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BACKGROUND: Orthopaedic surgeons prescribe more opioid narcotics than any other surgical specialty. Proximal humerus fractures (PHF) often occur in the high-risk elderly population. The opioid epidemic has led to public policy aimed at reductions in opioid prescription. This study aimed to evaluate the impact that new legislation has had on opioid prescription patterns in patients who sustained proximal humerus fractures. METHODS: A retrospective review of all patients who sustained PHF at a single academic institution from 1/1/2015-12/31/2019 was performed. A total of 762 proximal humerus fractures were identified and final analysis included 383 patients. Collected data included basic demographics and opioid prescriptions obtained through review of the electronic medical record. The North Carolina Strengthen Opioid Misuse Prevention act legislation that went into effect on July 1, 2017. RESULTS: There was no difference in the number of pre- or postoperative opioid prescriptions provided with the new legislation. Our data showed a significant reduction in MeQs prescribed preoperatively pre-STOP act (188.1 MeQs) and post-STOP act (99.4 MeQs). There was also a significant difference in the amount of postoperative narcotics prescribed in the pre-STOP (972.6 MeQs) and post-STOP act (508.6 MeQs) groups (p < 0.01). CONCLUSIONS: With the enactment of the STOP act in North Carolina, we have seen a significant reduction in the amount of narcotic prescribed after sustaining a proximal humerus fracture preoperatively and postoperatively. This data demonstrates the impact that implementation of state-wide regulatory changes in opioid prescribing policy has had for a common orthopedic condition.
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Fraturas do Úmero , Transtornos Relacionados ao Uso de Opioides , Fraturas do Ombro , Humanos , Idoso , Analgésicos Opioides/uso terapêutico , Padrões de Prática Médica , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Estudos Retrospectivos , Fraturas do Ombro/cirurgia , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/epidemiologiaRESUMO
BACKGROUND: The shift from fee-for-service to value-based care has focused payers and providers on resource utilization. One important component of value-based care is to reduce the use of post-discharge (PD) services in a clinically appropriate manner following total joint arthroplasty (TJA). Demand matching in healthcare is the process of tailoring appropriate medical care to a patient with respect to that patient's specific medical needs and social determinants. Outcomes following the implementation of a demand-matching algorithm for coordinating PD services after TJA were analyzed in this study. METHODS: Payment data from all Medicare patients undergoing primary unilateral TJA between July 2014 and December 2018 from a single orthopedic practice were included. These payments were separated into acute and PD care. The initial acute and PD costs were compared to costs at the end of the 4-year study period using multiple linear regression and chi-square. RESULTS: A total of 9,638 patients (4,212 total hip arthroplasties and 5,430 total knee arthroplasties) were included. Acute costs of TJA were stable averaging $13,712.00. PD costs fell steadily from a baseline average of $7,319.00 in July 2014 to $4,678.00 in December 2018 (P < .001), representing a 36.1% decline. Discharge to home increased steadily from 45.8% to 79.9% during the same interval (P < .001.) CONCLUSION: Our results demonstrate a statistically significant reduction in PD costs over a 4-year period using a demand-matching strategy to align with the Centers for Medicare and Medicaid Services mandate for value-based care. Based on these data, we conclude that thoughtful preoperative assessment of patient factors such as social determinants and medical comorbidities could allow for cost reduction through better utilization of PD services.
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Artroplastia de Quadril , Artroplastia do Joelho , Assistência ao Convalescente , Idoso , Humanos , Medicare , Alta do Paciente , Estados UnidosRESUMO
BACKGROUND: Acetabular fractures often require surgical intervention for fracture fixation and can result in premature osteoarthritis of the hip joint. This study hypothesized that total hip arthroplasty (THA) in patients with a prior acetabular fracture who had undergone open reduction and internal fixation (ORIF) is associated with a higher rate of subsequent periprosthetic joint infection (PJI). METHODS: About 72 patients with a history of acetabular fracture that required ORIF, undergoing conversion THA between 2000 and 2017 at our institution, were matched based on age, gender, body mass index, Charlson comorbidity index, and date of surgery in a 1:3 ratio with 215 patients receiving primary THA. The mean follow-up for the conversion THA cohort was 2.9 years (range, 1-12.15) and 3.06 years (range, 1-12.96) for the primary THA. RESULTS: Patients with a previous acetabular fracture, compared with the primary THA patients, had longer operative times, greater operative blood loss, and an increased need for allogeneic blood transfusion (26.4% vs 4.7%). Most notably, PJI rate was significantly higher in acetabular fracture group at 6.9% compared with 0.5% in the control group. Complications, such as aseptic revision, venous thromboembolism, and mortality, were similar between both groups. CONCLUSION: The present study demonstrates that conversion THA in patients with prior ORIF of acetabular fractures is associated with higher complication rate, in particular PJI, and less optimal outcome compared with patients undergoing primary THA. The latter findings compel us to seek and implement specific strategies that aim to reduce the risk of subsequent PJI in these patients.
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Artroplastia de Quadril , Fraturas do Quadril , Acetábulo/cirurgia , Artroplastia de Quadril/efeitos adversos , Fraturas do Quadril/cirurgia , Humanos , Redução Aberta , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/cirurgia , Reoperação , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: This study aimed to investigate the risk factors for mechanical failure of cement spacers and the impact on hip function after two-stage exchange arthroplasty for periprosthetic joint infection (PJI). METHODS: Thirty-one patients (19 males and 12 females) with hip PJIs underwent resection arthroplasty and implantation of cement spacers from January 2014 to December 2015. Patients who encountered spacer-associated mechanical complications in the interim period (14 of 31) were compared with those without complications (17 of 31). Complications were defined as spacer dislocation, spacer fracture, spacer fracture with dislocation, and femoral fracture during or following spacer implantation. Hip functional outcome was assessed using the Harris hip score (HHS). Treatment success was defined according to the following criteria: (1) no symptoms or signs indicative of infection; (2) no PJI-related mortality; and (3) no subsequent surgical intervention for infection after reimplantation surgery. Multivariate logistic regression and Kaplan-Meier survival curves were used for analysis. RESULTS: Fourteen patients (14/31 = 45%) suffered at least one spacer-related complication within the interim period. The development of spacer complications was associated with a younger age (odds ratio [OR] 0.91, 95% confidence interval [CI] 0.83-1.00, p = 0.045) and chronic PJI (OR 14.7, 95% CI 1.19-182, p = 0.036). Patients with spacer complications also had a lower median HHS (37 vs. 60, p < 0.001) before reimplantation in comparison to those without spacer complications. After reimplantation, the two groups had a similar median HHS (90 vs. 89, p = 0.945). Two patients did not undergo reimplantation due to extensive comorbidities, and subsequently retained the antibiotic spacer for definitive treatment. The 2-year treatment success rate was 84.6% in the spacer-complication group and 87.5% in the non-spacer-complication group (p = 0.81). CONCLUSION: There was a high complication rate for articulating PMMA spacers during the interim period of two-stage revision total hip arthroplasty. A young age and chronic infection were the primary risk factors associated with mechanical complications. Patients at high risk of spacer-related mechanical complications should be advised accordingly by surgeons. Knowing the possible risk factors, surgeons should educate patients thoroughly to avoid spacer complications, thereby increasing patient satisfaction in the interim stage. LEVEL OF EVIDENCE: Prognostic Level III.
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Artroplastia de Quadril/efeitos adversos , Cimentos Ósseos/efeitos adversos , Prótese de Quadril/efeitos adversos , Falha de Prótese , Infecções Relacionadas à Prótese/cirurgia , Fatores Etários , Idoso , Artroplastia de Quadril/instrumentação , Artroplastia de Quadril/métodos , Doença Crônica , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Polimetil Metacrilato/efeitos adversos , Infecções Relacionadas à Prótese/etiologia , Infecções Relacionadas à Prótese/mortalidade , Reoperação/efeitos adversos , Reoperação/instrumentação , Reoperação/métodos , Fatores de Risco , Resultado do TratamentoRESUMO
BACKGROUND: Our experience with direct anterior approach total hip arthroplasty (THA) suggests that it can be performed successfully with a morphometrically optimized metaphyseal-diaphyseal engaging femoral stem (NOT a short stem), a regular operating room table (NOT a special custom table), and WITHOUT intraoperative fluoroscopy. We report our minimum 2-year results. METHODS: A retrospective review of a single-surgeon series of primary direct anterior approach THAs was performed. All procedures were performed on a regular table, without fluoroscopy, using a cementless tapered femoral stem. Clinical, functional, and radiographic outcomes were evaluated at a minimum of 2 years. RESULTS: In total, 1017 primary THAs were performed. The preoperative Harris Hip Score was 40.7 ± 5.1 and improved to 95.3 ± 4.2 at minimum 2-year follow-up. There were 3 dislocations (0.3%) and 15 revisions (1.5%): 7 for infection (0.7%), 4 for periprosthetic fractures (0.4%), 2 for instability (0.2%), 1 for loosening (0.1%), and 1 for pain (0.1%). Five patients (0.5%) required blood transfusion. One patient developed deep vein thrombosis and pulmonary embolism. No intraoperative fractures, perforation, or THA-related mortality occurred. Neutral stem alignment was confirmed in 98.3%. Mean cup inclination was 38.8° ± 5.1° and anteversion was 16.2° ± 3.5°. The mean leg-length discrepancy was corrected from 1.2 ± 0.2 cm preoperatively to 0.2 ± 0.1 cm postoperatively. CONCLUSION: Using a morphometrically optimized metaphyseal-diaphyseal engaging tapered femoral stem instead of a short stem reduces component malposition and minimizes risk of loosening. Combining the use of this implant design and the technique and elements described in our cohort demonstrated to have excellent results at 2 years. The patients will need continued follow-up to demonstrate further durability of this device and technique compared to others performing direct anterior THA.
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Artroplastia de Quadril/instrumentação , Prótese de Quadril , Adulto , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/métodos , Artroplastia de Quadril/estatística & dados numéricos , Diáfises/cirurgia , Feminino , Fêmur/cirurgia , Fluoroscopia , Humanos , Luxações Articulares , Masculino , Pessoa de Meia-Idade , Mesas Cirúrgicas , Fraturas Periprotéticas , Período Pós-Operatório , Desenho de Prótese , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND: Administration of perioperative antibiotic prophylaxis is one of the most important practices for prevention of periprosthetic joint infection (PJI) in patients undergoing total hip arthroplasty (THA). It is common to continue perioperative antibiotic prophylaxis for 48 hours or longer in patients undergoing revision arthroplasty, until results of intraoperative culture samples become available. However, the utility of this practice remains unclear. We examined whether extended antibiotic prophylaxis following aseptic revision THA reduces the risk of subsequent PJI. METHODS: We retrospectively reviewed records of patients undergoing aseptic revision THA between January 2000 and December 2015. At our institution, some surgeons administer prophylactic antibiotics to revision patients for only 24 hours while others prefer to extend until intraoperative culture results become available. We matched 209 patients undergoing revision THA who received extended antibiotic prophylaxis (>24 hours) in a 1:1 ratio with 209 patients receiving standard antibiotic prophylaxis (≤24 hours). The matching criteria were age, sex, body mass index, Charlson comorbidity index, and operative time. RESULTS: The incidence of subsequent PJI was 4.8% in patients receiving extended antibiotic prophylaxis vs 2.4% in patients receiving standard. After adjusting for all cofounders and using multivariate logistic regression, the administration of extended prophylactic antibiotics did not reduce the incidence of subsequent infection. When stratified by postoperative antibiotic regimens, the 2 groups had similar infection-free implant survival rate (95.2% in extended and 97.6% in standard). CONCLUSION: It appears that extending perioperative prophylactic antibiotics until intraoperative culture results become available in patients undergoing revision THA for aseptic failures does not provide any additional benefit in terms of reducing the risk of subsequent PJI.
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Antibacterianos/uso terapêutico , Antibioticoprofilaxia/métodos , Artroplastia de Quadril/efeitos adversos , Infecções Relacionadas à Prótese/prevenção & controle , Reoperação/efeitos adversos , Adulto , Idoso , Estudos de Casos e Controles , Esquema de Medicação , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Infecções Relacionadas à Prótese/etiologia , Sistema de Registros , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: Although an abundance of literature exists linking malnutrition with infectious complications in surgical patients, there is little specifically examining the link between malnutrition and periprosthetic joint infection (PJI). This study evaluated the relationship between abnormal nutritional parameters and development of PJI in patients undergoing primary total joint arthroplasty (TJA). METHODS: We retrospectively reviewed TJA patients from 2000 to 2016 with preoperative nutritional screening at a single institution. Any development of PJI at 2 years was assessed as the primary outcome. The Musculoskeletal Infection society criteria were used to define PJI. The association between the aforementioned nutritional markers and PJI was evaluated in a bivariate analysis followed by multivariate logistic regression. Performance for markers was assessed using receiver operator characteristic curves. Sensitivity and specificity were also compared. RESULTS: Multivariate analysis demonstrated that low albumin (adjusted odds ratio [OR], 4.69; 95% confidence interval [CI], 2.428-9.085; P < .001) and low hemoglobin (adjusted OR, 2.718; 95% CI, 1.100-2.718; P = .018) were significantly associated with PJI. Albumin had the highest specificity and (95% CI, 97.8%-98.4%) and positive predictive value compared to all other markers. Platelet-to-white blood cell ratio had the highest sensitivity (95% CI, 29.5%-40.3%). The area under the curve was greatest for albumin (0.61; 95% CI, 0.55-0.67) followed by hemoglobin (0.57; 95% CI, 0.51-0.63), platelets (0.56; 95% CI, 0.50-0.62), and platelet-to-white blood cell ratio (0.54; 95% CI, 0.49-0.60). CONCLUSION: The most valuable predictor of PJI following primary TJA, among nutritional parameters examined, was preoperative albumin with a very high specificity and positive predictive value.
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Artrite Infecciosa/etiologia , Artroplastia do Joelho/efeitos adversos , Artroplastia de Substituição/efeitos adversos , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Desnutrição/complicações , Infecções Relacionadas à Prótese/etiologia , Idoso , Biomarcadores , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Valor Preditivo dos Testes , Curva ROC , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: This study investigated the prevalence of medical comorbidities, risk factors, and treatment outcomes in patients with fungal periprosthetic joint infection (PJI). METHODS: All patients with fungal PJI treated from 1999 to 2014 were retrospectively identified at a single institution. Demographic data, comorbidity, and surgical variables were obtained from medical records. Patients were followed up for at least 2 years. PJI was diagnosed using the Musculoskeletal Infection Society criteria. Treatment success was defined using the Delphi consensus criteria. Kaplan-Meier survivorship curves with 95% confidence interval were used for analysis. RESULTS: Overall, fungal PJIs accounted for 2.4% of the PJI treated at our institution. Twenty-seven patients (93.1%) had 2 or more underlying systemic illnesses. Age and revision surgery were significant risk factors for development of fungal PJI after adjusting for confounding variables. Overall treatment success was 55.2% at 1 year and 40.5% at 5 years. When stratified by initial surgical management, treatment success was 57.1% at 1 year and 28.6% at 5 years following irrigation and debridement; 33.3% at 1 year and 5 years following 1-stage revision; and 57.9% at 1 year and 46.3% at 5 years for 2-stage exchange arthroplasty. CONCLUSION: Patients with fungal PJI have a high prevalence of systemic illness and poor outcome after surgical management. Irrigation and debridement and single-stage revision demonstrate poor longterm outcomes and may have no place as treatment choices for fungal PJI. Moving forward, our efforts should concentrate on optimizing the systemic status of these patients prior to 2-stage exchange arthroplasty.
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Artrite Infecciosa/cirurgia , Desbridamento/estatística & dados numéricos , Micoses/cirurgia , Infecções Relacionadas à Prótese/cirurgia , Reoperação/estatística & dados numéricos , Idoso , Anti-Infecciosos/uso terapêutico , Artrite Infecciosa/epidemiologia , Artrite Infecciosa/microbiologia , Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Comorbidade , Desbridamento/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Micoses/tratamento farmacológico , Micoses/epidemiologia , Micoses/microbiologia , Infecções Relacionadas à Prótese/epidemiologia , Infecções Relacionadas à Prótese/microbiologia , Reoperação/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
BACKGROUND: Distal radius fractures (DRFs) are common upper extremity fractures and often require surgical fixation when they are intraarticular. Preoperative computed tomography (CT) has emerged as a surgical planning tool to evaluate intraarticular DRFs. Although CT affords additional details, patients receive higher radiation doses than standard radiographs. We aim to develop a low-dose CT (LDCT) protocol, relative to the institutional standard-dose CT wrist for intraarticular DRFs although providing adequate detail for surgical decision-making. METHODS: A single-institution prospective study was conducted on patients with intraarticular DRFs who underwent closed reduction and below-elbow splinting who otherwise would undergo wrist CT. Observations were defined as total measurements taken, with each view undergoing 44 measurements. Patients underwent 2 scans with a standard dose and a 10× dose reduction. Articular step and gap measurements were recorded in the sagittal and coronal images. RESULTS: A total of 11 patients were enrolled (7 women and 4 men). The mean age was 55 years (SD = 20.1). There were a total of 4 reviewers: 1 attending surgeon, 2 resident physicians, and 1 student. When comparing LDCT and conventional-dose CT (CDCT), there were no significant differences in step and gap measurements across all reviewers. CONCLUSION: This study demonstrated that LDCT provides comparable imaging quality for surgical planning as a CDCT without significant diagnostic decay in the setting of DRFs. This comes with the added benefit of a 10-fold reduction in radiation exposure. These results suggest that LDCT is an opportunity to reduce effective radiation in patients although providing beneficial preoperative imaging.
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Background: Total shoulder arthroplasty (TSA) is the preferred treatment for glenohumeral arthritis refractory to nonoperative measures. However, some surgeons have argued for a role for hemiarthroplasty (HA) in the setting of a smooth glenoid that articulates appropriately with the humeral head. The purpose of this study is to evaluate long-term revision rates and short-term postoperative complications in patients undergoing either HA or TSA for glenohumeral arthritis. Methods: A retrospective review of patients who underwent HA and TSA was conducted using a commercially available national database. Demographics, postoperative complications, risk factors, revision rates, and costs were analyzed using 2 sample t-tests, chi-squared tests, and multivariate logistic regressions. Results: Patients were stratified by operation: (1) HA (n = 1615) or 2) TSA (n = 7845). Patients undergoing primary TSA had higher rates of prior ipsilateral rotator cuff repair and corticosteroid injections. At 2 years, patients who underwent HA, 3.0% of patients had revision surgery, compared to 1.6% of patients who underwent TSA (P = .002); at 5 years, 3.7% of the HA cohort (P < .0001) had revision surgery, compared to 1.9% of patients who underwent TSA. Conclusions: Patients undergoing TSA or RTSA for glenohumeral arthritis had higher preoperative co-morbidities but had no difference in short-term complication rates with a lower risk of revision surgery at both 2-year and 5-year follow-up when compared to HA. Increasing age, female sex, hyperlipidemia, postoperative infection, shoulder instability, and thromboembolism all independently increased odds for revision shoulder arthroplasty for glenohumeral arthritis. Level of evidence Level: III.
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Perioperative management for patients undergoing shoulder arthroplasty has evolved significantly over the years to reduce overt complications and improve patient outcomes. The groundwork for perioperative care encompasses initial patient selection and education strategies for achieving successful outcome. Multimodal pain management strategies have advanced patient care with the increased use of new regional/local anesthetics. In addition, complications resulting from blood loss and transfusions have been curtailed with the use of synthetic antifibrinolytic agents. It remains critical for shoulder arthroplasty surgeons to optimize patients during the perioperative period through various modalities to maximize functional progression, outcomes, and patient's satisfaction following shoulder arthroplasty.
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Antifibrinolíticos , Artroplastia do Ombro , Anestésicos Locais , Artroplastia do Ombro/efeitos adversos , Humanos , Manejo da Dor/métodos , Dor Pós-Operatória/etiologiaRESUMO
INTRODUCTION: Step counts measured by activity monitoring devices (AMDs) and smartphones (SPs) can objectively measure a patient's activity levels after total hip and knee arthroplasty (total joint arthroplasty [TJA]). This study investigated the use and optimal body location of AMDs and SPs to measure step counts in the postoperative period. METHODS: This was a two-armed, prospective, observational study of TJA inpatients (n = 24) and 2-week status after TJA (n = 25) completing a 100-ft walk. Observer-counted steps were compared with those measured by AMDs (wrist and ankle) and SPs (hip and neck). Acceptable error was defined as <30%. Error rates were treated as both dichotomous and continuous variables. RESULTS: AMD and SP step counts had overall unacceptable error in TJA inpatients. AMDs on the contralateral ankle and SPs on the contralateral hip had error rates less than 30% at 2 weeks postoperatively. Two-week postoperative patients required lower levels of assist (11/25 walker; 4/25 no assist), and significant improvements in stride length (total hip arthroplasty 1.27 versus 1.83 ft/step; total knee arthroplasty 1.42 versus 1.83 ft/step) and cadence (total hip arthroplasty 74.6 versus 166.0 steps/min; total knee arthroplasty 73.5 versus 144.4 steps/min) were seen between inpatient and postoperative patients. Regression analysis found that increases in postoperative day and cadence led to a decrease in device error. CONCLUSION: In inpatients with TJA, AMDs and SPs have unacceptable variability and limited utility for step counting when using a walker. As gait normalizes and the level of ambulatory assist decreases, AMDs on the contralateral ankle and SPs on the contralateral hip demonstrated low error rates. These devices offer a novel method for measurement of objective outcomes and potential for remote monitoring of patient progress after TJA. LEVEL OF EVIDENCE: Level II, prospective, three-armed study, prognostic study.
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Artroplastia de Quadril , Artroplastia do Joelho , Monitores de Aptidão Física , Smartphone , Caminhada , Idoso , Tornozelo , Feminino , Quadril , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Estudos Prospectivos , PunhoRESUMO
Background: Microbiological culture has been considered the standard for pathogen identification for decades. However, culture is a laborious, time consuming, imperfect and outdated process. This study aims to inform the orthopedic community of the steps and timing of routine culture processing. Methods: We prospectively tracked 103 cultures from 33 revision hip and knee arthroplasty patients between September 2017-February 2018. Times were recorded at intraoperative collection; time of pick up from OR, transportation time; arrival at the laboratory; culture processing and plating time; and time to final result reporting. Results: Of the 103 cultures, 45.6% were processed and incubated in less than two hours, and 54.4% greater than or equal to two hours. The mean time spent in the OR, during transport, and within the laboratory prior to incubation was 0:53, 0:06 and 1:12. The range of time that samples remained at each stage varied considerably in the OR (0:03-3:33), in transit(0:04-0:16), and in the lab prior to incubation(0:26-3:01). The proportion of the total time to incubation attributed to idle time samples spent in the OR after initial sampling was 40.0%. In contrast, transport to the laboratory represented 5.1% of the total time. Idle time in the laboratory represented the greatest share at 54.9%. Conclusion: There is significant variability in the time to transport, process and incubate culture samples. Almost half of the specimens were processed outside the 2-hour recommended window. Surgeons should be aware of idle time during processing and seek to optimize their institutional pathways to maximize culture yield.