorical variables, respectively. Results TKA diclofenac patients had lower opioid consumption 12 hours postoperatively (p: 0.037). TKA patients in the diclofenac cohort were discharged to home less often (p: 0.025). Both diclofenac cohorts had greater patient satisfaction than the ketorolac cohorts (p: <0.05). There was no significant difference between groups in postoperative pain intensity at 24 or 48 hours or in the length of stay (p: >0.05 for all). Conclusion This study demonstrated that both TKA and THA patients treated with IV diclofenac had no difference in postoperative pain intensity while THA patients had no difference in opioid consumption relative to those treated with IV ketorolac. Further comparison of IV NSAIDs with other IV pain medications may provide broader insight into the ideal management for postoperative pain for this widening patient population.
Collapse
Affiliation(s)
| | - Cheryle Gurk-Turner
- Pain Management, Lifebridge Health-Rubin Institute for Advanced Orthopedics, Baltimore, USA
| | - Nequesha S Mohamed
- Orthopedics, Lifebridge Health-Rubin Institute for Advanced Orthopedics, Baltimore, USA
| | - Wayne A Wilkie
- Orthopedics, Lifebridge Health-Rubin Institute for Advanced Orthopedics, Baltimore, USA
| | - Ethan A Remily
- Orthopedics, Lifebridge Health-Rubin Institute for Advanced Orthopedics, Baltimore, USA
| | - Iciar M Dávila Castrodad
- Orthopedic Surgery, Hackensack Meridian School of Medicine at Seton Hall University, Nutley, USA
| | - Elana Roadcloud
- Orthopedics, Lifebridge Health-Rubin Institute for Advanced Orthopedics, Baltimore, USA
| | - Ronald Delanois
- Orthopedics, Lifebridge Health-Rubin Institute for Advanced Orthopedics, Baltimore, USA
| |
Collapse
|
9
|
Gwam CU, George NE, Etcheson JI, Rosas S, Plate JF, Delanois RE. Cementless versus Cemented Fixation in Total Knee Arthroplasty: Usage, Costs, and Complications during the Inpatient Period. J Knee Surg 2019; 32:1081-1087. [PMID: 30396202 PMCID: PMC6500756 DOI: 10.1055/s-0038-1675413] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cemented fixation has been the gold standard in total knee arthroplasty (TKA). However, with younger and more active patients requiring TKA, cementless (press-fit) fixation has sparked renewed interest. Therefore, we investigated differences in (1) patient demographics, (2) inpatient costs, (3) short-term complications, and (4) discharge disposition between patients who underwent TKA with cemented and cementless fixation. The National Inpatient Sample database was queried for TKA patients with cement or cementless fixation between October 1 and December 31, 2015. Primary outcomes of interest included complications, length of stay (LOS), discharge disposition, and inpatient costs. Student's t-test and chi-square analysis were used to assess continuous and categorical data, respectively. Multivariable analysis evaluated the effects of fixation type on the continuous and categorical dependent variables. Patients who received cementless fixation were more often younger (63.5 vs. 65.9 years), male (47.4 vs. 40.3%), Black (10.7 vs. 7.7%), from the Northeast census region (29.1 vs. 17.1%), and under private insurance (49.2 vs. 40.3%; p < 0.001 for all). Cementless fixation involved higher inpatient hospital costs (US$17,357 vs. US$16,888) and charges (US$67,366 vs. US$64,190; p < 0.001 for both), lower mean LOS (2.63 vs. 2.71 days; p < 0.001), and higher odds of being discharged to home (odds ratio = 1.99; p = 0.002). This study revisited the outcomes of TKA with cementless fixation and demonstrated higher inpatient charges and costs, shorter mean LOS, and higher odds of being discharged home. Future studies should investigate patient outcomes and complications past the inpatient period, evaluate long-term survivorship and failure rates, and implement a prospective study design.
Collapse
Affiliation(s)
- Chukwuweike U. Gwam
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Nicole E. George
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Jennifer I. Etcheson
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Samuel Rosas
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
| | - Johannes F. Plate
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
| | - Ronald E. Delanois
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| |
Collapse
|
10
|
George NE, Gwam CU, Etcheson JI, Smith SS, Semenistyy AA, Delanois RE. Short-term outcomes of the supine muscle-sparing anterolateral versus direct lateral approach to primary total hip arthroplasty. Hip Int 2019; 29:504-510. [PMID: 31389271 DOI: 10.1177/1120700018812717] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although total hip arthroplasty (THA) is among the most successful orthopaedic procedures, it is not without complications. As such, finding the optimal surgical approach has become an area of particular interest. In this study, we compare: (1) pain intensity; (2) opioid consumption; (3) lengths of stay (LOS); (4) complication rates; (5) discharge destination; and (6) ambulatory function between patients who underwent THA via the supine muscle-sparing anterolateral (MS-ALA) and conventional direct lateral (DLA) approaches. METHODS A retrospective analysis was conducted on 220 consecutive patients who received primary THA using the supine MS-ALA (n = 101) or DLA (n = 119) between 1 January 2014 and 31 December 2016. Outcomes included postoperative pain intensity, opioid consumption, LOS, discharge destination, complications, additional procedures, and time to independent ambulation. RESULTS We demonstrated significantly lower opioid consumption on postoperative days (POD) 1 and 2 (mean differences, -32.0 and -28.4 mg, respectively; p ⩽ 0.001) and decreased pain intensity during the second 24 hours of the hospital stay (mean difference, -22.0; p < 0.001) in patients receiving the MS-ALA. Relative to the DLA cohort, patients in the MS-ALA cohort were 2.04 times more likely to be discharged to home (p = 0.028) and 1.91 times less likely to experience postoperative abductor insufficiency (p = 0.039). CONCLUSION The present study is the 1st to compare postoperative outcomes, particularly pain intensity and opioid consumption, between the supine muscle-sparing anterolateral and direct lateral THA approaches. Further research should investigate the effect of surgical approach on quality and cost of care, include larger sample sizes, and involve longer-term follow-up.
Collapse
Affiliation(s)
- Nicole E George
- 1 Rubin Institute for Advanced Orthopaedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, USA
| | - Chukwuweike U Gwam
- 1 Rubin Institute for Advanced Orthopaedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, USA
| | - Jennifer I Etcheson
- 1 Rubin Institute for Advanced Orthopaedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, USA
| | - Spencer S Smith
- 2 Department of Orthopaedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, USA
| | - Anton A Semenistyy
- 3 Peoples' Friendship University of Russia, 13th Moscow City Clinical Hospital, Moscow, Russia
| | - Ronald E Delanois
- 1 Rubin Institute for Advanced Orthopaedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, USA
| |
Collapse
|
11
|
George NE, Gurk-Turner C, Castrodad IMD, Etcheson JI, Mohamed NS, Gwam CU, Passarrello AN, Ohanale CU, Delanois RE. Adjunctive Intravenous Diclofenac Decreases Opioid Consumption and Increases Satisfaction in the Primary Total Hip Arthroplasty Population. Surg Technol Int 2019; 34:456-461. [PMID: 30753743] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Despite the success of total hip arthroplasty (THA), postoperative pain management remains a concern. Although the nonsteroidal anti-inflammatory drug (NSAID) intravenous (IV) diclofenac is a promising addition, its impact on THA outcomes has not been investigated. This study evaluates the effects of adjunctive IV diclofenac on: 1) postoperative pain intensity; 2) opioid consumption; 3) discharge destination; 4) length of stay; and 5) patient satisfaction in primary THA patients. A retrospective study was performed for patients who underwent primary THA by a single surgeon between May 1 and September 31, 2017. Patients of the study group (n=25) were treated postoperatively with IV diclofenac and the standard pain control regimen while the control group (n=88) did not receive diclofenac. Patients receiving adjunctive IV diclofenac were more likely to be discharged home than to inpatient facilities (O.R. 4.02; p=0.049). Patient satisfaction with respect to how well and how often pain was controlled (p= 0.0436 and p=0.0217, respectively) was significantly greater in the IV diclofenac group. Patients who received IV diclofenac had lower opioid consumption on postoperative days one and two (-67.2 and -129.0mg, respectively; p=0.001 for both). The growth of THA as an outpatient procedure has intensified the urgency of improving postoperative pain management. This study demonstrates that THA patients receiving adjunctive IV diclofenac were more likely to be discharged home, had reduced opioid consumption, and experienced greater satisfaction. To further investigate the optimal regimen, future studies comprising a larger cohort and comparing IV diclofenac to other NSAIDs are warranted.
Collapse
Affiliation(s)
- Nicole E George
- Aultman Hospital, Department of Graduate Medical Education, Canton, Ohio
| | - Cheryle Gurk-Turner
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Iciar M Dávila Castrodad
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Jennifer I Etcheson
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Nequesha S Mohamed
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Chukwuweike U Gwam
- Department of Orthopedic Surgery, Wake Forest Baptist Medical Center, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Alexandra N Passarrello
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement Sinai Hospital of Baltimore, Baltimore, Maryland
| | | | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement Sinai Hospital of Baltimore, Baltimore, Maryland
| |
Collapse
|
12
|
Delanois RE, Etcheson JI, Sodhi N, Henn RF, Gwam CU, George NE, Mont MA. Biologic Therapies for the Treatment of Knee Osteoarthritis. J Arthroplasty 2019; 34:801-813. [PMID: 30612835 DOI: 10.1016/j.arth.2018.12.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 11/14/2018] [Accepted: 12/03/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The use of biologic therapies for the management of knee osteoarthritis has increased, despite insufficient evidence of efficacy. Our aim was to complete a systematic review and analysis of reports utilizing the highest level-of-evidence evaluating: (1) platelet-rich plasma injections (PRPs); (2) bone marrow-derived mesenchymal stem cells (BMSCs); (3) adipose-derived mesenchymal stem cells (ADSCs); and (4) amnion-derived mesenchymal stem cells (AMSCs). METHODS PubMed, Embase, and Cochrane Library databases were queried for studies evaluating PRP injections, BMSCs, ADSCs, and AMSCs in patients with knee osteoarthritis. Of 1009 studies identified within the last 5 years, 123 met inclusion criteria. A comprehensive analysis of all levels-of-evidence was performed, as well as separate analysis on level-of-evidence I studies. Level-of-evidence was determined by the American Academy of Orthopedic Surgeons classification system. RESULTS Although the majority of PRP reports demonstrated improvements in pain and/or function, others revealed no substantial improvements. Similar findings were noted for BMSCs, ADSCs, and AMSCs. Assessments of BMSC studies yielded majority with positive clinical results, although short-lived. Studies on ADSCs revealed improved clinical outcomes, but equivocal radiographic outcomes. Studies evaluating AMSCs demonstrated improvements in pain and function, and decreased radiographic evidence of osteoarthritis. CONCLUSION Despite some promising early results for PRP, BMSC, ADSC, and AMSC therapies, the majority of level-of-evidence I studies have multiple problems: small sample sizes, potentially inappropriate control cohorts, short-term follow-up, and so on. Despite the limitations, there still appears to be evidence justifying their use for knee osteoarthritis management. More high-level, larger human studies utilizing standardized protocols are needed.
Collapse
Affiliation(s)
- Ronald E Delanois
- Department of Orthopaedic Surgery, Rubin Institute for Advanced Orthopaedics, Center for Joint Preservation and Replacement, Sinai Hospital - Baltimore, Baltimore, MD
| | - Jennifer I Etcheson
- Department of Orthopaedic Surgery, Rubin Institute for Advanced Orthopaedics, Center for Joint Preservation and Replacement, Sinai Hospital - Baltimore, Baltimore, MD
| | - Nipun Sodhi
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York City, NY
| | - Ralph F Henn
- Department of Orthopaedic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Chukwuweike U Gwam
- Department of Orthopedic Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC
| | - Nicole E George
- Department of Orthopaedic Surgery, Rubin Institute for Advanced Orthopaedics, Center for Joint Preservation and Replacement, Sinai Hospital - Baltimore, Baltimore, MD
| | - Michael A Mont
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York City, NY
| |
Collapse
|
13
|
Etcheson JI, Gwam CU, George NE, Caughran AT, Mont MA, Delanois RE. Does the Amount of Opioid Consumed Influence How Patients Rate Their Experience of Care After Total Knee Arthroplasty? J Arthroplasty 2018; 33:3407-3411. [PMID: 30029929 DOI: 10.1016/j.arth.2018.06.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 06/15/2018] [Accepted: 06/25/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND With legislative efforts aimed at optimizing value of care, surgeons performing total knee arthroplasty (TKA) are faced with increased responsibility of optimizing patient perception of care. However, pain after TKA may negatively influence patient perception of care, as measured by Press Ganey (PG) patient satisfaction surveys. While opioid-based medications are best suited for acute pain alleviation, awareness of a growing opioid epidemic has spurred efforts to reduce its administration. Therefore, this study assessed the correlation between postoperative opioid consumption and 7 PG question domains: (1) overall hospital rating; (2) communication with nurses; (3) response time of hospital staff; (4) communication with doctors; (5) hospital environment; (6) pain management and; (7) communication about medication. METHODS We reviewed our institutional PG database for TKA patients from 2011 to 2014. A total of 406 patients were analyzed (mean age = 66, 73.4%). Opioid consumption was measured using a morphine milliequivalent conversion algorithm. Bivariate correlation analysis assessed the association between opioid consumption and PG domains. Spearman's r was utilized to assess the strength of the association. RESULTS No association between total opioid consumption and overall hospital rating (r = 0.044), communication with doctors (r = 0.080), communication with nurses (r = 0.072), responsiveness of hospital staff (r = 0.084), pain management (r = 0.100), communication about medicines (r = 0.083), or hospital environment (r = 0.155) were found. DISCUSSION Our findings demonstrate that PG scores are not influenced by immediate postoperative opioid use. These results suggest opioid-based pain medications should be administered exclusively on the basis of clinical guidelines and patient needs without concern regarding satisfactions scores and reimbursement penalties.
Collapse
Affiliation(s)
- Jennifer I Etcheson
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Chukwuweike U Gwam
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Nicole E George
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Alexander T Caughran
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| |
Collapse
|
14
|
Gwam CU, George NE, Etcheson JI, Tarazi JM, Han GR, Griffith KME, Mont MA, Delanois RE. Clostridium difficile infection in the USA: incidence and associated factors in revision total knee arthroplasty patients. Eur J Orthop Surg Traumatol 2018; 29:667-674. [PMID: 30350019 DOI: 10.1007/s00590-018-2319-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 10/07/2018] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Revision total knee arthroplasty (TKA) procedures performed secondary to periprosthetic joint infection (PJI) are associated with significant morbidity and mortality. These poor outcomes may be further complicated by postoperative infection requiring antibiotics. However, antibiotic overuse may suppress patients' bacterial flora, leading to Clostridium difficile infection (CDI). Therefore, we aimed to study the: (1) incidence; (2) costs; and (3) risk factors associated with CDI in revision TKA patients. METHODS The National Inpatient Sample database was queried for individuals diagnosed with PJI who underwent revision TKA between 2009 and 2013 (n = 83,806). Patients who developed CDI during their inpatient stay were identified (n = 799). Logistic regression analysis was conducted to assess the association between hospital- and patient-specific characteristics and the development of CDI. RESULTS The incidence of CDI after revision TKA was 1.0%. These patients were older (mean age 69.05 vs. 65.52 years), had greater LOS (median 11 vs. 5 days) and greater costs ($30,612.93 vs. 18,873.75), and experienced higher in-hospital mortality (3.6 vs. 0.5%; p < 0.001 for all) compared to those without infection. Patients with CDI were more likely to be treated in urban, not-for-profit, medium/large hospitals in the Northeast or Midwest (p < 0.05 for all) and to have underlying depression (OR 4.267; p = 0.007) or fluid/electrolyte disorders (OR 3.48; p = 0.001). CONCLUSION Although CDI is rare following revision TKA, it can have detrimental consequences. We demonstrate that CDI is associated with longer LOS, higher costs, and greater in-hospital mortality. With increased legislative pressure to lower healthcare expenditures, it is crucial to identify means of preventing costly complications.
Collapse
Affiliation(s)
- Chukwuweike U Gwam
- Rubin Institute for Advanced Orthopaedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA
| | - Nicole E George
- Rubin Institute for Advanced Orthopaedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA
| | - Jennifer I Etcheson
- Rubin Institute for Advanced Orthopaedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA
| | - John M Tarazi
- Rubin Institute for Advanced Orthopaedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA
| | - Ga-Ram Han
- Rubin Institute for Advanced Orthopaedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA
| | - Korie M E Griffith
- Rubin Institute for Advanced Orthopaedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA
| | - Michael A Mont
- Department of Orthopaedic Surgery, Center for Joint Preservation and Reconstruction, Lenox Hill Hospital, 100 East 77th Street, New York, NY, 10075, USA
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopaedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA.
| |
Collapse
|
15
|
Etcheson JI, Gwam CU, George NE, Walia N, Jerjian C, Han GR, Virani S, Miller SJ, Delanois RE. Opiate Pain Medication Consumption in Cigarette Smokers following Total Hip Arthroplasty. Joints 2018; 6:157-160. [PMID: 30582103 PMCID: PMC6301853 DOI: 10.1055/s-0038-1673405] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 08/26/2018] [Indexed: 11/16/2022]
Abstract
Purpose
The purpose of the present study was to assess perception of pain and pain management in smokers versus nonsmokers who received a total hip arthroplasty (THA).
Methods
Patients who underwent THA from 2010 to 2016 were propensity score matched 1:1 based on race, body mass index, age, and sex. This yielded 124 smokers and 124 nonsmokers. Pain intensity was quantified using area under the curve for visual analog scale pain scores. Opioid consumption was determined using a morphine milliequivalent (mEq) conversion algorithm. An independent samples
t
-test and Chi-square analysis was conducted to assess continuous and categorical variables respectively.
Results
Smokers experienced a nonsignificantly increased pain intensity (198.1 vs. 185.7;
p
= 0.063). Smokers demonstrated significantly higher opioid consumption in both immediate postoperative (65.9 vs. 59.3 mEq;
p
= 0.045) and 90 days postoperative periods (619.9 vs. 458.9 mEq;
p
= 0.029).
Conclusion
Our study demonstrated a nonsignificantly increased pain intensity, and (in both the immediate and 90 days postoperative periods) a significantly higher opioid consumption following THA in patients who smoke cigarettes. This may be due to a relatively small effect size, warranting the need for larger prospective studies. Nevertheless, arthroplasty surgeons should encourage preoperative smoking cessation and alternative nonopioid analgesics to smoking patients receiving THA.
Level of Evidence
This is a level III, retrospective cohort study.
Collapse
Affiliation(s)
- Jennifer I Etcheson
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, United States
| | - Chukwuweike U Gwam
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, United States
| | - Nicole E George
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, United States
| | - Naval Walia
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, United States
| | - Christophe Jerjian
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, United States
| | - Ga-Ram Han
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, United States
| | - Sana Virani
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, United States
| | - Seth J Miller
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, United States
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, United States
| |
Collapse
|
16
|
Gwam CU, Urquico KB, Etcheson JI, George NE, Higuera Rueda CA, Delanois RE. Use of new interactive patient-provider software improves patient satisfaction and outcomes-a retrospective single-center study. Arthroplast Today 2018; 5:73-77. [PMID: 31020027 PMCID: PMC6470365 DOI: 10.1016/j.artd.2018.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 05/15/2018] [Accepted: 05/17/2018] [Indexed: 11/25/2022] Open
Abstract
Background While a number of studies have explored patient- and provider-related factors contributing to quality of care, few studies have explored the role of technology in improving quality and optimizing patient-provider communication. This study explores the use of an interactive patient-provider software platform (IPSP) at a single institution. Specifically, we compared: (1) patient satisfaction scores, (2) complication rates, and (3) readmission rates before and after the use of an IPSP on patients undergoing total hip arthroplasty and total knee arthroplasty. Material and Methods A retrospective review was performed on all total hip arthroplasty and total knee arthroplasty patients who completed a Press Ganey survey at a single institution between the years 2014 and 2017. Primary outcomes included Press Ganey patient satisfaction scores and 90-day complication and readmission rates. Mann-Whitney U testing and chi-squared analyses were conducted to assess continuous and categorical variables, respectively. Results Analysis revealed an improvement in median Clinician and Group Consumer Assessment of Healthcare Providers and Systems (89 vs 97) and Hospital for Consumer Assessment of Healthcare Providers and Systems scores (9 vs 10; P < .001) between pre-IPSP and post-IPSP. There was a decrease in 90-day complication rates (17.3 vs 11.2%; P = .035) but no decrease in readmission rates (0.30 vs 0.18%, P = .322) between the 2 time points. Conclusions The use of an IPSP proved instrumental in improving patient satisfaction and lowering 90-day complication rates at a single institution. The implementation of an IPSP may prove beneficial to arthroplasty surgeons and health-care institutions alike seeking to optimize the quality of care. Larger multicenter studies are necessary to validate the results of the present study.
Collapse
Affiliation(s)
- Chukwuweike U Gwam
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Kathleen B Urquico
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Jennifer I Etcheson
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Nicole E George
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | | | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| |
Collapse
|
17
|
Etcheson JI, Gwam CU, George NE, Virani S, Mont MA, Delanois RE. Response to Letter to the Editor on "Patients With Major Depressive Disorder Experience Increased Perception of Pain and Opioid Consumption Following Total Joint Arthroplasty". J Arthroplasty 2018; 33:2700-2701. [PMID: 29748071 DOI: 10.1016/j.arth.2018.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 04/09/2018] [Indexed: 02/01/2023] Open
Affiliation(s)
- Jennifer I Etcheson
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Chukwuweike U Gwam
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Nicole E George
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Sana Virani
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Michael A Mont
- Department of Orthopaedics, Lenox Hill Hospital, New York, New York
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| |
Collapse
|
18
|
McGinn TL, Etcheson JI, Gwam CU, George NE, Mohamed NS, Mistry JB, Ananaba U, Bhave A. Short-term outcomes for total knee arthroplasty patients with active extension lag. Ann Transl Med 2018; 6:204. [PMID: 30023367 DOI: 10.21037/atm.2018.05.38] [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] [Indexed: 11/06/2022]
Abstract
Background Despite the success of total knee arthroplasty (TKA), quadriceps strength can fail to recover. Active extension lag [quadriceps lag (Q-lag)] is a function of quadriceps weakness. Q-lag presents itself in patients who maintain a full passive range of motion (ROM), but are limited in active extension ROM. Few studies have evaluated the outcomes of post-TKA patients in the presence of post-operative Q-lag. Thus, this study aims to compare: (I) pain scores; and (II) rates of readmission to physical therapy (PT) in TKA patients with Q-lag of ≥15 degrees to patients without Q-lag. Methods A retrospective review of primary TKA patients between 2013 and 2015 was performed. A total of 150 patients (mean age 63.0 years) with a mean follow-up of 30.7 months were analyzed. All patients received an evidence-based protocol for PT at our institution. Patient readmission to PT was recorded if the orthopedic surgeon wrote an additional prescription for PT intervention following the standard of care following TKA. An independent samples t-test and chi-square analysis was conducted to assess the continuous and categorical variables, respectively. Results Fifty-one patients had Q-lag ≥15 degrees and 97 patients had Q-lag <15 degrees. Analysis of mean pain scores between the groups demonstrated a significant difference in mean pain scores (1.9 vs. 3.9; P=0.043). Chi-square analysis demonstrated no significant difference in rates of PT readmission between patients who presented with Q-lag, and patients without Q-lag (23.5% vs. 13.4%; P=0.118). Conclusions There was no significant difference in readmission rates; however, patients with Q-lag experienced a clinically significant higher pain level. Since this is the first study of its kind, we suggest further investigations on the effect of Q-lag on patient outcomes following primary TKA.
Collapse
Affiliation(s)
- Tanner L McGinn
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Jennifer I Etcheson
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Chukwuweike U Gwam
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Nicole E George
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Nequesha S Mohamed
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Jaydev B Mistry
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Ugochi Ananaba
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Anil Bhave
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| |
Collapse
|
19
|
Affiliation(s)
- Jaydev Mistry
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - R Frank Henn
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jennifer I Etcheson
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Chukwuweike U Gwam
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Nicole E George
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| |
Collapse
|
20
|
Etcheson JI, George NE, Gwam CU, Nace J, Caughran AT, Thomas M, Virani S, Delanois RE. Trends in Total Hip Arthroplasty Under the Patient Protection and Affordable Care Act: A National Database Analysis Between 2008 and 2015. Orthopedics 2018; 41:e534-e540. [PMID: 29771399 DOI: 10.3928/01477447-20180511-04] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 02/26/2018] [Indexed: 02/03/2023]
Abstract
The Patient Protection and Affordable Care Act expanded health coverage for low-earning individuals and families. With more Americans having access to care, the use of elective procedures, such as total hip arthroplasty (THA), was expected to increase. Therefore, the aim of this study was to evaluate trends in THA before and after the initiation of the Patient Protection and Affordable Care Act regarding race, age, body mass index, and sex between 2008 and 2015. The National Surgical Quality Improvement Program database was queried for all individuals who had undergone primary THA between 2008 and 2015. This yielded a total of 104,209 patients. Descriptive statistics were used to analyze patient-level data. A Cochran-Armitage test assessed trends in categorical data points over time. Analysis indicated an increased percentage of blacks or African Americans undergoing THA (7.8% vs 9.2%, P<.001), followed by Native Americans or Pacific Islanders (0.0% vs 0.4%, P<.001), American Indians or Alaskan Natives (0.3% vs 0.5%, P=.016), and Asians (1.4% vs 1.5%, P=.002). An increased percentage of patients 55 to 80 years old received THAs (68.6% vs 74.1%, P<.001). The percentage of patients with a body mass index of 25.0 to 29.9 kg/m2, 30.0 to 34.9 kg/m2, and 35.0 to 39.9 kg/m2 increased (32.9% vs 33.1%, 24.2% vs 25.6%, 12.6% vs 13.3%, respectively, P<.001 for all). These findings may provide insight on the changing patient characteristics for orthopedic surgeons performing THA. Furthermore, these findings may inform health policy makers interested in increasing access to procedures underutilized by specific patient populations and the creation of strategies to meet increased demand. [Orthopedics. 2018; 41(4):e534-e540.].
Collapse
|
21
|
Gwam CU, McGinnis T, Etcheson JI, George NE, Sultan AA, Delanois RE, Bhave A, Harwin SF, Mont MA. Use of Neuromuscular Electrical Stimulation During Physical Therapy May Reduce the Incidence of Arthrofibrosis After Total Knee Arthroplasty. Surg Technol Int 2018; 32:356-360. [PMID: 29791704] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Arthrofibrosis remains a major complication following total knee arthroplasty (TKA) that negatively impacts patient outcomes and exhausts healthcare resources. The use of neuromuscular electrical stimulation (NMES) has demonstrated the ability to facilitate quadriceps muscle recovery and reduce pain. Therefore, the purpose of this study was to compare TKA patients who received physical therapy (PT) and adjuvant NMES therapy versus physical therapy alone in terms of: 1) rates of manipulation under anesthesia (MUA) to treat arthrofibrosis; and 2) post-therapy range of motion (ROM). MATERIALS AND METHODS This was a retrospective review of TKA patients from multiple institutions who underwent physical therapy versus physical therapy and adjuvant NMES therapy following primary TKA. A total of 206 patients were reviewed in the two cohorts that either received PT alone (n=86) or PT and adjuvant NMES therapy (n=120). Data regarding the requirement of MUA postoperatively for treatment of arthrofibrosis were collected for every patient. Additionally, pre- and post-therapy knee ROM data was also collected. Outcomes in both cohorts were then compared and analyzed. RESULTS Lower rates of arthrofibrosis requiring MUA were recorded in patients who used NMES therapy and PT when compared to PT alone (7.5% vs. 19.8%; p=0.009). Log regression analysis revealed lower odds of needing MUA in patients who utilized NMES therapy in adjunct with PT (odds ratio [OR]=0.36; 95% CI: 0.115 to 0.875; p=0.023). Patients who received the NMES therapy were shown to have a statistically greater mean improvement in ROM when compared to those patients who did not receive NMES (+2.63, p=0.04). Log regression analysis also demonstrated that post-PT ROM decreased the odds of receiving MUA with a larger ROM (OR=92; 95% CI: 0.824 to 0.9855; p<0.001). CONCLUSION This study demonstrated that the use of NMES during PT may reduce the incidence of arthrofibrosis and improve patient ROM. Prospective, randomized controlled, and larger-scale studies are needed to validate these results. Nevertheless, this novel report demonstrated the positive outcomes for a new application of the NMES therapy.
Collapse
Affiliation(s)
- Chukwuweike U Gwam
- Department of Orthopaedic Surgery, Sinai Hospital of Baltimore Rubin Institute for Advanced Orthopaedics, Baltimore, Maryland
| | - Tanner McGinnis
- Department of Orthopaedic Surgery, Sinai Hospital of Baltimore Rubin Institute for Advanced Orthopaedics, Baltimore, Maryland
| | - Jennifer I Etcheson
- Department of Orthopaedic Surgery, Sinai Hospital of Baltimore Rubin Institute for Advanced Orthopaedics, Baltimore, Maryland
| | - Nicole E George
- Department of Orthopaedic Surgery, Sinai Hospital of Baltimore Rubin Institute for Advanced Orthopaedics, Baltimore, Maryland
| | - Assem A Sultan
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Anil Bhave
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Steven F Harwin
- Department of Orthopaedic Surgery, Sinai Hospital of Baltimore Rubin Institute for Advanced Orthopaedics, Baltimore, Maryland
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
22
|
Delanois RE, George NE, Etcheson JI, Gwam CU, Mistry JB, Mont MA. Risk Factors and Costs Associated With Clostridium difficile Colitis in Patients With Prosthetic Joint Infection Undergoing Revision Total Hip Arthroplasty. J Arthroplasty 2018; 33:1534-1538. [PMID: 29273290 DOI: 10.1016/j.arth.2017.11.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 11/13/2017] [Accepted: 11/20/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND With the increased demand for primary total hip arthroplasty (THA) and corresponding rise in revision procedures, it is imperative to understand the factors contributing to the development of Clostridium difficile colitis. We aimed to provide a detailed analysis of: (1) the incidence of; (2) the demographics, lengths of stay, and total costs for; and (3) the risk factors and mortality associated with the development of C. difficile colitis after revision THA. METHODS The National Inpatient Sample database was queried for all individuals diagnosed with a periprosthetic joint infection and who underwent all-component revision THA between 2009 and 2013 (n = 40,876). Patients who developed C. difficile colitis during their inpatient hospital stay were identified. Multilevel logistic regression analysis was conducted to assess the association between hospital- and patient-specific characteristics and the development of C. difficile colitis. RESULTS The overall incidence of C. difficile colitis after revision THA was 1.7%. These patients were significantly older (74 vs 65 years), had greater lengths of hospital stay (19 vs 9 days), accumulated greater costs ($51,641 vs $28,282), and were more often treated in an urban hospital compared to their counterparts who did not develop C. difficile colitis (P < .001 for all). Patients with colitis also had a significantly higher in-hospital mortality compared to those without (5.6% vs 1.4%; P < .001). CONCLUSION While C. difficile colitis infection is an uncommon event following revision THA, it can have potentially devastating consequences. Our analysis demonstrates that this infection is associated with a longer hospital stay, higher costs, and greater in-hospital mortality.
Collapse
Affiliation(s)
- Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Nicole E George
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Jennifer I Etcheson
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Chukwuweike U Gwam
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Jaydev B Mistry
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
23
|
Mohamed NS, Gwam CU, Etcheson JI, George NE, Piuzzi NS, Rosas S, Sohdi N, Sultan AA, Khlopas A, Delanois RE. Impact factors of orthopaedic journals between 2010 and 2016: trends and comparisons with other surgical specialties. Ann Transl Med 2018; 6:114. [PMID: 29955574 DOI: 10.21037/atm.2018.03.02] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background With increased legislative efforts to utilize evidence-based medicine as a guide for clinical practice, orthopaedists feel increasing pressure to publish research in higher-quality journals that reach a larger audience. Impact factor (IF) is used to quantify and rank journal apparent quality, and is the most standardized method for journal appraisal. In this study, we assessed the trends for IF among orthopaedic journals and compared these trends to those of medicine and general surgery journals. Methods Journal IFs from Journal Citation Reports (JCR) between the years 2010 to 2016 were obtained and analyzed for trends. Only journals that were considered primarily orthopaedic journals were included. The top 10 journals by IF in both internal medicine and surgery were also included for comparison. Each journal was analyzed by IF, and trends across time were noted. The differences in mean IF between orthopaedic specialty groups were analyzed using an independent samples t-test. Results The mean IF of orthopaedic increased from 1.4 (range, 0.0-3.9) in 2010 to 1.9 (range, 0.5-5.7) in 2016. In 2016, the percentage of English journals increased to 87.3% (n=48), while the percentage of journals published in the United States was 47.3% (n=26). There was a significant difference between the IF of journals published in English and those published in other languages (P=0.004). The mean IF of both general and specialized orthopaedic journals increased from 2010 to 2016, but the difference was nonsignificant. The mean IF of the top 10 journals in both surgery and internal medicine also increased from 2010 to 2016, but the increase was also nonsignificant. Conclusions Overall, the mean IF for peer-reviewed orthopaedic journals has increased in the past years, as has the number of journals. English journals from the United States continue to have the largest impact when compared to non-English journals and journals from outside the United States. Future studies should aim to better qualify journal impact, while limiting confounders such as self-citation.
Collapse
Affiliation(s)
- Nequesha S Mohamed
- Rubin Institute for Advanced Orthopaedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Chukwuweike U Gwam
- Rubin Institute for Advanced Orthopaedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Jennifer I Etcheson
- Rubin Institute for Advanced Orthopaedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Nicole E George
- Rubin Institute for Advanced Orthopaedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Samuel Rosas
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina, USA
| | - Nipun Sohdi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Assem A Sultan
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anton Khlopas
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopaedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| |
Collapse
|
24
|
Etcheson JI, Gwam CU, George NE, Virani S, Mont MA, Delanois RE. Patients With Major Depressive Disorder Experience Increased Perception of Pain and Opioid Consumption Following Total Joint Arthroplasty. J Arthroplasty 2018; 33:997-1002. [PMID: 29129615 DOI: 10.1016/j.arth.2017.10.020] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 10/10/2017] [Accepted: 10/13/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Pain in the immediate postoperative period following total joint arthroplasty is influenced by various patient factors, including major depressive disorder (MDD). Therefore, this study aimed to compare the patient perception of pain and opioid consumption between patients with and without MDD who received either a total knee arthroplasty (TKA) or total hip arthroplasty (THA). Specifically, we compared (1) pain intensity, (2) lengths of stay, (3) opioid consumption, and (4) patient perception of pain control. METHODS We reviewed our institutional Press Ganey database to identify patients with a diagnosis of MDD who received a THA (n = 48) and TKA (n = 68) between 2012 and 2016. An independent samples t-test and chi-square analyses were conducted to assess continuous and categorical variables, respectively. Analysis of covariance assessed the effects of depression on postoperative pain intensity. Mixed-design analysis of variance assessed the difference in opioid consumption between groups. RESULTS Patients with MDD who received THA or TKA demonstrated a higher mean pain intensity score when compared to those without MDD; however, this was not statistically different (235.6 vs 207.7; P = .264 and 214.8 vs 185.1; P = .055, respectively). Patients with MDD who received THA or TKA consumed more opioids when compared to those without MDD (P = .048 and P = .038, respectively). CONCLUSION Patients with MDD undergoing total joint arthroplasty consume more opioids compared to their matched cohort during the immediate postoperative period. Identifying patient-specific factors, such as MDD, could help arthroplasty surgeons modulate patients' course of recovery. These findings warrant more cooperation between arthroplasty surgeons and primary care providers to optimize outcome.
Collapse
Affiliation(s)
- Jennifer I Etcheson
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Chukwuweike U Gwam
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Nicole E George
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Sana Virani
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| |
Collapse
|
25
|
Pal S, Chughtai M, Sultan AA, Khlopas A, Sodhi N, George NE, Etcheson JI, Gwam CU, Newman JM, Samuel LT, Bhave A, DaVanzo JE, Mont MA. Impact of Neuromuscular Electrical Stimulation (NMES) on 90-Day Episode Costs and Post-Acute Care Utilization in Total Knee Replacement Patients with Disuse Atrophy. Surg Technol Int 2017; 31:384-388. [PMID: 29316600] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
INTRODUCTION This study evaluated differences in: 1) total episode payments, 2) probability of hospital readmission, 3) probability of inpatient rehab facility (IRF) and utilization, and 4) probability of skilled nursing care facility (SNF) utilization in patients who had disuse atrophy and underwent a total knee arthroplasty (TKA) and either did, or did not, receive preoperative home-based neuromuscular electrical stimulation (NMES) therapy. MATERIALS AND METHODS We used the Medicare limited dataset for a 5% sample of beneficiaries from 2014 and 2015 to construct episodes-of-care for TKA (DRG-470) patients with disuse atrophy who underwent a TKA during the 30 days prior to hospital admission and 90 days post-discharge. Patients were stratified into those who either did or did not receive pre- and postoperative NMES therapy. An ordinary least square (OLS) model was used to estimate the impact of NMES on total episode. Linear probability models were used to estimate the impact of NMES on SNF or IRF utilization and readmission. RESULTS A $3,274 reduction in episode payments for patients who used preoperative NMES versus those who did not (p<0.001) was demonstrated. The probability of readmission was 12.7% lower for those who used preoperative NMES therapy versus those who did not (p=0.609). The probability of utilizing IRF and SNF was 56.7% (p=0.061) and 46.4% (p=<0.001) lower for those who used pre- and postoperative NMES versus those who did not, respectively. CONCLUSION Significant reduction in total episode payments and SNF utilization for TKA patients with disuse atrophy who had NMES therapy was demonstrated.
Collapse
Affiliation(s)
| | - Morad Chughtai
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Assem A Sultan
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Anton Khlopas
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Nipun Sodhi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Nicole E George
- Department of Orthopaedic Surgery, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopaedics, Baltimore, Maryland
| | - Jennifer I Etcheson
- Department of Orthopaedic Surgery, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopaedics, Baltimore, Maryland
| | - Chukwuweike U Gwam
- Department of Orthopaedic Surgery, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopaedics, Baltimore, Maryland
| | - Jared M Newman
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Linsen T Samuel
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Anil Bhave
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | | | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
26
|
Siddiqi A, White PB, Etcheson JI, George NE, Gwam CU, Mistry JB, Patel NG, Adam H, Delanois RE. Acute Kidney Injury after Total Knee Arthroplasty: A Clinical Review. Surg Technol Int 2017; 31:243-252. [PMID: 29301167] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Patients who develop acute kidney injury (AKI) have an increased risk for progression to chronic kidney disease, end-stage renal disease, and increased mortality. The outcomes of total knee arthroplasty (TKA) patients who develop AKI have remained controversial. The purpose of this review was to summarize and identify the current literature focused on 1) major risk factors, 2) short-term outcomes, and 3) costs associated with the development of perioperative AKI after TKA. MATERIALS AND METHODS A literature search was performed using PubMed and Ovid to find literature relevant to AKI in TKA. All abstracts found via literature search were screened for relevancy to the study topics: (1) risk factors, (2) short-term outcomes, and (3) cost. RESULTS A total of 447 abstracts were initially identified. Irrelevant abstracts and those not in English were excluded from the study (n=336). Forty-five papers focused on risk factors associated with AKI, six papers focused on short-term outcomes, and seven discussed cost savings. Increased body mass index, metabolic syndrome, perioperative antibiotics, antihypertensive medications, and antibiotic-impregnated cement spacers are amongst the many modifiable patient and drug-induced risk factors associated with AKI after TKA. Perioperative renal injury is associated with increased inpatient and long-term mortality with increased length of stay and extended care facility discharge. CONCLUSION Increased length of stay and comorbidities have shown higher cost utilization and readmission rates. Inpatient and long-term complications and mortality are associated with postoperative AKI and a multidisciplinary perioperative approach is necessary to appropriately identify and, ultimately, prevent patients at higher risk for acute renal failure.
Collapse
Affiliation(s)
- Ahmed Siddiqi
- Department of Orthopedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA
| | - Peter B White
- Department of Orthopedic Surgery, Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania
| | - Jennifer I Etcheson
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Nicole E George
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Chukwuweike U Gwam
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Jaydev B Mistry
- Department of Orthopedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY
| | - Nirav G Patel
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Hephizibah Adam
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| |
Collapse
|
27
|
Gwam CU, Etcheson JI, George NE, Mistry JB, Mohamed N, Patel A, Gwam PN, Piuzzi NS, Delanois RE. Presentation of Knee Osteoarthritis in the Emergency Department: A Problem Worth Mentioning? Surg Technol Int 2017; 31:277-284. [PMID: 29313316] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Osteoarthritis (OA) of the knee is a progressive debilitating disease affecting more than 27 million Americans. Treatment is often aimed at reducing pain and slowing disease progression. However, patients with significant barriers to healthcare may elect to visit the emergency department (ED) due to OA-related knee pain. The purpose of this study is to provide a detailed analysis of 1) patient demographics; 2) payor type; 3) charges; and 4) discharge status of patients presenting to the emergency department with a primary diagnosis of knee OA. MATERIALS AND METHODS The Nationwide Emergency Department Sample from 2009 to 2013 was queried for all patients who presented to the ED with a primary diagnosis of knee OA (ICD-9 CM=715.96) and did not have a concomitant major injury. This yielded 215,253 patients. An analysis of variance (ANOVA) test with a post-hoc Turkey-Kramer test was conducted to assess mean differences of continuous data over time. All categorical data was analyzed using chi-square analysis. RESULTS The incidence of ED visits dropped significantly between the years 2009 and 2010 (68,661 to 36,846) and plateaued between the years 2010 and 2013. Patients had a mean age of 59.9 years and were primarily women (67.3%). The majority of patients were at the lowest 50% income bracket (68.8%). The Southern US census region had the highest number of ED visits (n=91,995; 42.7%), and Medicare was the primary payor in most cases (n=87,323; 40.7%). The mean charge for ED visits from 2009 to 2013 was $1,368.39, and there was a statistically significant increase in ED-related charges between 2009 and 2013 (p<0.001). The majority of discharges from the ED were routine (n=202,247; 93.8%). CONCLUSION While the early management of knee osteoarthritis is largely successful at delaying the need for surgery, there are still many patients who do not receive adequate care and present to the emergency room for non-emergent evaluation. This, along with rising charges for ED visits, is likely increasing resource consumption and the financial impact on the healthcare system. Future efforts should focus on improving access to care for patients with knee OA before it develops into an overwhelming burden.
Collapse
Affiliation(s)
- Chukwuweike U Gwam
- Department of Orthopaedic Surgery, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Jennifer I Etcheson
- Department of Orthopaedic Surgery, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Nicole E George
- Department of Orthopaedic Surgery, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Jaydev B Mistry
- Department of Orthopaedic Surgery, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Nequesha Mohamed
- Department of Orthopaedic Surgery, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Aamir Patel
- Department of Orthopaedic Surgery, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Peace N Gwam
- University of Maryland, College of Behavioral and Social Sciences, Department of Economics, College Park, Maryland
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ronald E Delanois
- Department of Orthopaedic Surgery, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| |
Collapse
|
28
|
George NE, Gurk-Turner C, Etcheson JI, Gwam CU, De Souza R, Smith SS, Nace J, Delanois RE. The Addition of Diclofenac to a Multimodal Pain Control Regimen Decreases Postoperative Pain and Opioid Consumption. Surg Technol Int 2017; 31:346-351. [PMID: 29316592] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Total knee arthroplasty (TKA) is a commonly-performed orthopaedic procedure in the United States. However, inadequate postoperative pain management following TKA has been associated with a number of negative consequences, including chronic postoperative pain requiring long-term opioid use. Multimodal pain control is a recently-popularized means of maximizing analgesia and postoperative outcomes. We aimed to evaluate the outcomes of a multimodal pain regimen incorporating diclofenac, including: 1) length of stay (LOS); 2) pain intensity; and 3) opioid consumption in primary TKA patients. MATERIALS AND METHODS A prospective cohort study was performed. All patients scheduled for primary TKA by a single surgeon between March 1, 2017 and August 31, 2017 were screened for study involvement, yielding 46 consecutive patients (52 TKAs). This study group was treated with a postoperative regimen of intravenous (IV) diclofenac, in addition to a perioperative pain control regimen including adductor canal blockade (ACB) and periarticular multimodal drug injection (PMDI). Postoperative outcomes in this group were compared to those of a matched cohort of 78 patients (88 primary TKAs) who had previously been treated with the same perioperative pain control regimen. RESULTS Patients prescribed a postoperative diclofenac regimen had lower mean LOS (2.10 vs. 2.33 days; p=0.053) and lower 24-hour postoperative pain intensity (76 vs. 104; p=0.056) as compared to the untreated group. The diclofenac-treated group had a significantly lower opioid consumption in the first 24 hours postoperatively than did their untreated counterparts (39.8 vs. 53.1 morphine milligram equivalents [MME]; p=0.041). In addition, 17 patients (18 TKAs, 35%) in the diclofenac group had zero opioid requirements during the first 12 hours postoperatively, and 12 of these patients (13 TKAs, 25%) continued to not require any opioids through the first 24 hours postoperatively. DISCUSSION In the midst of the rapidly-increasing rates of TKA in the US, multimodal pain control has emerged as an extremely effective means of maximizing postoperative patient outcomes. To our knowledge, this is the first study to evaluate the postoperative outcomes of TKA patients treated with a regimen of IV diclofenac. We demonstrate shorter LOS, decreased 24-hour pain intensity, and significantly decreased 24-hour opioid consumption in patients treated with adjunctive IV diclofenac compared to patients managed with our institution's standard perioperative regimen.
Collapse
Affiliation(s)
- Nicole E George
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | | | - Jennifer I Etcheson
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Chukwuweike U Gwam
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Randal De Souza
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Spencer S Smith
- Department of Orthopaedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - James Nace
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| |
Collapse
|
29
|
Gwam CU, Mistry JB, Mohamed NS, George NE, Etcheson JI, Virani S, Scalsky R, Singh S, Piuzzi NS, Delanois RE. The Effect of Preoperative Physical Status on Pain Management in Total Knee Arthroplasty Patients Receiving Adductor Canal Blockade. Surg Technol Int 2017; 31:237-242. [PMID: 29121695] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Managing postoperative pain can be challenging for arthroplasty surgeons. While pain control modalities, such as adductor canal blockade (ACB), have been proven effective, the multifactorial nature of pain perception may serve as an obstacle for optimizing pain control. This study assesses the effect of patient pre-operative physical status on patient perception of pain. Specifically, we compared 1) lengths of hospital stay (LOS), 2) pain levels, and 3) opioid consumption in patients receiving total knee arthroplasty (TKA) who presented with an American Society of Anesthesiologists physical status score (ASA) of 2 and 3. MATERIALS AND METHODS A single hospital, single surgeon database was reviewed for patients who had TKA between January 2015 and April 2016. Only patients with an ASA class of 2 or 3 who received ACB were analyzed. This yielded 106 patients with a mean age of 63 years, comprised of 36 men and 70 women. Patients were stratified into those with an ASA class of 2 (n= 58) and those with an ASA class of 3 (n= 48). Electronic medical records were reviewed to obtain demographic and endpoint data. Pain was quantified using Visual Analog Scale (VAS). Continuous variables were compared using the student' s t-test and analysis of variance, while categorical variables were compared using chi-square analysis. RESULTS There was no significant difference found between the two groups in LOS (2.25 days vs. 2.19 days; p=0.805), VAS scores (4.95 vs. 5.75; p=0.306), and opioid consumption on day 0 (17.77 morphine eq vs. 23.49 morphine eq; p=0.233) and day 3 (9.11 morphine eq vs. 19.87 morphine eq; p=0.100). However, patients with an ASA score of 2 had a significantly lower opioid consumption on day 1 (32.20 morphine eq vs. 52.70 morphine eq; p=0.049), day 2 (19.21 morphine eq vs. 40.71 morphine eq; p=0.018), and overall (78.30 morphine eq vs. 135.77 morphine eq; p=0.024). CONCLUSION Despite the effectiveness of ACB in controlling pain, patient pre-operative status may affect perception of pain. This study demonstrates that patients with a higher ASA physical status classification consumed more opioid medication postoperatively, despite having similar pain scores and lengths of stay to those with a lower classification. Future studies should assess all ASA classifications and stratify for preoperative opioid consumption and tolerance as a possible confounder.
Collapse
Affiliation(s)
- Chukwuweike U Gwam
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Jaydev B Mistry
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Nequesha S Mohamed
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Nicole E George
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Jennifer I Etcheson
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Sana Virani
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ryan Scalsky
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Shreya Singh
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| |
Collapse
|
30
|
McGraw-Tatum MA, Groover MT, George NE, Urse JS, Heh V. A Prospective, Randomized Trial Comparing Liposomal Bupivacaine vs Fascia Iliaca Compartment Block for Postoperative Pain Control in Total Hip Arthroplasty. J Arthroplasty 2017; 32:2181-2185. [PMID: 28318860 DOI: 10.1016/j.arth.2017.02.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [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: 06/15/2016] [Revised: 01/31/2017] [Accepted: 02/06/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Increasing demand for total hip arthroplasty (THA) in a climate of increasing focus on clinical outcomes, patient satisfaction, and cost has created a need for better acute postoperative pain control for patients. An ideal pain control method would have few side effects, decreased opioid consumption, improved pain control, early ambulation, and decreased hospital length of stay (LOS). METHODS We performed a prospective randomized, controlled study involving 79 patients undergoing elective THA between June 2015 and February 2016. Forty patients received liposomal bupivacaine and 39 patients received a fascia iliaca compartment block (FICB). In addition, the medical records of 28 patients who underwent elective THA between May 2015 and December 2015 were retrospectively examined. The primary outcome was visual analog scale pain scores and the secondary outcomes were LOS and total opioid consumption. SPSS, version 22, was used to run 1-way analysis of variance with contrast and Mood's median test on the data. RESULTS There were statistically significant decreases in pain intensity (P = .019) and LOS (P = .041) in both the liposomal bupivacaine group and the FICB group compared with those in the retrospective control group. In addition, only the FICB group showed statistically significant decreased total opioid consumption compared with that in the retrospective group (P = .028). CONCLUSION Patients undergoing elective THA have decreased overall pain intensity and a shorter LOS with multimodal pain management regimen that includes either liposomal bupivacaine or FICB. Patients who received FICB required less overall total opioids than the control group.
Collapse
Affiliation(s)
| | - Michael T Groover
- Orthopaedic Surgery Department, Grandview Medical Center, Dayton, Ohio
| | - Nicole E George
- Ohio University Heritage College of Osteopathic Medicine, Athens, Ohio
| | - John S Urse
- Orthopaedic Surgery Department, Grandview Medical Center, Dayton, Ohio
| | - Victor Heh
- Ohio University Heritage College of Osteopathic Medicine, Dublin, Dublin, Ohio
| |
Collapse
|