Trends in inpatient orthopedic surgery during the COVID-19 pandemic in Japan: a nationwide data study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has resulted in substantial morbidity and mortality globally. The National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) covers 99.9% of health insurance claim receipts by general practitioners. The purpose of this study is to investigate the nationwide number of inpatient orthopedic surgeries in Japan during the effect of state of emergency (SoE) due to COVID-19. METHOD: The NDB has been publicly available since 2014. We retrospectively reviewed the NDB from April 2019 to March 2022. We gathered the monthly number of all inpatient orthopedic surgeries. We also classified orthopedic surgeries into the following 11 categories by using K-codes, Japanese original surgery classification: fracture, arthroplasty, spine, arthroscopy, hardware removal, hand, infection/amputation, ligament/tendon, tumor, joint, and others. By using the average number from April to December 2019 as the reference period, we investigated the increase or decrease orthopedic surgeries during the pandemic period. RESULTS: The NDB showed that the average number of total inpatient orthopedic surgeries during the reference period was 115,343 per month. In May 2020, monthly inpatient orthopedic surgeries decreased by 29.6% to 81,169 surgeries, accounting for 70.3% of the reference period. The second SoE in 2021 saw no change, while the third and fourth SoEs showed slight decreases compared to the reference period. Hardware removal and tumor surgeries in May 2020 decreased to 45.3% and 45.5%, respectively, while fracture surgeries had relatively small decreases. CONCLUSION: According to NDB, approximately 1.3 million orthopedic inpatient surgeries were performed or claimed in a year in Japan. In May 2020, the first SoE period of the COVID-19 pandemic, the number of inpatient orthopedic surgeries in Japan decreased by 30%. Meanwhile, the decrease was relatively small during the SoE periods in 2021.

Orthopedic Surgery Volume Trends During the COVID-19 Pandemic and Postvaccination Era: Implications for Healthcare Planning.

BACKGROUND: The Coronavirus Disease 2019 (COVID-19) pandemic decreased surgical volumes, but prior studies have not investigated recovery through 2022, or analyzed specific procedures or cases of urgency within orthopedic surgery. The aims of this study were to (1) quantify the declines in orthopedic surgery volume during and after the pandemic peak, (2) characterize surgical volume recovery during the postvaccination period, and (3) characterize recovery in the 1-year postvaccine release period. METHODS: We conducted a retrospective cohort study of 27,476 orthopedic surgeries from January 2019 to December 2022 at one urban academic quaternary referral center. We reported trends over the following periods: baseline pre-COVID-19 period (1/6/2019 to 1/4/2020), COVID-19 peak (3/15/2020 to 5/16/2020), post-COVID-19 peak (5/17/2020 to 1/2/2021), postvaccine release (1/3/2021 to 1/1/2022), and 1-year postvaccine release (1/2/2022 to 12/30/2022). Comparisons were performed with 2 sample t-tests. RESULTS: Pre-COVID-19 surgical volume fell by 72% at the COVID-19 peak, especially impacting elective procedures (P < .001) and both hip and knee joint arthroplasty (P < .001) procedures. Nonurgent (P = .024) and urgent or emergency (P = .002) cases also significantly decreased. Postpeak recovery before the vaccine saw volumes rise to 92% of baseline, which further rose to 96% and 94% in 2021 and 2022, respectively. While elective procedures surpassed the baseline in 2022, nonurgent and urgent or emergency surgeries remained low. CONCLUSIONS: The COVID-19 pandemic substantially reduced orthopedic surgical volumes, which have still not fully recovered through 2022, particularly nonelective procedures. The differential recovery within an orthopedic surgery program may result in increased morbidity and can serve to inform department-level operational recovery.

Artificial intelligence in shoulder and elbow surgery: overview of current and future applications.

Artificial intelligence (AI) is amongst the most rapidly growing technologies in orthopedic surgery. With the exponential growth in healthcare data, computing power, and complex predictive algorithms, this technology is poised to aid providers in data processing and clinical decision support throughout the continuum of orthopedic care. Understanding the utility and limitations of this technology is vital to practicing orthopedic surgeons, as these applications will become more common place in everyday practice. AI has already demonstrated its utility in shoulder and elbow surgery for imaging-based diagnosis, predictive modeling of clinical outcomes, implant identification, and automated image segmentation. The future integration of AI and robotic surgery represents the largest potential application of AI in shoulder and elbow surgery with the potential for significant clinical and financial impact. This editorial's purpose is to summarize common AI terms, provide a framework to understand and interpret AI model results, and discuss current applications and future directions within shoulder and elbow surgery.

National Trends in Orthopaedic Pain Management from 2016 to 2020.

INTRODUCTION: Effective pain management is vital in orthopaedic care, impacting postoperative recovery and patient well-being. This study aimed to discern national and regional pain prescription trends among orthopaedic surgeons through Medicare claims data, using geospatial analysis to ascertain opioid and nonopioid usage patterns across the United States. METHODS: Physician-level Medicare prescription databases from 2016 to 2020 were filtered to orthopaedic surgeons, and medications were categorized into opioids, muscle relaxants, anticonvulsants, and NSAIDs. Patient demographics were extracted from a Medicare provider demographic data set, while county-level socioeconomic metrics were obtained primarily from the American Community Survey. Geospatial analysis was conducted using Geoda software, using Moran I statistic for cluster analysis of pain medication metrics. Statistical trends were analyzed using linear regression, Mann-Whitney U test, and multivariate logistic regression, focusing on prescribing rates and hotspot/coldspot identification. RESULTS: Analysis encompassed 16,505 orthopaedic surgeons, documenting more than 396 million days of pain medication prescriptions: 57.42% NSAIDs, 28.57% opioids, 9.84% anticonvulsants, and 4.17% muscle relaxants. Annually, opioid prescriptions declined by 4.43% ( P < 0.01), while NSAIDs rose by 3.29% ( P < 0.01). Opioid prescriptions dropped by 210.73 days yearly per surgeon ( P < 0.005), whereas NSAIDs increased by 148.86 days ( P < 0.005). Opioid prescriptions were most prevalent in the West Coast and Northern Midwest regions, and NSAID prescriptions were most prevalent in the Northeast and South regions. Regression pinpointed spine as the highest and hand as the lowest predictor for pain prescriptions. DISCUSSION: On average, orthopaedic surgeons markedly decreased both the percentage of patients receiving opioids and the duration of prescription. Simultaneously, the fraction of patients receiving NSAIDs dramatically increased, without change in the average duration of prescription. Opioid hotspots were located in the West Coast, Utah, Colorado, Arizona, Idaho, the Northern Midwest, Vermont, New Hampshire, and Maine. Future directions could include similar examinations using non-Medicare databases.

Allografts use in orthopedic surgery: trend change over the past 11 years from a regional tissue bank.

Allografts are the second most transplanted tissue in medicine after blood and are now increasingly used for both primary and revision surgery. Allografts have the advantages of lower donor site morbidity, availability of multiple grafts, and shorter operative time. The Banks represents the bridge between Donor and Recipient and guarantees the quality and safety of the distributed allografts Given the increasing interest in these tissues, a retrospective analysis of data collected from the Regional Musculoskeletal Tissue Bank registry over an 11-year period (2009-2019) was conducted. The statistical analyses used were the Shapiro-Wilk normality test and a Poisson regression model. From January 2009 to December 2019, a total of 14,199 musculoskeletal tissues stored in the Regional Musculoskeletal Tissue Bank were provided for surgical allograft procedures. In 2009, the number of allografts performed was 925; this figure has steadily increased to 1599 in 2019. Epiphyses were taken as the reference tissue with an almost constant trend over the period, while a significant increase was denoted for extensor mechanism allograft, ligaments, tendons and long bone corticals (p < 0.001), processed bone tissues had no change in trend (p = 0.841). There was also a gradual decrease in the rate of microbiological positivity, as determined by bacteriological and serological tests performed on the collected tissues. This phenomenon is due to improved sampling techniques and the training of a dedicated team. Thus, we have seen how the use of allografts in orthopedic surgery has increased over the past 11 years, uniformly in terms of tissue type, except for the noticeable increase in ligamentous tissue.

Recommendations for Orthopedic Surgeons during the COVID-19 Pandemic.

BACKGROUND: Toward the end of 2019, the coronavirus disease-2019 (COVID-19) pandemic began to create turmoil for global health organizations. The illness, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), spreads by droplets and fomites and can rapidly lead to life-threatening lung disease, especially for the old and those with health co-morbidities. Treating orthopedic patients, who presented with COVID-19 while avoiding nosocomial transmission, became of paramount importance. OBJECTIVES: To present relevant methods for pandemic control and hospital accommodation with emphasis on orthopedic surgery. METHODS: We searched search PubMed and Google Scholar electronic databases using the following keywords: COVID-19, SARS-CoV-2, screening tools, personal protective equipment, and surgery triage. RESULTS: We included 25 records in our analysis. The recommendations from these records were divided into the following categories: COVID-19 disease, managing orthopedic surgery in the COVID-19 era, general institution precautions, triage of orthopedic surgeries, preoperative assessment, surgical room setting, personal protection equipment, anesthesia, orthopedic surgery technical precautions, and department stay and rehabilitation. CONCLUSIONS: Special accommodations tailored for each medical facility, based on disease burden and available resources can improve patient and staff safety and reduce elective surgery cancellations. This article will assist orthopedic surgeons during the COVID-19 medical crisis, and possibly for future pandemics.

Orthopedic and neurosurgical care of X-linked hypophosphatemia.

X-linked hypophosphatemia (XLH) is due to mutations in the PHEX gene leading to unregulated production of FGF23 and uncontrollable hypophosphatemia. XLH is characterized in children by rickets, short stature, waddling gait, and leg bowing of variable morphology and severity. Phosphate supplements and oral vitamin D analogs partially or, in some cases, fully restore the limb straightness. XLH patients may also be affected by premature, complete, or partial ossification of sutures between cranial bone, which could eventually result in cranial dysmorphia, decreased intracranial volume, and secondary abnormally high intracranial pressure with a cerebral compression. Our goal is to address the criteria and the management of the skeletal complications associated with XLH, mainly orthopedic and neurosurgical care, and reflect on decision-making and follow-up complexities.

Comparative study between admission, orthopaedic surgery, and economic trends during Covid-19 and non-Covid-19 pandemic in an Italian tertiary hospital: a retrospective review.

BACKGROUND: The COVID-19 pandemic represents one of the most massive health emergencies in the last century and has caused millions of deaths worldwide and a massive economic and social burden. The aim of this study was to evaluate how the COVID-19 pandemic-during the Italian lockdown period between 8 March and 4 May 2020-influenced orthopaedic access for traumatic events to the Emergency Department (ER). METHODS: A retrospective review of the admission to the emergency room and the discharge of the trauma patients' records was performed during the period between 8 March and 4 May 2020 (block in Italy), compared to the same period of the previous year (2019). Patients accesses, admissions, days of hospitalisation, frequency, fracture site, number and type of surgery, the time between admission and surgery, days of hospitalisation, and treatment cost according to the diagnosis-related group were collected. Chi-Square and ANOVA test were used to compare the groups. RESULTS: No significant statistical difference was found for the number of emergency room visits and orthopaedic hospitalisations (p < 0.53) between the year 2019 (9.5%) and 2020 (10.81%). The total number of surgeries in 2019 was 119, while in 2020, this was just 48 (p < 0.48). A significant decrease in the mean cost of orthopaedic hospitalisations was detected in 2020 compared (261.431 euros, equal to - 52.07%) relative to the same period in 2019 (p = 0.005). Although all the surgical performances have suffered a major decline, the most frequent surgery in 2020 was intramedullary femoral nailing. CONCLUSION: We detected a decrease in traumatic occasions during the lockdown period, with a decrease in fractures in each district and a consequent decrease in the diagnosis-related group (DRG).

The effect of care transition pathway implementation on patients undergoing joint replacement during the COVID-19 pandemic: a quasi-experimental study from a tertiary care hospital orthopedic department in Beijing, China.

BACKGROUND: The coronavirus disease (COVID-19) pandemic has had a massive impact on individuals globally. The Chinese government has formulated effective response measures, and medical personnel have been actively responding to challenges associated with the epidemic prevention and control strategies. This study aimed to evaluate the effect of the implementation of a care transition pathway on patients that underwent joint replacement during the COVID-19 pandemic. METHODS: A quasi-experimental study was designed to evaluate the effect of implementing a care transition pathway for patients who underwent joint replacement during the COVID-19 pandemic in the orthopedic department of a tertiary care hospital in Beijing, China. Using a convenient sampling method, a total of 96 patients were selected. Of these, 51 patients who had undergone joint replacement in 2019 and received treatment via the routine nursing path were included in the control group. The remaining 45 patients who underwent joint replacement during the COVID-19 epidemic in 2020 and received therapy via the care transition pathway due to the implementation of epidemic prevention and control measures were included in the observation group. The quality of care transition was assessed by the Care Transition Measure (CTM), and patients were followed up 1 week after discharge. RESULTS: The observation group was determined to have better general self-care preparation, written planning materials, doctor-patient communication, health monitoring, and quality of care transition than the control group. CONCLUSIONS: A care transition pathway was developed to provide patients with care while transitioning through periods of treatment. It improved the patient perceptions of nursing quality. The COVID-19 pandemic is a huge challenge for health professionals, but we have the ability to improve features of workflows to provide the best possible patient care.

Postoperative delirium mediates 180-day mortality in orthopaedic trauma patients.

BACKGROUND: Frailty has been associated with increased incidence of postoperative delirium and mortality. We hypothesised that postoperative delirium mediates a clinically significant (≥1%) percentage of the effect of frailty on mortality in older orthopaedic trauma patients. METHODS: This was a single-centre, retrospective observational study including 558 adults 65 yr and older, who presented with an extremity fracture requiring hospitalisation without initial ICU admission. We used causal statistical inference methods to estimate the relationships between frailty, postoperative delirium, and mortality. RESULTS: In the cohort, 180-day mortality rate was 6.5% (36/558). Frail and prefrail patients comprised 23% and 39%, respectively, of the study cohort. Frailty was associated with increased 180 day mortality from 1.4% to 12.2% (11% difference; 95% confidence interval [CI], 8.4-13.6), which translated statistically into an 88.7% (79.9-94.3%) direct effect and an 11.3% (5.7-20.1%) postoperative delirium mediated effect. Prefrailty was also associated with increased 180 day mortality from 1.4% to 4.4% (2.9% difference; 2.4-3.4), which was translated into a 92.5% (83.8-99.9%) direct effect and a 7.5% (0.1-16.2%) postoperative delirium mediated effect. CONCLUSIONS: Frailty is associated with increased postoperative mortality, and delirium might mediate a clinically significant, but small percentage of this effect. Studies should assess whether, in patients with frailty, attempts to mitigate delirium might decrease postoperative mortality.

Intraoperative consultation of vascular surgeons is increasing at a major American trauma center.

OBJECTIVE: Vascular surgeons are often called to aid other surgical specialties for complex exposure, hemorrhage control, or revascularization. The evolving role of the vascular surgeon in the management of intraoperative emergencies involving trauma patients remains undefined. The primary aims of this study included determining the prevalence of intraoperative vascular consultation in trauma, describing how these interactions have changed over time, and characterizing the outcomes achieved by vascular surgeons in these settings. We hypothesized that growing endovascular capabilities of vascular surgeons have resulted in an increased involvement of vascular surgery faculty in the management of the trauma patient over time. METHODS: A retrospective review of all operative cases at a single level I trauma center where a vascular surgeon was involved, but not listed as the primary surgeon, between 2002 and 2017 was performed. Cases were abstracted using Horizon Surgical Manager, a documentation system used in our operating room to track staff present, the type of case, and use. All elective cases were excluded. RESULTS: Of the 256 patients initially identified, 22 were excluded owing to the elective or joint nature of the procedure, leaving 234 emergent operative vascular consultations. Over the 15-year study period, a 529% increase in the number of vascular surgery consultations was seen, with 65% (n = 152) being intraoperative consultations requiring an immediate response. Trauma surgery (n = 103 [44%]) and orthopedic surgery (n = 94 [40%]) were the most common consulting specialties, with both demonstrating a trend of increasing consultations over time (general surgery, 1400%; orthopedic surgery, 220%). Indications for consultation were extremity malperfusion, hemorrhage, and concern for arterial injury. The average operative time for the vascular component of the procedures was 2.4 hours. Of patients presenting with ischemia, revascularization was successful in 94% (n = 116). Hemorrhage was controlled in 99% (n = 122). In-hospital mortality was relatively low at 7% (n = 17). Overall, despite the increase in intraoperative vascular consultations over time, a concomitant increase in the proportion of procedures done using endovascular techniques was not seen. CONCLUSIONS: Vascular surgeons are essential team members at a level I trauma center. Vascular consultation in this setting is often unplanned and often requires immediate intervention. The number of intraoperative vascular consultations is increasing and cannot be attributed solely to an increase in endovascular hemorrhage control, and instead may reflect the declining experience of trauma surgeons with vascular trauma. When consulted, vascular surgeons are effective in quickly gaining control of the situation to provide exposure, hemorrhage control, or revascularization.

COVID-19 Impact on Orthopedic Surgeons: Elective Procedures, Telehealth, and Income.

OBJECTIVES: The purpose of this study was to investigate the response in orthopedic surgery to the coronavirus disease 2019 (COVID-19) pandemic across the United States by surveying surgeons about their care setting, timing of restrictions on elective surgery, use of telehealth, and estimated economic impact. METHODS: A survey was distributed via REDCap through state orthopedic organizations between April and July 2020. The 22-question digital survey collected information regarding restrictions on elective procedures, location of care, utilization of telehealth, and estimated reductions in annual income. RESULTS: In this study, 192 participants responded to the survey (average age 49.9 ± 11.0 years, 92.7% male). Responses primarily originated from Alabama (30.2%), Georgia (30.2%), and Missouri (16.1%). The remainder of the responses were grouped into the category "other." Respondents did not vary significantly by state in operative setting or income type (salary, work relative value units, or collections). Most of the participants documented elective procedure restrictions in hospital and ambulatory settings. The highest frequency of closures occurred between March 18 and 20 (47% in hospital, 51% in ambulatory). Of the participants, financial loss estimates varied across states (P = 0.005), with 50% of physicians claiming >50% losses of income in Alabama (24% Georgia, 10% Missouri, 31% other). Regarding telehealth, practices set up for these services before 2020 varied across states. None of the orthopedic practices in Alabama had telehealth before the COVID-19 pandemic (Missouri 25%, Georgia 9%, other 8%, P = 0.06); however, respondents generally were split when considering the anticipation of implementing telehealth into routine practice. CONCLUSIONS: Most practices did implement restrictions for elective clinic visits and procedures early during the pandemic. COVID-19 ultimately will result in a large revenue loss for elective orthopedic practices. Services such as telehealth may help offset these losses and help deliver orthopedic care to patients remotely.