Early postoperative physical activity and function: a descriptive case series study of 53 patients after lumbar spine surgery.

BACKGROUND: The purpose of this prospective case series study was to compare changes in early postoperative physical activity and physical function between 6 weeks and 3 and 6 months after lumbar spine surgery. METHODS: Fifty-three patients (mean [95% confidence interval; CI] age = 59.2 [56.2, 62.3] years, 64% female) who underwent spine surgery for a degenerative lumbar condition were assessed at 6 weeks and 3- and 6-months after surgery. The outcomes were objectively-measured physical activity (accelerometry) and patient-reported and objective physical function. Physical activity was assessed using mean steps/day and time spent in moderate to vigorous physical activity (MVPA) over a week. Physical function measures included Oswestry Disability Index (ODI), 12-item Short Form Health Survey (SF-12), Timed Up and Go (TUG), and 10-Meter Walk (10 MW). We compared changes over time in physical activity and function using generalized estimating equations with robust estimator and first-order autoregressive covariance structure. Proportion of patients who engaged in meaningful physical activity (e.g., walked at least 4400 and 6000 steps/day or engaged in at least 150 min/week in MVPA) and achieved clinically meaningful changes in physical function were compared at 3 and 6 months. RESULTS: After surgery, 72% of patients initiated physical therapy (mean [95%CI] sessions =8.5 [6.6, 10.4]) between 6 weeks and 3 months. Compared to 6 weeks post-surgery, no change in steps/day or time in MVPA/week was observed at 3 or 6 months. From 21 to 23% and 9 to 11% of participants walked at least 4400 and 6000 steps/day at 3 and 6 months, respectively, while none of the participants spent at least 150 min/week in MVPA at these same time points. Significant improvements were observed on ODI, SF-12, TUG and 10 MW (p <  0.05), with over 43 to 68% and 62 to 87% achieving clinically meaningful improvements on these measures at 3 and 6 months, respectively. CONCLUSION: Limited improvement was observed in objectively-measured physical activity from 6 weeks to 6 months after spine surgery, despite moderate to large function gains. Early postoperative physical therapy interventions targeting physical activity may be needed.

Do psychosocial interventions improve rehabilitation outcomes after anterior cruciate ligament reconstruction? A systematic review.

OBJECTIVE: To examine the role of psychosocial interventions in improving patient-reported clinical outcomes, including return to sport/activity, and intermediary psychosocial factors after anterior cruciate ligament reconstruction. METHODS: MEDLINE/PubMed, CINAHL, PsycINFO, and Web of Science were searched from each database's inception to March 2017 for published studies in patients after anterior cruciate ligament reconstruction. Studies were included if they reported on the effects of a postoperative psychosocial intervention on a patient-reported clinical measure of disability, function, pain, quality of life, return to sport/activity, or intermediary psychosocial factor. Data were extracted using a standardized form and summary effects from each article were compiled. The methodological quality of randomized trials was assessed using the Physiotherapy Evidence Database Scale and scores greater than 5/10 were considered high quality. RESULTS: A total of 893 articles were identified from the literature search. Of these, four randomized trials ( N = 210) met inclusion criteria. The four articles examined guided imagery and relaxation, coping modeling, and visual imagery as postoperative psychosocial interventions. Methodological quality scores of the studies ranged from 5 to 9. There were inconsistent findings for the additive benefit of psychosocial interventions for improving postoperative function, pain, or self-efficacy and limited evidence for improving postoperative quality of life, anxiety, or fear of reinjury. No study examined the effects of psychosocial interventions on return to sport/activity. CONCLUSION: Overall, there is limited evidence on the efficacy of postoperative psychosocial interventions for improving functional recovery after anterior cruciate ligament reconstruction.

A Comparative Study of Clinical Outcomes and Functional Status after Knee Fracture and Knee Fracture Dislocation.

The aim of this study was to compare outcomes of tibial plateau fracture dislocations (FD) with tibial plateau fractures alone. This study was an analysis of a series of tibial plateau fractures, in which FD was defined as a fracture of the tibial plateau with an associated loss of congruent joint reduction and stability of the knee, and classified by the Moore system. Patient data collected included demographics, injury information, and functional outcomes (short musculoskeletal function assessment [SMFA] score and Pain by the visual analog scale). Clinical outcomes at follow-up were recorded including knee range of motion, knee stability and development of complications. There were a total of 325 tibial plateau fracture patients treated operatively, of which 22.2% were identified as FD (n = 72). At injury presentation there was no difference with regard to nerve injury or compartment syndrome (both p > 0.05). FD patients had a higher incidence of arterial injury and acute ligament repair (both p < 0.005). At a mean follow-up of 17.5 months, FD patients were similar with regard to pain, total SMFA scores, and return to sports than their non-FD counterparts (p = 0.884, p = 0.531, p = 0.802). FD patients were found to have decreased knee flexion compared with non-FD patients by 5 degrees (mean: 120 and 125 degrees) (p < 0.05). FD patients also had a higher incidence of late knee instability and subsequent surgery for ligament reconstruction (p < 0.005 & p < 0.05). However, there was no difference in neurological function between groups at follow-up (p = 0.102). Despite the higher incidence of ligamentous instability and decreased range of motion, FD patients appear to have similar long-term functional outcomes compared with non-FD of the tibial plateau. While FD patients initially presented with a higher incidence of arterial injury, neurovascular outcomes at final follow-up were similar to those without a dislocation.

A Conceptual Model for Spine Surgery Recovery: A Qualitative Study of Patients' Expectations, Experiences, and Satisfaction.

STUDY DESIGN: Qualitative interview study. OBJECTIVE: The aim was to develop a conceptual model for Spine Surgery Recovery in order to better understand why patients undergo lumbar spine surgery and what factors influence patient satisfaction. SUMMARY OF BACKGROUND DATA: Quantitative studies have assessed patients' expectations for lumbar spine surgery outcomes, with greater expectation fulfillment leading to higher satisfaction. However, there is limited literature using qualitative methods to understand the patient perspective from the decision to undergo lumbar spine surgery through long-term recovery. MATERIALS AND METHODS: Semistructured phone interviews were conducted with 20 participants (nine females, mean age ±SD=61.2±11.1 yr) and three focus groups with 12 participants (nine females, mean age ±SD=62.0±10.9 yr). Sessions were audio recorded and transcribed. Two independent researchers coded the transcripts using a hierarchical coding system. Major themes were identified and a conceptual model was developed. RESULTS: A total of 1355 coded quotes were analyzed. The decision to have lumbar spine surgery was influenced by chronic pain impact on daily function, pain coping, and patient expectations. Results demonstrated that fulfilled expectations and setting realistic expectations are key factors for patient satisfaction after surgery, while less known constructs of accepting limitations, adjusting expectations, and optimism were found by many patients to be essential for a successful recovery. Emotional factors of fear, anxiety, and depression were important aspects of presurgical and postsurgical experiences. CONCLUSION: Our Spine Surgery Recovery conceptual model provides guidance for future research and clinical practice to optimize treatment and improve overall patient satisfaction. Recommendations based on this model include the assessment of patient expectations and mental well-being throughout postoperative recovery as well as preoperatively to help set realistic expectations and improve satisfaction. Educational, acceptance-based or positive psychological interventions may be potentially beneficial for addressing key factors identified in this model.

Orthopaedic Urgent Care Versus the Emergency Department: Cost Implications for Low-energy Fracture Care.

INTRODUCTION: This study compared costs, length of visit, and utilization trends for patients with fractures seen in an immediate care orthopaedic center (I-Care) versus the emergency department (ED) in a major metropolitan area. METHODS: A retrospective chart review of consecutive patients seen on an outpatient basis in the ED and I-Care over a 6-month period was conducted. Patient demographics, procedures done, care category, estimated costs, and disposition information were included for statistical analysis. Within the low-acuity fracture care group, a cost-comparison analysis was conducted. RESULTS: A total of 610 patients met inclusion criteria with 311 seen in I-Care and 299 in the ER. I-Care patients were more likely to have low-acuity injuries compared with ED patients (60.1% versus 18.1%, P < 0.001). The length of visit was longer for patients seen in the ED compared with I-Care (6.1 versus 1.43 hours, P value < 0.001). A cost analysis of low-acuity patients revealed that an estimated $62,150 USD could have been saved in healthcare costs by the initial diversion of low-acuity patients seen in the ER to I-Care during the study period. DISCUSSION: These results suggest that the I-Care orthopaedic urgent care model is a more cost-effective and more efficient alternative to the ED for patients with fractures requiring procedural treatment and low-acuity patients managed on an outpatient basis.

Composite psychosocial risk based on the fear avoidance model in patients undergoing anterior cruciate ligament reconstruction: Cluster-based analysis.

OBJECTIVES: To examine associations between preoperative fear-avoidance model (FAM) risk subgroup status and patient expectation of surgical success with postoperative outcomes at 6 and 12 months after anterior cruciate ligament reconstruction (ACLR). DESIGN: Cohort study. SETTING: Academic medical center. PARTICIPANTS: 54 patients (25 females) undergoing unilateral ACLR. MAIN OUTCOME MEASURES: Cluster analysis distinguished FAM risk subgroups based on preoperative fear of movement/reinjury, self-efficacy, and pain catastrophizing. Preoperative expectation for surgical success was assessed with a numeric rating scale. Six and 12-month outcomes included Subjective Patient Outcomes for Return to Sport, Knee Injury and Osteoarthritis Outcome Score (KOOS) sports/recreation and quality of life, and International Knee Documentation Committee (IKDC) Subjective Knee Form. RESULTS: Thirteen (24%) patients were "moderate-to-high FAM risk." Moderate-to-high FAM risk patients had lower odds of return to sport at 12 months (OR = 0.3, p = .05) and lower KOOS sports/recreation at 6 months (st. beta = -0.27, p = .05), KOOS quality of life at 12 months (st. beta = -0.42, p = .007), and IKDC at 6 (st. beta = -0.29, p = .04) and 12 months (st. beta = -0.47, p = .001). Higher expectation was associated with lower 6-month IKDC (st. beta = -0.36, p = .008) and 12-month KOOS quality of life (st. beta = -0.29, p = .05). CONCLUSIONS: Preoperative FAM risk influences patient-reported outcomes and return to sport at 6 and 12 months.

Gender-related Differences in Research Productivity, Position, and Advancement Among Academic Orthopaedic Faculty Within the United States.

INTRODUCTION: The number of female residents in orthopaedic surgery is rising; however, orthopaedics currently has the lowest percentage of women among all medical specialties. The Hirsch index (h-index) is a metric used to determine research productivity, an important factor for academic promotion in the field of orthopaedics. The purpose of this study was to compare research productivity (using the h-index) among male and female orthopaedic surgeons at academic residency programs within the United States. METHODS: The websites for all Accreditation Council for Graduate Medical Education-accredited orthopaedic surgery residency programs in the United States were evaluated and the following information was collected: geographic region of the institution, sex, specialty, academic rank, and institutional leadership positions of faculty members. The h-index for each faculty member was collected from the Web of Science Database. RESULTS: H-indices of 4,323 academic orthopaedic surgeons from 160 residency programs in the United States were collected. In total, 1,587 faculty members were assistant professors (220, 13.9% women), 839 were associate professors (91, 10.8% women), 902 were professors (50, 5.5% women), and academic rank was not specified for 991 (74, 7.5% women). One hundred forty-three faculty members held the position of department chair (2, 1.4% women) and 701 were division chiefs (58, 8.3% women). In geographic regions with a greater proportion of female orthopaedic faculty members, women had greater research productivity. Among Department Chairs, associate professors, and professors there was no difference in research productivity between male and female academic orthopaedic surgeons. By contrast, among assistant professors, there was a significant difference in research productivity. CONCLUSION: A higher proportion of female faculty in an orthopaedic department was positively associated with increased female research productivity. Female faculty at the highest ranks and leadership positions are as academically productive as their male counterparts. Despite similar research productivity, female orthopaedic surgeons are not nearly as well represented as their male counterparts in orthopaedics in general and in leadership positions within the field. In addition, a significantly smaller research productivity among female assistant professors disappears at the higher ranks in comparison to their male counterparts. This indicates a critical gap in factors that influence research productivity according to sex at the most junior faculty rank. LEVEL OF EVIDENCE: Level III.

Part I: epidemiology and risk factors for stress fractures in female athletes.

Objectives: Stress fractures (SFx) are a common athletic injury, occurring in up to 40% of athletes at some point in their career. These injuries can cause pain, permanent disability, financial burden, and loss of playing time. This review presents updated epidemiology and comprehensive analysis of risk factors for stress fractures, especially as it pertains to female athletes.Results: Stress fractures (SFx) account for up to 10% of all orthopedic injuries and up to 20% of injuries seen in sports medicine clinics, with an incidence among female athletes as high as 13%. Lower extremity SFx represent 80-95% of SFx, and the increased popularity of endurance running has contributed to the tibia (49% prevalence) replacing the metatarsals (9%) as the most common location for lower extremity SFx. Studies have demonstrated that 50% of peak bone mass is acquired during adolescence, a 'peak time' for eating disorder and female athlete triad development; furthermore, catch-up growth cannot be expected in athletes with diminished bone growth in this critical period. The female athlete triad (low energy availability with or without disordered eating, menstrual dysfunction, and low bone mineral density) are well-known risk factors for SFx; the risk of SFx for female athletes presenting with a single aspect of the triad is 15-20%, and this risk increases to 30-50% for female athletes presenting with multiple aspects of the triad.Conclusion: This review provides a basis for how to identify populations at greatest risk for SFx. Prompt recognition of the intrinsic and extrinsic risk factors for SFx in female athletes is imperative to early diagnosis and to develop targeted strategies to prevent SFx occurrence or recurrence.

Modification of a Validated Risk Stratification Tool to Characterize Geriatric Hip Fracture Outcomes and Optimize Care in a Post-COVID-19 World.

OBJECTIVES: (1) To demonstrate how a risk assessment tool modified to account for the COVID-19 virus during the current global pandemic is able to provide risk assessment for low-energy geriatric hip fracture patients. (2) To provide a treatment algorithm for care of COVID-19 positive/suspected hip fractures patients that accounts for their increased risk of morbidity and mortality. SETTING: One academic medical center including 4 Level 1 trauma centers, 1 university-based tertiary care referral hospital, and 1 orthopaedic specialty hospital. PATIENTS/PARTICIPANTS: One thousand two hundred seventy-eight patients treated for hip fractures between October 2014 and April 2020, including 136 patients treated during the COVID-19 pandemic between February 1, 2020 and April 15, 2020. INTERVENTION: The Score for Trauma Triage in the Geriatric and Middle-Aged ORIGINAL (STTGMAORIGINAL) score was modified by adding COVID-19 virus as a risk factor for mortality to create the STTGMACOVID score. Patients were stratified into quartiles to demonstrate differences in risk distribution between the scores. MAIN OUTCOME MEASUREMENTS: Inpatient and 30-day mortality, major, and minor complications. RESULTS: Both STTGMA score and COVID-19 positive/suspected status are independent predictors of inpatient mortality, confirming their use in risk assessment models for geriatric hip fracture patients. Compared with STTGMAORIGINAL, where COVID-19 patients are haphazardly distributed among the risk groups and COVID-19 inpatient and 30 days mortalities comprise 50% deaths in the minimal-risk and low-risk cohorts, the STTGMACOVID tool is able to triage 100% of COVID-19 patients and 100% of COVID-19 inpatient and 30 days mortalities into the highest risk quartile, where it was demonstrated that these patients have a 55% rate of pneumonia, a 35% rate of acute respiratory distress syndrome, a 22% rate of inpatient mortality, and a 35% rate of 30 days mortality. COVID-19 patients who are symptomatic on presentation to the emergency department and undergo surgical fixation have a 30% inpatient mortality rate compared with 12.5% for patients who are initially asymptomatic but later develop symptoms. CONCLUSION: The STTGMA tool can be modified for specific disease processes, in this case to account for the COVID-19 virus and provide a robust risk stratification tool that accounts for a heretofore unknown risk factor. COVID-19 positive/suspected status portends a poor outcome in this susceptible trauma population and should be included in risk assessment models. These patients should be considered a high risk for perioperative morbidity and mortality. Patients with COVID-19 symptoms on presentation should have surgery deferred until symptoms improve or resolve and should be reassessed for surgical treatment versus definitive nonoperative treatment with palliative care and/or hospice care. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

Cognitive-behavioral-based physical therapy to enhance return to sport after anterior cruciate ligament reconstruction: An open pilot study.

OBJECTIVES: To describe feasibility, adherence, acceptability, and outcomes of a cognitive-behavioral-based physical therapy (CBPT-ACLR) intervention for improving postoperative recovery after anterior cruciate ligament reconstruction (ACLR). DESIGN: Pilot study. SETTING: Academic medical center. PARTICIPANTS: Eight patients (mean age [SD] = 20.1 [2.6] years, 6 females) participated in a 7-session telephone-based CBPT-ACLR intervention beginning preoperatively and lasting 8 weeks after surgery. MAIN OUTCOME MEASURES: At 6 months, patients completed Knee Injury and Osteoarthritis Outcome Score (KOOS) sports/recreation and quality of life (QOL) subscales, International Knee Documentation Committee (IKDC), Tampa Scale of Kinesiophobia (TSK), Pain Catastrophizing Scale (PCS), and Knee Self-Efficacy Scale (K-SES), return to sport (Subjective Patient Outcome for Return to Sports), and satisfaction. Minimal clinically important difference (MCID) was used for meaningful change. RESULTS: Seven (88%) patients completed all sessions. Seven (88%) patients exceeded MCID on the TSK, 6 (75%) on the PCS, 5 (63%) on the KOOS sports/recreation subscale, 4 (50%) on the IKDC, and 3 (38%) on the KOOS QOL subscale. Three (38%) patients returned to their same sport at the same level of effort and performance. All patients were satisfied with their recovery. CONCLUSIONS: A CBPT-ACLR program is feasible and acceptable for addressing psychological risk factors after ACLR.

Increased Mortality and Major Complications in Hip Fracture Care During the COVID-19 Pandemic: A New York City Perspective.

OBJECTIVES: To examine one health system's response to the essential care of its hip fracture population during the COVID-19 pandemic and report on its effect on patient outcomes. DESIGN: Prospective cohort study. SETTING: Seven musculoskeletal care centers within New York City and Long Island. PATIENTS/PARTICIPANTS: One hundred thirty-eight recent and 115 historical hip fracture patients. INTERVENTION: Patients with hip fractures occurring between February 1, 2020, and April 15, 2020, or between February 1, 2019, and April 15, 2019, were prospectively enrolled in an orthopaedic trauma registry and chart reviewed for demographic and hospital quality measures. Patients with recent hip fractures were identified as COVID positive (C+), COVID suspected (Cs), or COVID negative (C-). MAIN OUTCOME MEASUREMENTS: Hospital quality measures, inpatient complications, and mortality rates. RESULTS: Seventeen (12.2%) patients were confirmed C+ by testing, and another 14 (10.1%) were suspected (Cs) of having had the virus but were never tested. The C+ cohort, when compared with Cs and C- cohorts, had an increased mortality rate (35.3% vs. 7.1% vs. 0.9%), increased length of hospital stay, a greater major complication rate, and a greater incidence of ventilator need postoperatively. CONCLUSIONS: COVID-19 had a devastating effect on the care of patients with hip fracture during the pandemic. Although practice patterns generally remained unchanged, treating physicians need to understand the increased morbidity and mortality in patients with hip fracture complicated by COVID-19. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

Advances in Patellofemoral Arthroplasty.

PURPOSE OF REVIEW: To describe current indications, implants, economic benefits, comparison to TKA, and functional and patient-reported outcomes of patellofemoral arthroplasty. RECENT FINDINGS: Modern onlay implants and improved patient selection have allowed for recent improvements in short- and long-term outcomes after patellofemoral joint replacement surgery. Patellofemoral arthroplasty has become an increasingly utilized technique for the successful treatment of isolated patellofemoral arthritis. Advances in patient selection, implant design, and surgical technique have resulted in improved performance and longevity of these implants. Although short- and mid-term data for modern patellofemoral arthroplasties appear promising, further long-term clinical studies are needed to evaluate how new designs and technologies will affect patient outcomes and long-term implant performance.