Optimal Duration of Physical Therapy Following Total Knee Arthroplasty

Aims & Objectives

The purpose of this study was to identify patient characteristics associated with engagement and completion of physical therapy (PT) following total knee arthroplasty (TKA) and examine the relationship between number of PT sessions attended and outcomes during the first 12 weeks after surgery.

Methods

Patients underwent unilateral primary TKA by a single surgeon and were advised to complete 17 PT sessions over 6 weeks at a hospital-affiliated facility. Analyses examined predictors of PT engagement (attendance of ≥2 sessions) and completion (attendance of 17 ± 1 sessions) within 6 weeks and associations between number of PT sessions attended and changes in range of motion (ROM) and Knee Injury and Osteoarthritis Outcome Score (KOOS) values.

Results

Patients living <40 km were more likely to be engaged in PT than those living ≥40 km from the clinic (P < .0001). Among patients who completed PT within 6 weeks, 95.0%, 85.1%, and 56.4% achieved flexion of, respectively, ≥90°, ≥100°, and ≥110°. Among engaged patients, the active flexion thresholds of ≥90°, ≥100°, and ≥110° were achieved by, respectively, 94.4%, 82.5%, and 58.1% by 6 weeks and by 96.7%, 92.1%, and 84.2% by 12 weeks. Improvement in KOOS Symptoms (P = .029), Function in daily living (P = .030) and quality of life (P = .031) linearly decreased as number of PT sessions increased.

Conclusions

These results raise the question of whether patients who meet satisfactory outcomes before completing 6 weeks of prescribed PT and those who attend more PT sessions than prescribed may be over-utilizing healthcare resources without additional benefit.

Fix or Replace? Patient Preferences for the Treatment of Geriatric Lower Extremity Fractures: A Discrete Choice Experiment

Introduction

When considering treatment options for geriatric patients with lower extremity fractures, little is known about which outcomes are prioritized by patients. This study aimed to determine the patient preferences for outcomes after a geriatric lower extremity fracture.

Materials and Methods

We administered a discrete choice experiment survey to 150 patients who were at least 60 years of age and treated for a lower extremity fracture at a Level I trauma center. The discrete choice experiment presented study participants with 8 sets of hypothetical outcome comparisons, including joint preservation (yes or no), risk of reoperation at 6 months and 24 months, postoperative weightbearing status, disposition, and function as measured by return to baseline walking distance. We estimated the relative importance of these potential outcomes using multinomial logit modeling.

Results

The strongest patient preference was for maintained function after treatment (59%, P < .001), followed by reoperation within 6 months (12%, P < .001). Although patients generally favored joint preservation, patients were willing to change their preference in favor of joint replacement if it increased function (walking distance) by 13% (SE, 66%). Reducing the short-term reoperation risk (12%, P < .001) was more important to patients than reducing long-term reoperation risk (4%, P = .33). Disposition and weightbearing status were lesser priorities to patients (9%, P < .001 and 7%, P < .001, respectively).

Discussion

After a lower extremity fracture, geriatric patients prioritized maintained walking function. Avoiding short-term reoperation was more important than avoiding long-term reoperation. Joint preservation through fracture fixation was the preferred treatment of geriatric patients unless arthroplasty or arthrodesis provides a meaningful functional benefit. Hospital disposition and postoperative weightbearing status were less important to patients than the other included outcomes.

Conclusions

Geriatric patients strongly prioritize function over other outcomes after a lower extremity fracture.

Prediction of Non-Home Discharge Following Total Hip Arthroplasty in Geriatric Patients

Introduction

The majority of total hip arthroplasty (THA) patients are discharged home postoperatively, however, many still require continued medical care. We aimed to identify important characteristics that predict nonhome discharge in geriatric patients undergoing THA using machine learning. We hypothesize that our analyses will identify variables associated with decreased functional status and overall health to be predictive of non-home discharge.

Materials and Methods

Elective, unilateral, THA patients above 65 years of age were isolated in the NSQIP database from 2018-2020. Demographic, pre-operative, and intraoperative variables were analyzed. After splitting the data into training (75%) and validation (25%) data sets, various machine learning models were used to predict non-home discharge. The model with the best area under the curve (AUC) was further assessed to identify the most important variables.

Results

In total, 19,840 geriatric patients undergoing THA were included in the final analyses, of which 5194 (26.2%) were discharged to a non-home setting. The RF model performed the best and identified age above 78 years (OR: 1.08 [1.07, 1.09], P < .0001), as the most important variable when predicting non-home discharge in geriatric patients with THA, followed by severe American Society of Anesthesiologists grade (OR: 1.94 [1.80, 2.10], P < .0001), operation time (OR: 1.01 [1.00, 1.02], P < .0001), anemia (OR: 2.20 [1.87, 2.58], P < .0001), and general anesthesia (OR: 1.64 [1.52, 1.79], P < .0001). Each of these variables was also significant in MLR analysis. The RF model displayed good discrimination with AUC = .831.

Discussion

The RF model revealed clinically important variables for assessing discharge disposition in geriatric patients undergoing THA, with the five most important factors being older age, severe ASA grade, longer operation time, anemia, and general anesthesia.

Conclusions

With the rising emphasis on patient-centered care, incorporating models such as these may allow for preoperative risk factor mitigation and reductions in healthcare expenditure.

Functional Outcomes of Anterior-Based Muscle Sparing Approach Compared to Direct Lateral Approach for Total HIP Arthroplasty Following Acute Femoral Neck Fractures

Introduction

Total hip arthroplasty (THA) performed for femoral neck fractures (FNFs) is becoming a more frequent treatment in the active elderly population. Since there is limited research available presenting clinical outcomes after THA using the anterior-based muscle sparing (ABMS) approach, the aim of this study was to compare this surgical approach to the direct lateral (DL) approach in patients treated by THA for FNFs.

Materials and Methods

We retrospectively reviewed the data prospectively collected as a part of our "Hip Fracture Unit" and included 163 patients who underwent THA from January 2016 to January 2019 for acute displaced FNFs.

Results

A total of 132 patients who completed a minimum 2-years follow up (69 in the ABMS group and 63 in DL group) were included. The ABMS group demonstrated significantly shorter time to reach milestone for hospital discharge (1.5 Days vs 2.1 days, P = .018), while no statistically significant differences were detected in peri-operative complications. At 3 months, the timed up and go test, the Harris Hip Score (HHS) and the Oxford ip Score (OHS) were significantly better (P = .024, .032 and .034, respectively) in the ABMS group compared to the DL group. No differences were found in functional outcomes (HHS and OHS) nor in complication rate at 6, 12 and 24 months.

Discussion

This is one of the first studies to analyze functional results of THA performed for FNFs through an ABMS approach. Results are in line with those already present in the Literature.

Conclusion

ABMS approach allows earlier mobilization and better early functional outcomes, compared to DL approach, in patients undergoing THA for acute displaced FNF. No differences are found after 6 months in functional results and complications rate.

A Novel Osteoporosis Screening Protocol to Identify Orthopedic Surgery Patients for Preoperative Bone Health Optimization

Introduction

Osteoporosis is highly prevalent in elective orthopedic surgery. While preoperative bone health optimization decreases osteoporosis-related complications, there is an unmet need to establish who may benefit from preoperative dual-energy x-ray absorptiometry (DXA). This study assesses a novel, simple screening protocol to identify orthopedic surgical patients for preoperative DXA.

Materials/Methods

This retrospective cohort study included 628 patients undergoing total knee, hip, or shoulder arthroplasty or thoracolumbar spine fusion. Inclusion criteria were ≥40 years undergoing primary elective surgery. Screening criteria defining who should obtain DXA due to high osteoporosis risk included: female ≥65, male ≥70, fracture history when ≥50 years, or FRAX major osteoporotic fracture risk (without bone mineral density [BMD]-adjustments) ≥8.4%. Osteoporosis was defined by World Health Organization criteria [T-score ≤ -2.5], clinical National Osteoporosis Foundation (NOF) criteria [T-score ≤ -2.5, elevated BMD-adjusted FRAX risk, or prior hip/spine fracture], and modified clinical criteria [NOF criteria simplified to include any non-traumatic prior fracture and FRAX without BMD].

Results

The study included 100 TKAs, 100 THAs, 251 TSAs, and 177 spine fusions, average age 65.6 ± 9.8. DXA was available for 209 patients. Screening criteria recommending DXA was met by 362 patients. For those with DXA, screening sensitivity was .96 (CI: .78 to .99) and specificity was .19 (CI: .14 to .25) for identifying T-score osteoporosis. Similar sensitivity of .99 (CI: .91 to .99) and specificity of .61 (CI: .56 to .66) were found for modified clinical osteoporosis. For modified clinical osteoporosis, 192 patients with osteoporosis met criteria (true pos.), 1 patient with osteoporosis did not meet criteria (false neg.), 170 patients without osteoporosis met criteria (false pos.), and 265 patients without osteoporosis did not meet criteria (true neg.).

Discussion/Conclusion

A simple screening protocol identifies orthopedic surgical candidates at risk of T-score or clinical osteoporosis for preoperative DXA with high sensitivity.

Radiological Outcome Measures Indicate Advantages of Precontoured Locking Compression Plates in Elderly Patients With Split-Depression Fractures to the Lateral Tibial Plateau (AO41B3)

Background

Split-depression fractures to the lateral tibial plateau (AO41B3) often feature severe joint surface destructions. Precontoured locking compression plates (LCPs) are designed for optimum support of the reduced joint surface and have especially been emphasized in reduced bone quality. A lack of evidence still inhibits their broad utilization in elderly patients. Thus, aim of the present study was to investigate the implant-specific radiological outcomes of AO41B3-fractures in young versus elderly patients.

Methods

The hospital’s database was screened for isolated AO41B3-factures, open reduction and internal fixation (ORIF), and radiological follow-up ≥12 months. CT-scans, radiographs, and patients’ records were analyzed. Patients were attributed as young (18–49) or elderly (≥50 years). Additional subgrouping was carried out into precontoured LCP and conventional implants. The Rasmussen Radiological Score (RRS) after 12 months was set as primary outcome parameter. The RRS postoperatively and the medial proximal tibial angle (MPTA) postoperatively and after 12 months were secondary outcome parameters.

Results

Fifty nine consecutive patients were included (26 young, 38.2 ± 7.8 years; 33 elderly, 61.3 ± 9.4 years). There were no significant differences regarding mean size and depression depth of the lateral joint surface fragments. Prior to implant-specific subgrouping, the radiological outcome measures revealed no significant differences between young (RRS = 7.7 ± 1.7; MPTA = 90.3 ± 2.3°) and elderly (RRS = 7.2 ± 1.7; MPTA = 90.5 ± 3.3°). After implant-specific subgrouping, the radiological outcome revealed significantly impaired results in young patients with conventional implants (RRS_(C) = 6.9 ± 1.6, RRS_(LCP) = 8.5 ± 1.5, P = .015; MPTA_(C) = 91.5 ± 1.9°, MPTA_(LCP) = 89.1 ± 2.1°, P = .01). The effect was even more pronounced in elderly patients, with highly significant deterioration of the radiological outcome measures for conventional implants compared to precontoured LCP (RRS_(C) = 5.7 ± 1.6, RRS_(LCP) = 8.2 ± .8, P < .001; MPTA_(C) = 92.6 ± 4.2°, MPTA_(LCP) = 89.2 ± 1.4°, P = .002).

Conclusion

Utilizing precontoured LCP in the treatment of AO41B3-fractures is associated with improved radiological outcomes. This effect is significant in young but even more pronounced in elderly patients. Consequently, precontoured LCP should closely be considered in any AO41B3-fracture, but especially in elderly patients.

A Solution to After-Hours Fatigue and Surgical Backlog

After-hours surgery represents a novel solution that can effectively combat surgical fatigue of care teams in addition to addressing the high volume of surgical backlog associated with the repercussions of the COVID-19 pandemic. This commentary seeks to rationalize how successful employment of a dedicated after-hours surgical team and protocol has tremendous potential for increased efficiency while maintaining good surgical outcomes in patients.

A Nomogram for Predicting 30-day Mortality in Elderly Patients Undergoing Hemiarthroplasty for Femoral Neck Fractures

Introduction

Femoral neck fractures in the elderly are increasingly common as a result of a growing geriatric population with 1-year mortality rates approaching 35%. While preoperative medical optimization and early time to surgery have reduced morbidity and mortality, patients with numerous medical comorbidities remain high risk for death in the perioperative period. Identifying those with greatest risk with a scoring system or nomogram may assist multidisciplinary teams in reducing mortality following hemiarthroplasty.

Purpose

Identify predictors of 30-day mortality in elderly patients who underwent hemiarthroplasty for a femoral neck fracture to generate a predictive nomogram to determine the probability of post-operative mortality.

Methods

Retrospective evaluation using data from the ACS-NSQIP database from 2005 to 2014 with CPT code 27125 for hip hemiarthroplasty. Multiple factors including demographics and comorbidities were compared in patients who experienced 30-day mortality and those who did not. T-test and chi-square tests were used to analyze data and a multivariate model was generated using logistic regression.

Results

Advanced age (odds ratio (OR) 1.04), underweight BMI (OR 1.55), male sex (OR 1.80), reduced functional status (OR 2.04), heart failure within 30 days prior to surgery (OR 2.22), American Society of Anesthesiologists grade > 2 (OR > 2.50), disseminated cancer (OR 3.43) were all found to have statistically significant odds ratios for 30-day mortality following hemiarthroplasty.

Conclusion

A tool based on easily identifiable risk factors, demographics, and comorbidities was developed that can help predict elderly patients who will experience mortality within 30 days of following hemiarthroplasty. In addition to identifying high risk patients, the nomogram can serve as a counseling tool for physicians to use with patients and their families to assist with better understanding of perioperative mortality risk.

Utilization of an Orthopedic Hood as Personal Protective Equipment for Intubation of Coronavirus Patients: a Brief Technical Report

Background

The novel coronavirus disease (COVID-19) has afflicted millions of people worldwide since its first case was reported in December 2019. Personal protective equipment (PPE) has been tailored accordingly, but as of April 2020, close to 10 000 health care workers in the United States have contracted COVID-19 despite wearing recommended PPE. As such, standard guidelines for PPE may be inadequate for the health care worker performing high-risk aerosolizing procedures such as endotracheal intubation. In this brief technical report, we describe the integration of an orthopedic hood cover as an item for full barrier protection against COVID-19 transmission.

Technical Description

The Coronavirus Airway Task Force at Virginia Commonwealth University Medical Center approved this initiative and went live with the full barrier suit during the last week of March 2020. The PPE described in this report includes a Stryker T4 Hood, normally used in conjunction with the Stryker Steri-Shield T4 Helmet. Instead of the helmet, the hood is secured to the head via a baseball cap and binder clip. This head covering apparatus is to be used as an accessory to other PPE items that include an N95 mask, waterproof gown, and disposable gloves. The motor ventilation system is not used in order to prevent airborne viral entry into the hood.

Discussion

An advantage of the full barrier suit is an additional layer of droplet protection during intubation. The most notable disadvantage is the absence of a ventilation system within the hood covering.

Conclusion

Modification of existing PPE may provide protection for health care workers during high-risk aerosolizing procedures such as endotracheal intubation. Although the integration of this medical equipment meets the immediate needs of an escalating crisis, further innovation is on the horizon. More research is needed to confirm the safety of modified PPE.

The Impact of Music and Noise-Cancellation on Sedation Requirements During Total Knee Replacement: A Randomized Controlled Trial

Background:

Music has emerged as a well-received medical intervention. Patients may be uncomfortable during total joint replacement, which can result in high sedation requirements. These requirements place elderly patients at risk for delirium. This study compares the effect of noise-cancellation versus music medicine on sedation requirements, pain, and opioid consumption during elective total knee replacement.

Methods:

This prospective, double-blinded, randomized clinical trial was conducted at Virginia Commonwealth University Medical Center between July 2018 and July 2019. All participants underwent primary total knee arthroplasty with a combined spinal-epidural as their primary anesthetic and received noise-cancelling, wireless headphones. Patients in the control group received the noise-cancellation feature only, while patients in the experimental group were permitted to listen to music of their choice. Patients signaled a request for sedation by squeezing a noise-making rubber hippopotamus toy. The primary outcomes included whether sedation was requested by the participant, the number of sedation demand doses requested, and the amount of propofol sedation administered during the procedure. Secondary outcomes included postoperative pain scores, total opioid consumption, and time to first opioid request.

Results:

Seventy-one percent (n = 36) of patients agreed to participate in the study. Forty-four percent of participants in the noise-cancellation group and 19% of participants in the music group requested sedation (P = .25). The median propofol consumption was not different between groups (0 [0-6.7] µg/kg/min vs 0 [0-0] µg/kg/min, P = .101 for noise cancellation vs music, respectively). Pain scores and opioid consumption were not different between groups.

Discussion:

To date, this is the first study to use Bluetooth communication, noise-cancellation, and an Internet-based music streaming service to determine whether this technology has an impact on outcomes during major orthopedic surgery.

Conclusion:

As an isolated intervention, the benefits of music in a complex operating room environment may be overstated. However, music integration with noise-reduction technology and patient-controlled sedation may lead to a safer and more satisfying anesthetic. More research is needed to determine the nonpharmacologic interventions that will produce positive outcomes for the geriatric population.

The "Hip Fracture" Bundle-Experiences, Challenges, and Opportunities

Introduction:

With growing popularity and success of alternative-payment models (APMs) in elective total joint arthroplasties, there has been recent discussion on the probability of implementing APMs for geriatric hip fractures as well.

Significance:

Despite the growing interest, little is known about the drawbacks and challenges that will be faced in a stipulated “hip fracture” bundle.

Results:

Given the varying intricacies and complexities of hip fractures, a “one-size-fits-all” bundled payment may not be an amenable way of ensuring equitable reimbursement for participating physicians and hospitals.

Conclusions:

Health-policy makers need to advocate for better risk-adjustment methods to prevent the creation of financial disincentives for hospitals taking care of complex, sicker patients. Hospitals participating in bundled care also need to voice concerns regarding the grouping of hip fractures undergoing total hip arthroplasty to ensure that trauma centers are not unfairly penalized due to higher readmission rates associated with hip fractures skewing quality metrics. Physicians also need to consider the launch of better risk-stratification protocols and promote geriatric comanagement of these patients to prevent occurrences of costly adverse events.

Long-Term Results of Hip Arthroplasty Using Extensive Porous-Coated Stem-A Minimum Follow-Up of 15 Years

Introduction:

We report the clinical and radiographic results of hip arthroplasty using extensive porous-coated stems over 15 years in Korea.

Methods:

This retrospective study included 210 patients (268 hips) who underwent total hip arthroplasties (232 hips) and bipolar hemiarthroplasties (36 hips) between June 1996 and December 2002 for avascular necrosis of the femoral head, hip fracture, or osteoarthritis, after excluding those who died or were lost to follow-up. One senior author (K.H.M.) evaluated Harris Hip Score (HHS); limping gait; and leg length discrepancy, and 3 independent reviewers assessed the radiographic findings, including the level of stress shielding, Dorr classification, subsidence and loosening of femoral stem, heterotopic ossification (Brooker classification), osteolysis of acetabulum, wear rate of the polyethylene liner, component loosening, and revision rate.

Results:

The mean follow-up duration was 16.9 years and average age at operation was 50.9 years. The HHS improved at the last follow-up. Stress shielding was grade 1 in 185 hips, grade 2 in 35 hips, grade 3 in 37 hips, and grade 4 in 11 hips. Femoral stem subsidence was <3 mm in 4 hips and >3 mm in 6 hips. Femoral stems with stable bony ingrowth were observed in 258 hips, fibrous stable femoral stems in 4 hips, and unstable femoral stems in 6 hips. Heterotopic ossification was class 1 in12 and class 2 in 4 hips. Revision surgery was performed for periprosthetic osteolysis of cup (45 hips), recurrent dislocation (1), unstable femoral stem (1), and infection (1). The Kaplan-Meier survivorship at the 15-year follow-up was 86.2%. The survivorship of femoral stem at 15 years was 99.3%, and if including impending revision due to unstable femoral stem was 97.1%.

Disscussion:

This study has all the limitations inherent with a retrospective design. However, a large number of patients in this cohort operated on by a single surgeon and a long-term follow-up are some of the potential advantages of the current study.

Conclusions:

At the 15-year follow-up, extensive porous-coated stem showed relatively good survivorship even in geriatric patients (Dorr type C).

The Positive Benefits of Negative Movement Patterns Following Total Knee Arthroplasty

Introduction:

Eccentric (negative) resistance exercise of the legs using specialized machines has been reported to be useful and often superior to standard exercise following total knee arthroplasty (TKA). Movements that utilize body mass and gravity as a mode of eccentric resistance exercise in a more pragmatic rehabilitation paradigm may also be useful in reversing chronic muscle impairments observed years following surgery. This study explores whether an eccentrically biased, body mass resistance exercise induces greater magnitude of sagittal plane extensor angular impulse of the support torque and individual net joint torque contributions during both squatting and lunging movement patterns 6 weeks following TKA.

Methods:

Cross-sectional laboratory-based study design including 10 patients following primary unilateral TKA (6.5 ± 0.8 weeks.). All patients completed 3 trials of the squat and lunge movement pattern under both a concentric and an eccentric condition. Extensor angular impulse of the support torque and net joint torque contributions were calculated by integrating the joint torque versus time curves. A Two-way analysis of covariance was conducted and contracts of clinical interest were computed using Wald posttest. P Values for all pairwise comparisons were adjusted for multiplicity using Bonferroni multiple comparison procedure.

Results:

The eccentric condition, compared to the concentric condition, displayed larger magnitude of extensor angular impulse during both the squat (P < .001) and lunge (P < .001) movement patterns for the support torques. Similarly, the eccentric condition, compared to the concentric condition, displayed larger magnitude of extensor angular impulse of the hip, knee, and ankle (P < .001) during both movement patterns.

Conclusion:

Eccentrically biased, body mass movement exercises can produce higher levels of extensor angular impulse on the surgical limb in patients early after TKA. Patients in this study were able to tolerate the higher extensor angular impulse demands and performed the eccentrically biased conditions (without specialized machines) that could be beneficial in postoperative rehabilitation.

Operative Trends in the Treatment of Hip Fractures and the Role of Arthroplasty

Introduction:

There is a projected exponential increase in the number of hip fractures in the United States. Trends in patient demographics and the role of total hip arthroplasty (THA) and its associated outcomes following hip fractures surgery have not been well studied.

Methods:

Patients with proximal femur fractures between 1990 and 2007 were identified in the National Hospital Discharge Survey database. Demographics, comorbidities, perioperative complications, and discharge status for patients undergoing THA, hemiarthroplasty, or internal fixation were examined. Multivariable regression was performed to determine independent risk factors for perioperative complications.

Results:

Between 1990 and 2007, there was a statistically significant increase in patient age, adverse events, medical comorbidities, surgical complications, medical complications, and nonroutine discharge across all surgical treatment modalities. In the same time period, the utilization of THA for all fracture types decreased significantly.

Discussion:

Total hip arthroplasty was found to be an independent risk factor for perioperative complications. Orthopedic surgeons should be aware that the hip fracture population continues to get older, with more medical comorbidities and are at higher risk for perioperative complications.

Conclusion:

Total hip arthroplasty is associated with a higher rate of perioperative complications in the hip fracture population.

Preoperative Factors Influencing Decision Between Hemiarthroplasty and Total Hip Arthroplasty in Femoral Neck Fractures in Indian Patients-Retrospective Single-Center Study

INTRODUCTION

The percentage of elderly population is increasing worldwide, with increasing incidence of femoral neck fractures. An increasing trend of arthroplasty for femoral neck fracture is observed. We aim to retrospectively analyze the preoperative factors that seem to influence the decision between hemiarthroplasty and total hip arthroplasty for managment of the same.

MATERIALS AND METHODS

Patients admitted with femoral neck fracture during January 2010 to March 2015 in our institute were included in the study. The preinjury independency status was assessed using Katz index scoring system. Based on the data obtained from case sheets, the patients were segregated into hemiarthroplasty group and total hip arthroplasty group. Variables that preferentially appeared in the individual group were identified.

RESULTS

A total of 206 hips of 199 patients were included in the study. The factors that seem to influence the decision between hemiarthroplasty and total hip arthroplasty with a statistical significance were age, Katz index score, and American Society of Anesthesiologists (ASA) grade. Higher ASA grades caused delay in surgery, increasing the length of hospital stay, and these patients more commonly underwent hemiarthroplasty.

DISCUSSION

Patients' preinjury functional status influenced the decision between hemiarthroplasty and total hip arthroplasty, especially in the age between 65 and 80 years. Preoperative comorbidities did not prevent the patient from undergoing total hip replacement due to early optimization for surgery with the help of the dedicated orthogeriatric team.

CONCLUSION

We conclude that preinjury functional independency of a patient is an important decisive factor in the choice between hemiarthroplasty and total hip arthroplasty. In addition to other factors including age and comorbidity pattern, scoring methods for preinjury functional status of patient could aid in decision-making. Early optimization, early surgery, and faster rehabilitation help the patients to achieve their preinjury functional status.

Disparities in Total Hip Arthroplasty Versus Hemiarthroplasty in the Management of Geriatric Femoral Neck Fractures

Introduction:

Recent clinical evidence suggests that total hip arthroplasty (THA) provides improved clinical outcomes as compared to hemiarthroplasty (HA) for displaced femoral neck fractures in elderly individuals. However, THA is still utilized relatively infrequently. Few studies have evaluated the factors affecting utilization and the role socioeconomics plays in THA versus HA.

Methods:

In the United States, the National Inpatient Sample (NIS) database was used to identify patients treated surgically for femoral neck fracture, between 2009 and 2010. Patients were identified using International Classification of Diseases, Ninth Revision, codes for closed, transcervical femoral neck fractures and closed fractures at unspecified parts of the femoral neck. All candidate predictors of THA versus HA were entered into a multilevel mixed-effect regression model.

Results:

Older patient age, being Asian or Pacific Islander, and having Medicaid payer status were all associated with lower odds of receiving THA. Patients with private insurance including Health Maintenance organization (HMO) had higher odds of THA as did patients with other insurance. Odds of THA were significantly lower among patients in teaching hospitals and higher at hospitals with greater THA volume.

Discussion:

Ethnicity, payer status, hospital size, and institutional THA volume were all associated with the utilization of THA versus HA in the treatment of geriatric femoral neck fractures.

Level of Evidence:

Level III Retrospective Cohort study.

The Use of MoCA and Other Cognitive Tests in Evaluation of Cognitive Impairment in Elderly Patients Undergoing Arthroplasty

OBJECTIVE

To examine the prevalence and effect of cognitive impairment on treatment outcomes in elderly patients undergoing arthroplasty and to describe the feasibility of cognitive tests.

MATERIALS AND METHODS

The participants were 52 patients with a mean age of 78 years 11 months (SD: 3.3), waiting for primary arthroplasty. We translated Montreal Cognitive Assessment (MoCA) into Finnish and compared it with Mini-Mental State Examination (MMSE), Mini-Cog, and clock-drawing tests prior to and 3 months after the surgery. The ability to perform activities of daily living, depression, quality of life, and years of education were evaluated.

RESULTS

The mean MoCA score on the first visit was 20.7 (SD: 4.1). The pre- and postoperative cognitive tests implied there were no changes in cognitive functioning. Unambiguous delirium was detected in 6 patients. Delirium was not systematically assessed and consequently hypoactive delirium cases were possibly missed. Both MMSE and Mini-Cog found 3/6 of those and clock drawing and MoCA 6/6. Low preoperative MoCA, MMSE, and Mini-Cog scores predicted follow-up treatment in health-care center hospitals (P = .02, .011, and .044, respectively). During the 5-year follow-up period, 11/52 patients died. Higher education was the only variable associated with survival. The survivors had attained the median of 8 (range: 4-19) years of education compared with 6 (range: 4-8) years among the deceased.

CONCLUSION

The prevalence of cognitive impairment among older patients presenting for arthroplasty is high and mostly undiagnosed. It is feasible to use the MoCA to identify cognitive impairment preoperatively in this group. The clock-drawing test was abnormal in all patients with postoperative delirium, which could be used as a screening test. Higher education predicted survival on a 5-year follow-up period.

Distal Radius Fracture Outcomes and Rehabilitation

Distal radius fractures account for nearly 1 of every 5 fractures in individuals aged 65 or older. Moreover, increased susceptibility to vertebral and hip fractures has been documented in patients a year after suffering a distal radius fracture. Although women are more susceptible to hip fractures, men experience a higher mortality rate in the 7 years following a distal radius fracture. Traditional approaches to distal radius fractures have included both surgical and nonsurgical treatments, with predominant complaints involving weakness, stiffness, and pain. Nonsurgical approaches include immobilization with or without reduction, whereas surgical treatments include dorsal spanning bridge plates, percutaneous pinning, external fixation, and volar plate fixation. The nature of the fracture will determine the best treatment option, and surgeons employ a multifactorial treatment approach that includes the patient’s age, nature of injury, joint involvement, and displacement among other factors. Historically, closed reduction and percutaneous pinning have been the most popular approaches. However, volar plate fixation is quickly becoming a popular option as it minimizes tendon irritation, reduces immobilization time, and decreases risk of complication. The goal of treatment is to restore mobility, reduce pain, and improve functional outcomes following rehabilitation. The aim of this review is to summarize the most common treatments and importance of early referral to hand therapy to improve functional outcomes.

Retentive Cup Arthroplasty in Selected Hip Fracture Patients-A Prospective Series With a Minimum 3-Year Follow-Up

Objective:

To evaluate the efficacy of the use of retentive cup primary total hip replacement (THR) in high-dislocation risk subcapital fracture patients.

Methods:

During the years 2008 to 2012, 354 patients with displaced subcapital fracture were operated at our institute. The patients were selected to undergo primary constrained THR according to the following criteria: (1) a preinjury grade 4 or more on the Functional Independence Measure mobility item “5. Locomotion: walking/wheelchair” and grade 4 is defined as “4. Minimal assistance Requiring incidental hands-on help only” (patient performs >75% of the task) and (2) a disease leading to poor motor control. Exclusion criteria were normal muscular control and known infection of the involved joint.

Results:

Of the 354 patients, 87 fulfilled the inclusion criteria and underwent constrained total hip. Average age was 78 years with a female predominance (73%). Fifteen patients had prior hemiparesis, 19 had Parkinson disease, and 35 had generalized sarcopenia. Eighty-five patients had an uneventful recovery, with an average Hip Disability and Osteoarthritis Outcome Score (HOOS) of 76 ± 7 at 2 years. In 2 patients, the prostheses dislocated. In both cases, the dislocation was due to ring displacement and the inner head dislocated. One case was infected and the patient was treated by a Girdlestone procedure. In the other case, the prosthetic head was revised. The patient remained asymptomatic and at 4-year follow-up had an HOOS of 85.

Discussion:

It appears that constrained prosthesis is a suitable treatment for patients with poor muscular control having subcapital fractures. The functional results appear to be superior to those of bipolar arthroplasty and similar to the results of primary total hip arthroplasty while the dislocation risk is <3%.

Conclusion:

Semielective total hip arthroplasty using a retentive cup liner appears to offer good functional results with a low dislocation rate in patients with poor muscular control.

Review of Postoperative Delirium in Geriatric Patients Undergoing Hip Surgery

Postoperative delirium is a serious complication following hip surgery in elderly patients that can adversely affect outcomes in both hip fracture and arthroplasty surgery. Recently, the incidence of hip fracture in the Medicare population was estimated at approximately 500 000 patients per year, with the majority treated surgically. The annual volume of total hip arthroplasty is nearly 450 000 patients and is projected to increase over the next 15 to 20 years. Subsequently, the incidence of postoperative delirium will rise. The incidence of postoperative delirium after hip surgery in the elderly patients ranges between 4% and 53%, and it is identified as the most common surgical complication of older patients. The most common risk factors include advanced age, hip fracture surgery (vs elective hip surgery), and preoperative delirium/cognitive impairment. Exact pathophysiology has not been fully defined. It is hypothesized that imbalances in cortical neurotransmitters or inflammatory cytokine pathway mechanisms contribute to delirium. Development of postoperative delirium is associated with longer hospital stay, increased medical complications, and poorer short-term functional outcome. Patients who develop postoperative delirium are also at increased risk for cognitive decline beyond the acute phase. Following acute care, postoperative delirium is associated with the need for a higher level of care, an additional cost. Management of postoperative delirium centers on prevention and early recognition. Medical prophylaxis has been demonstrated to have limited utility. Utilization of delirium detection methods contributed to early recognition. The most effective means of prevention involved a multidisciplinary team focused on adequate hydration, optimization of analgesia, reduction in polypharmacy, aggressive physiotherapy, and early recognition of the delirium symptoms.

Self-Reduction of Displaced Bucket-Handle Medial Meniscal Tear in a 71-Year-Old Patient: A Case Report

Background:

Bucket-handle meniscal tears are rare in geriatric patients. Displaced bucket-handle meniscal tears are usually treated operatively. Due to the rarity of these tears in elderly patients and conflicting evidence regarding the use of arthroscopy versus conservative treatment, it is valuable to report the clinical presentation, treatment, and outcome of these injuries in elderly patients.

Case Description:

We describe a 71-year-old man who presented with an acute, displaced, magnetic resonance imaging (MRI)-confirmed right medial meniscal bucket-handle tear with mild effusion and no signs of degenerative joint disease. On physical examination, the patient was unable to fully extend the right leg due to locking of the knee. At 2-month follow-up, MRI showed mild degenerative changes and an anatomically reduced tear. At 6-month follow-up, the patient reported normal, pain-free knee function, and MRI showed the tear healing in anatomic position with minimal inferior surface changes and no effusion. He returned to his pain-free baseline level of physical activity.

Literature Review:

Upon review of the English literature, this 71-year-old patient is an exceptional case and one of the oldest patients reported to have sustained a displaced medial meniscal bucket-handle tear treated successfully with nonoperative means. Two reported cases of spontaneously reduced meniscal bucket-handle tears were found in the English literature, although both cases were seen in much younger males and involved the lateral meniscus.

Clinical Relevance:

This case suggests that in elderly patients with displaced medial meniscus bucket-handle tears that reduce spontaneously, the physician can safely and efficaciously use conservative, nonoperative management to achieve restoration of baseline knee function and anatomic meniscal healing while avoiding the risks of arthroscopic surgery. Surgical intervention for reduction without repair may be an available option, but no literature is present to direct care; however, complete documentation as in the current case would be instructive. Katz et al have reported that physical therapy was as efficacious as surgical intervention, although the specific displaced bucket-handle tear was not reported.

Factors Influencing Discharge Destination After Total Hip Arthroplasty: A California State Database Analysis

INTRODUCTION

With this growing demand, the length of stay for total hip arthroplasty (THA) procedures has decreased, and as a trade-off, we have seen a higher utilization of extended care facilities (ECFs). Both trends have significant economic implications on the health care system, and predicting the discharge destinations of THA patients would help policy makers plan for future health expenditures. We performed a retrospective data analysis of a large patient database to determine which variables are significant in predicting discharge destinations of THA patients.

METHODS

We used the California Hospital Discharge data set of the year 2010, collected and provided by the Office of Statewide Health Planning and Development. The data set includes information about patient demographics, insurance type, diagnoses and procedures, and patient disposition. The study cohort included 14 326 patients. Discharge to home was the reference category. Discharge to ECF and discharge to home with home care were the 2 additional alternatives.

RESULTS

In all, 46.9% of patients were discharged home with home health care, followed by 29.6% to ECF, and 23.5% to home without care. Discharge to ECF was more likely for patients with more comorbidities and a higher age. The strongest predictors were Medicaid and black or Asian race. Medicare relative to private payer was a strong predictor of ECF discharge. Male gender was the only factor that lowered the risk of discharge to ECF. The strongest predictor for discharge to home with home care was black race relative to whites. Medicaid lowered the risk of home care, and gender did not matter.

CONCLUSION

This study serves to provide insight on which patient characteristics influence discharge destination after THA. Race, insurance, and morbidity were highly significant factors on patient discharge destination to a subacute nursing facility.

Does a Preoperative Educational Class Increase Patient Compliance

Past studies have shown successful outcomes regarding the use of various interventional education methods in improving patient compliance. At our institution, different educational resources are offered and encouraged, including a 2-hour–long educational class, to prepare patients who are undergoing total joint arthroplasty procedures. Given the significant impact that patient compliance with preoperative instruction can have on overall outcomes of these procedures, this study was intended to assess the effects that the educational classes can have on patient compliance with this institution’s 6-point preoperative total joint arthroplasty protocol. The study analyzed 2 groups, those who did and did not attend the preoperative classes, and compliance rates were compared between the 2. It was hypothesized that patients who did attend the classes would be more compliant to the protocol compared to those who did not. Although results from the study showed that there were no significant differences in adherence between the 2 groups, future quality assessment studies can build off this in order to move toward achieving optimal patient compliance with preoperative instructions.

Preoperative factors and early complications associated with hemiarthroplasty and total hip arthroplasty for displaced femoral neck fractures

Displaced femoral neck fractures are common injuries in the elderly individuals. There is controversy about the best treatment with regard to total hip arthroplasty (THA) versus hemiarthroplasty. This study uses the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to evaluate the preoperative risk factors associated with the decision to perform THA over hemiarthroplasty. We also evaluate the risk factors associated with postoperative complications after each procedure. Patients older than 50 years undergoing hemiarthroplasty or THA after fracture in the NSQIP database from 2007 to 2010 were compared to each other in terms of preoperative medical conditions, postoperative complications, and length of stay. Multivariate logistic regression models were used to adjust for preoperative risk factors for undergoing a THA versus a hemiarthroplasty and for complications after each procedure. In all, 783 patients underwent hemiarthroplasty and 419 underwent THA for fracture. Hemiarthroplasty patients had longer hospital stays. On multivariate logistic regression, the only significant predictor for having a THA after fracture over hemiarthroplasty was being aged 50 to 64 years. The patient characteristics/comorbidities that favored having a hemiarthroplasty were age >80 years, hemiplegia, being underweight, having a dependent functional status, being on dialysis, and having an early surgery. High body mass index, American Society of Anesthesiologists (ASA) class, gender, and other comorbidities were not predictors of having one procedure over another. Disseminated cancer and diabetes were predictive of complications after THA while being overweight, obese I, or a smoker were protective. High ASA class and do-not-resuscitate status were significant predictors of complications after a hemiarthroplasty. This study identified clinical factors influencing surgeons toward performing either THA or hemiarthroplasty for elderly patients after femoral neck fractures. Younger, healthier patients were more likely to receive THA. Patients particularly at higher risks of complications after hemiarthroplasty should be monitored closely.

Outliers: hospitals with consistently lower and higher than predicted joint arthroplasty readmission rates

BACKGROUND

Little is known about readmission rates for total hip and total knee arthroplasty (THA and TKA). Our objective was to examine readmission rates and whether hospitals with high and low readmission rates at baseline remain outliers in subsequent years.

METHODS

We identified Medicare beneficiaries who underwent THA (N = 245 995) and TKA (N = 517 867) between 2003 and 2005. We created four different hospital cohorts: low and high volume for THA and TKA. We calculated 30-day risk-standardized readmission rates (RSRRs) for each hospital for each year. Hospitals were defined as having low (lowest 25% of all hospitals), high (highest 25% of hospitals), and intermediate readmission rates (all others) for each year. Hospitals were labeled outliers if they had consistently low or high readmission rates for all years. We examined the number and characteristics of outlier and nonoutlier hospitals.

RESULTS

Unadjusted readmission rates in 2003 for THA ranged from 0% to 94.7% (inter-quartile range: 0%-7.0%) and for TKA from 0% to 94.4% (inter-quartile range: 0.7%-5.9%). Of 255 low-volume THA hospitals with low readmission rates in 2003 (RSRRs ≤3.5%), 34 were outliers for all 3 years-significantly more than predicted (P < .0001). Likewise, of 256 low-volume THA hospitals with high readmission rates (RSRRs ≥5.8%) in 2003, 33 were outliers for all 3 years (P < .0001). Outlier and nonoutlier hospitals did not differ in meaningful ways (teaching status and staffing ratios). Results were similar for other hospital cohorts.

CONCLUSIONS

Using a 3-year window allows for identification of hospitals with consistently higher and lower readmission rates than predicted.