Orthopedic Surgeon and Care Team Perceptions and Use of Patient-Reported Outcomes in Total Joint Replacement Patients

BACKGROUND

The recent shift toward value-based health care and bundled payments in orthopedic surgery has increased the use patient-reported outcomes (PROs) in standard clinical care. Such assessments of patient function and satisfaction are particularly important among total joint arthroplasty (TJA) patients to monitor postoperative health.

PURPOSE

The purpose of this study was to assess orthopedic care team perceptions of current and future PRO usage and compare current rates and modes of PRO collection between three urban, academic health care systems.

METHODS

A literature search was conducted on current PRO uses and barriers to their adoption to generate a 26-question survey. The survey was disseminated to orthopedic surgeons and care team members at three academic health care institutions (institutions A, B, and C). Responses were analyzed for qualitative and quantitative insights.

RESULTS

Among institutions A, B, and C, PRO collection generally declined from baseline (60%, 90%, 89%) to 6 weeks (67%, 82%, 71%) and 3 months postoperatively (44%, 36%, 47%). However, there were large variations in reported PRO collection intervals among institutions. Respondents reported assessing patient baseline functional status as the most useful current application of PROs and cited the prediction of patient benefit from TJA as the most useful future application for PROs. Though respondents were largely optimistic about PRO utility in clinical care, a small minority remained skeptical.

CONCLUSIONS

Perceptions of PRO utilization and collection intervals varied considerably among respondents. For PROs to be an accurate and useful clinical tool, standardization and thorough understanding of PRO collection among orthopedic care team members is essential.

Revision rotator cuff repair: a systematic review

BACKGROUND

The incidence of revision rotator cuff repair (RCR) has increased along with the incidence of primary RCR over the past 2 decades. The purpose of this study was to perform a systematic review to analyze the clinical outcomes of revision RCR and chiefly to identify prognostic factors that may influence postoperative outcomes.

METHODS

The PubMed, MEDLINE (Ovid), Embase (Elsevier), and Cochrane Library (Wiley) databases were searched from database inception through November 2018 for studies assessing revision RCR. All studies were screened in duplicate for eligibility. Pooled analysis correlations between mean preoperative range-of-motion measures, American Shoulder and Elbow Surgeons (ASES) scores, and visual analog scale (VAS) pain scores and mean postoperative outcomes with revision RCR were examined via linear regression and reported with the strength of the Spearman correlation coefficient (r_s).

RESULTS

A total of 22 studies met the inclusion criteria, including 3 level III and 19 level IV studies. Mean preoperative forward flexion had the greatest correlation with the mean postoperative ASES score (r_s = 0.98). A strong positive correlation was also found between mean preoperative forward flexion and mean postoperative forward flexion (r_s = 0.83). The mean preoperative VAS pain score was strongly correlated with the mean postoperative VAS pain score (r_s = 0.88) and demonstrated a moderate negative association with the mean postoperative ASES score (r_s = -0.48). Finally, the mean preoperative ASES score was moderately correlated with the mean postoperative ASES score (r_s = 0.56).

CONCLUSIONS

The results of this systematic review demonstrate favorable clinical outcomes following RCR revision performed both in an open manner and arthroscopically. Preoperative forward flexion was identified as a possible prognostic factor for improved outcomes.

Abstract 45: Systemic Illness in Ece1 Ablated Adult Mice

Endothelin converting enzyme-1 (ECE1) catalyzes the conversion of inactive big endothelin 1 (ET1) to active ET1. Homozygous Ece1 knock out (KO) mice die in utero or at birth, displaying multiple abnormalities including mandibular hypoplasia and cardiac outflow tract malformations, in spite of the presence of ample tissue ET1. However, increased ECE1 activity and circulating and/or tissue ET1 are associated with many adult cardiovascular diseases, including idiopathic pulmonary fibrosis (IPF), a chronic and fatal lung disease. There is an apparent paradox between the need for ET1 in development and its harmful effects in adult disease. Therefore, our lab developed a conditional Ece1 KO mouse, in which Ece1 is ablated following tamoxifen (tam) treatment. We hypothesized that ECE1 serves to localize ET1 signals to specific cell populations and is essential in normal adult physiology. We studied the following groups: mice given vehicle rather than tam, mice lacking tam-inducible Cre recombinase, mice harboring a normal Ece1 allele ( Ece1 +/flox ), and the experimental animals (Cre Ece1 -/flox ). Mice were treated with vehicle or tam at 8-9 weeks of age. Cre Ece1 -/flox mice showed 85-100% mRNA knock-down efficiency 8 weeks after tam treatment. By 17 weeks of age, Cre Ece1 -/flox mice have tachypnea, decreased activity, and weight loss, requiring euthanasia for humane considerations. They display depleted adipose tissue mass compared to controls. By two weeks after treatment, Cre Ece1 -/flox mice had lower blood pressure relative to controls, which persisted until euthanasia at 17-20 weeks old (p=0.004). Between 17-20 weeks of age, most of Cre Ece1 -/flox mice develop pectus excavatum, enlarged right hearts and have reduced stroke volume and cardiac output as analyzed by echocardiography. Histological examination revealed eosinophilic crystalline pneumonia and increased collagen in the lung and heart. These findings are consistent with development of IPF in the experimental mice. Our findings show that Ece1 ablation in post-natal animal results in a severe cardiorespiratory disease, suggesting that ectopic activation of ET1 by other tissue proteases is the primary mechanism underlying the association of increased ET1 signaling in disease states.

Abstract 195: Endothelin Converting Enzyme-1 (ECE1) is Essential in Adult Normal Physiology

Endothelin converting enzyme-1 (ECE1) catalyzes the conversion of inactive big endothelin 1 (ET1) to active ET1. Homozygous Ece1 knock out (KO) mice die in utero or at birth, displaying multiple abnormalities including mandibular hypoplasia and cardiac outflow tract malformations, in spite of the presence of ample tissue ET1. In contrast, increased ECE1 activity and circulating and/or tissue ET1 are associated with many adult cardiovascular diseases, including idiopathic pulmonary fibrosis (IPF), a chronic and fatal lung disease. There is an apparent paradox between the need for ET1 in development and its harmful effects in adult disease. Therefore, our lab developed a conditional Ece1 KO mouse, in which the gene is ablated following tamoxifen (tam) treatment. We hypothesized that ECE1 serves to localize ET1 signals to specific cell populations and is essential in adult normal physiology. We studied the following groups: mice given vehicle rather than tam, mice lacking tam-inducible Cre recombinase, mice harboring a normal Ece1 allele ( Ece1 +/flox ), and the experimental animals (Cre Ece1 -/flox ). Mice were treated with vehicle or tam at 8-9 weeks of age. Cre Ece1 -/flox mice showed 85-100% mRNA knock-down efficiency 8 weeks after tam treatment, but there was no significant difference in ET1 mRNA level. By 17 weeks of age, Cre Ece1 -/flox mice have significantly reduced body weight compared to controls (p=0.005) and most also have impaired breathing. Two weeks after treatment, Cre Ece1 -/flox mice had lower blood pressure relative to controls, which persisted until euthanasia at 17-20 weeks old (p=0.004). Between 17-20 weeks of age, most of Cre Ece1 -/flox mice develop pectus excavatum, cardiac arrhythmia, reduced cardiac output, and depleted adipose tissue mass. Histological examination revealed eosinophilic crystalline pneumonia and increased collagen in the lung. These findings are consistent with development of IPF in the experimental mice. Our findings show that Ece1 ablation in post-natal animal results in a severe progressive disease requiring euthanasia for humane considerations, suggesting that ectopic activation of ET1 by other tissue proteases is the primary mechanism underlying the association of increased ET1 signaling in disease states.

Presacral tumors: case report, review of the literature

A case report involving a 42-year-old female is presented. The symptoms and objective physical findings manifest a diagnostic problem. The anatomical site of the tumor depends on the consideration of the numerous possible etiological factors, and one of which is the embryologic knowledge of the region involved. The clinical, pathological, and embryologic features of a case of presacral tumor is presented.

[Alcohol and the pancreas]

In the last decenniums the importance of alcohol for the pathology of the pancreas has increased in Middle Europe. The inhibition of the pancreas secretion which was to be observed at an occasional alcohol intake is when a regular ethanol supply is present changed by a hyperfunction with secretion of a pancreatic juice rich in protein with high enzyme and calcium content. This predisposes to the protein precipitation in the small and medium ducts with resulting intrapancreatic obstruction, which on its part gives the impact to the changes of chronic pancreatitis. In 80-90% of the cases the ethanol-induced lesion of the pancreas is manifest under the picture of an acute pancreatitis. Nevertheless, in most cases the first shift of a chronic relapsing pancreatitis is concerned, the peculiarity of which is the frequent occurrence of calcifications. Clinical picture, complications and sequelae are described.

[Immunological studies on the pancreas]

From 1969 to 1974 on 38 diabetic patients with terminal renal insufficiency 1,500 haemodialyses were carried out. Out of them 21 were or are in the prolonged programme of dialysis. The average duration of diabetes up to the terminal renal insufficiency was 20 years. The survival time under dialysis between 50 to 616 days was on the average nearly 248 days. The waste of substances normally contained in the urine and the normalisation of changes of minerals under dialysis is to be compared with that one in non-diabetics. The conduction of the diabetic metabolism in advanced diabetic nephropathy is independent on the form of therapy chosen difficult and undergoes strong variations. For this practical recommendations are given. Dependent on the beginning of the dialysis in 8 cases we succeeded in a temporarily limited full rehabilitation, 5 patients were partially rehabilitated and in 8 patients the general condition could be improved by the treatment without successful rehabilitation. The main complications, which were also dominating causes of death, were seen from the side of the system of coronary circulation. Mediascleroses of the arterial walls partly of a high degree allow the supposition that in these cases additionally a secondary hyperparathyroidism was in question.

[Pancreas-secretion test in pregnancy]

In 3 groups of young women - non-pregnant, early pregnant and highly pregnant - the function of the excretory pancreas was examined with the help of the analysis of the duodenal juice after specific stimulation of the pancreas the evocation test. In these cases the secretion of the pancreases was significantly limited during pregnancy; during early pregnancy the findings were clearer than in the late pregnancy. In the first trimester of pregnancy the values of blood amylasis were low, around the date of birth they were normal with inclination to increased values.