TREATMENT OF HIP AND KNEE PERIPROSTHETIC JOINT INFECTION REQUIRES EXTENSIVE ADMINISTRATIVE WORK.

INTRODUCTION: Treatment of periprosthetic joint infections (PJI) typically requires more resource utilization than primary total joint arthroplasty (TJA). This study quantifies the amount of time spent in the electronic medical record (EMR) for patients who have PJI requiring surgical intervention. METHODS: A retrospective analysis of EMR activity for 165 hip and knee PJI was performed to capture work during the preoperative and postoperative time periods. Independent sample t tests were conducted to compare total time based on procedure, age, insurance, health literacy, sex, race, and ethnicity. RESULTS: The EMR work performed by the orthopaedic team was 338.4 minutes (min) (SD [standard deviation] 130.3), with 119.4 minutes (SD 62.8) occurring preoperatively and 219.0 minutes (SD 112.9) postoperatively. Preoperatively, the surgeon's work accounted for 35.7 minutes (SD 25.4), mid-level providers 21.3 minutes (SD 15.9), nurses 38.6 minutes (SD 36.8), and office staff 32.7 minutes (SD 29.9). Infectious Disease (ID) colleagues independently performed 158.9 minutes (SD 108.5) of postoperative work. Overall, PJI of the knees required more postoperative work. Secondary analysis revealed that patients who have hip PJI and a BMI < 30 and patients < 65 years required more work when compared to the PJI of heavier and older individuals. There was no difference in total work based on insurance, health literacy, race, or ethnicity. CONCLUSION: Over 8 hours of administrative work is required for surgical management of PJI. Surgeons alone performed 451% more work for PJI during the preoperative period (7.9 versus 35.7min) compared to primary TJA. In efforts to provide best care for our sickest patients, much work is required perioperatively. This work is necessary to consider when assigning value and physician reimbursement.

Extensive Preoperative Work Is Required for Revision Hip and Knee Arthroplasty.

BACKGROUND: Determining the clinical effort associated with preparing for revision total hip and knee arthroplasty is necessary to maintain the appropriate work relative value unit rating. We have investigated the work done by the orthopedic surgical team in the days and weeks prior to revision hip and knee arthroplasty using a count of time by team members in the electronic medical record (EMR). METHODS: EMR audit logs were generated, and preoperative work (POW) was calculated for members of the surgical team for 200 sequential revision cases. Independent samples t-tests were conducted to compare total POW for procedure, age, gender, insurance, and health literacy; significance threshold was set at P = .05. RESULTS: POW was 97.7 minutes (standard deviation [SD] 53.1). Surgeon POW accounted for 10.5 minutes (SD 9.3), nurses for 29.9 minutes (SD 34.2), mid-level providers for 22.1 minutes (SD 17.0), and office technicians for 34.1 minutes (SD 35.2). There was no difference in total POW based on procedure (hip vs knee), age, gender, insurance type, or health literacy. CONCLUSION: Revision arthroplasty requires substantial preoperative preparation from the surgical team. Most of this is by nurses, mid-level providers, and office staff. This does not seem to be different for hip or knee revisions or by age and gender. EMR audit logs capture the bare minimum POW required to prepare a patient for revision arthroplasty.

How long after maximal physical exertion should baseline computerized neurocognitive testing and symptom assessment be administered?

Objective: Prior research suggests maximal physical exertion (MPE) may negatively affect the reliability and validity of computerized neurocognitive testing (CNT); the purpose of this study was to identify aclinically relevant recovery interval following MPE for the administration of baseline CNT.Design: Random-crossover.Participants: Thirty (M = 21.87 ± 2.29 y), moderately-active,healthy participants, without history of ADHD, learning disabilities, psychological disorders or concussion (within the last six months).Intervention: Participants completed four randomly ordered experimental trials. Except for the control trial, CNT was administered following MPE with assigned recovery intervals [Immediate, 10-minutes,or 20-minutes]. Aseries of repeated measures analysis of variance (ANOVAs) were performed on CNT composite and total symptom scores.Results: Total symptom scores were significantly greater (p < .01) at the immediate, 10-minute,and 20-minuterecovery intervals compared to the control trial. Processing speed was significantly faster at the 20-minuterecovery interval compared to the control trials. Visual memory, verbal memory, or reaction time did not differ across recovery intervals.Conclusions: Clinicians should wait more than 20 minutes before assessing baseline concussion symptoms following about of MPE.

Establishing Test-Retest Reliability and Reliable Change for the King-Devick Test in High School Athletes.

OBJECTIVE: To establish test-retest reliability in nonconcussed high school athletes and compare absolute change, reliable change indices (RCIs), and minimal detectable change (MDC) methods for classifying impairment after sport-related concussion. DESIGN: Prospective, repeated measures. SETTING: High schools from the Midwest and Central regions of the United States. PARTICIPANTS: A convenience sample of 772 nonconcussed high school athletes (n = 546 men) completed preseason K-D testing. In addition, 69 athletes completed a second postseason K-D test, and 54 athletes sustained a concussion and completed postconcussion K-D tests. INTERVENTION: K-D test. MAIN OUTCOME MEASURES: Data for age, sex, and concussion history were determined using preseason K-D test outcomes. Test-retest reliability, RCIs, and MDCs were calculated using postseason K-D tests (M = 98.9, SD = 9.1 days). Postinjury K-D assessments within 5 days of injury (M = 1.5, SD = 1.5 days) were used to classify impairment on K-D using absolute change, RCI, and MDC methods. RESULTS: Significant effects for age (P < 0.001) and history of concussion (P = 0.001) were supported on baseline K-D time, with no sex differences (P = 0.21). Preseason to postseason reliability for K-D times was 0.60 (intraclass correlation coefficient, 95% CI, 0.43-0.73), although 38% of athletes exhibited slower postseason K-D times compared with baseline. Impairment on K-D exhibited for 72% of the concussed sample using absolute change, 48% using MDC, and 44% using RCI methods. CONCLUSIONS: K-D exhibited moderate test-retest reliability across 1 season. Absolute change yielded the highest sensitivity for preinjury to postinjury impairment on the K-D compared with RCI and MDC methods.

Electronic Medical Record Audit Time Logs as a Measure of Preoperative Work Before Total Joint Arthroplasty.

BACKGROUND: In order to achieve rapid recovery total joint arthroplasty, surgeons and their teams are spending more time in the weeks before surgery to prepare patients. This study aims to quantify total knee and hip prearthroplasty work using retrospective electronic medical record (EMR) activity audit log analysis. METHODS: EMR activity in 100 elective knee and 100 elective hip arthroplasty cases was performed using audit logs. Each mouse click and action in the EMR was recorded. The time between mouse clicks was calculated and summed for each member of the clinical team. Descriptive statistics and independent samples t-tests were conducted to quantify and compare total preoperative work (POW) between groups defined by gender, procedure, age, insurance type, or health literacy (P < .05). RESULTS: The mean number of days defined in the prearthroplasty time period was 69.1 days (standard deviation [SD] 42.8; range 8-191). The mean time spent in each patient's chart in the prearthroplasty period was 76.8 (SD 47.8) minutes. Surgeon's work in the medical record accounted for 7.9 (SD 7.9) minutes, registered nurses 46.7 minutes (SD 39.1), physician extenders 10.8 minutes (SD 16.9), and licensed practical nurses and patient care technicians 9.8 minutes (SD 13.0). A significant difference was observed when groups were dichotomized based on age <65 and insurance provider type. CONCLUSION: A considerable amount of POW is required to prepare patients for surgery from the clinic date one decides to pursue total joint arthroplasty and the day prior to surgery. Retrospective electronic time stamps from the EMR should represent the minimum time required for surgical preparation.

Prospective Changes in Vestibular and Ocular Motor Impairment After Concussion.

BACKGROUND AND PURPOSE: The utility of prospective changes on the Vestibular/Ocular Motor Screening (VOMS) assessment are unknown, and 2 methods of scoring are published in the literature. Total scores are the total symptom scores for each VOMS component, and change scores are the difference between the pretest total symptom score and component total symptom scores. This study documented prospective changes in vestibular and ocular motor impairments and symptoms in high school athletes with concussion using the total and change scoring methods and compared the percentage of scores over clinical cutoffs using the total and change scoring methods for the VOMS. METHODS: Sixty-three athletes (15.53 ± 1.06 years) completed the VOMS at baseline (ie, preinjury), 1 to 7 days, and 8 to 14 days after concussion. A series of repeated-measures multivariate analyses of variance were conducted on total and change scores. A 2-way repeated-measures analysis of variance was performed on the near-point convergence distance. A series of χ analyses compared scores exceeding clinical cutoffs between the total and change scoring methods. RESULTS: Total scoring revealed impairments (Wilks λ = 0.39, F16,47 = 4.54, P < 0.001, η = 0.61) on all VOMS components at 1 to 7 and 8 to 14 days compared to baseline. Change scoring revealed postinjury impairments compared with baseline (Wilks λ = 0.58, F14,49 = 2.52, P = 0.009, η = 0.42) on all components at 1 to 7 days; however, impairments at 8 to 14 days were revealed only for the vertical vestibular oculomotor reflex and vestibular motor sensitivity components. Total scoring identified significantly more scores over cutoffs at 1 to 7 days (χ1,63 = 5.97, P = 0.02) compared with change scores. DISCUSSION AND CONCLUSIONS: Both total and change scoring methods on the VOMS are useful for identifying impairments following concussion.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A230).

Risk Stratification of Acute Invasive Fungal Rhinosinusitis in Patients With Hematologic Pathology.

OBJECTIVE: The purpose of this study is to identify objective perioperative diagnostic factors for acute invasive fungal rhinosinusitis (AIFS) to create a diagnostic scoring system using objective criteria. METHODS: Retrospective case-control study performed at an academic, tertiary care center. Biopsy-proven cases of AIFS identified from pathology records (2015-2019) were compared to patients the otolaryngology service was consulted to "Rule out AIFS" in the year 2019, only including those with underlying hematologic malignancy. Eighteen patients with AIFS and 20 patients without were included. One and two tailed T-tests were used for p-values. Receiver operating characteristic curves were generated for the significant data, and Youden's J-statistic was used to create the ideal cutoff values for each. Likelihood ratios were used to give a power for the scoring system. RESULTS: Compared to patients with non-hematologic malignancy-related AIFS, patients with hematologic malignancy-related AIFS have significantly elevated C-reactive protein (CRP) and blood glucose; while albumin, hematocrit, platelet count, and absolute neutrophil count (ANC) were found to be significantly lower. In addition, Lund-Mackay score asymmetry, extra-sinus spread, aspergillus antigen, and pre-existing diabetes mellitus correlated with disease. A scoring system with three categories: AIFS Unlikely, Indeterminate/AIFS Suspicious, and AIFS Highly Likely was developed. CONCLUSION: Patients with hematologic malignancy-related AIFS have measurable differences in lab values and standard imaging that could be used in determining the diagnostic probability of AIFS including: CRP, albumin, hematocrit, platelets, ANC, blood glucose, aspergillus antigen, Lund-Mackay score asymmetry, extra-sinus spread, and pre-existing diabetes mellitus. A novel scoring system was proposed that will require prospective validation. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:1059-1064, 2023.

Postoperative and 1-Year Functional Outcomes After Free Flap Surgery Among Patients 80 Years or Older.

OBJECTIVE: To evaluate the postoperative and 1-year functional outcomes after free flap surgery among patients ≥80 years old. STUDY DESIGN: Retrospective chart review. SETTING: Single tertiary care center. METHODS: We conducted a retrospective review of 596 patients who underwent head and neck ablation and reconstruction with free tissue over a 7-year period. Patients ≥80 years of age were included. RESULTS: Fifty patients were ≥80 years old, with an average age of 83.7 years. Ninety-day mortality was 12.0%, and those who died were of older age (87.5 vs 83.1 years, P = .036). Prior radiation therapy (odds ratio, 6.8 [95% CI, 1.1-42.7]) and a Charlson Comorbidity Index ≥3 (odds ratio, 10.0 [95% CI, 1.5-67.0]) were associated with an increased risk of 90-day mortality. Overall 21 (42.0%) patients experienced a 30-day complication; 7 (14.0%) were readmitted within 30 days; and 5 (10.0%) underwent additional flap-related operations. Flap failure occurred in 2 (4.0%) patients. Before surgery, 45 (90%) patients were living independently or within assisted living; among these, 19.5% declined to dependent functional status at 90-day follow-up. At 90 days, 2 (8.3%) of 24 patients remained tracheostomy dependent, and 20 (66.7%) of 30 patients required feeding tube supplementation. Among 42 patients, 36 (85.7%) had unrestricted or modified oral diets at 90 days. Charlson Comorbidity Index ≥2 was associated with an increased risk of 1-year mortality (odds ratio, 5.1 [95% CI, 1.4-18.6]). CONCLUSION: The potential for functional decline and risk of 90-day mortality should be discussed with patients aged ≥80 years.

A Review of Periprosthetic Tibial Fractures: Diagnosis and Treatment.

Periprosthetic fracture occurring during or after total knee arthroplasty is a rare injury. Literature concerning periprosthetic tibial factures is sparse, and there is limited guidance for evidence-based management. This review aims to provide readers with an overview of the epidemiology, risk factors, and classification of these fractures. Management includes nonoperative treatment of nondisplaced fractures, fixation for those with stable implants, and revision for those with loose implants.

Preliminary Study of Fear of Re-Injury following Sport-Related Concussion in High School Athletes.

The influence of fear of re-injury that this variable has on recovery outcomes following sports-related concussion remains unknown. We examined changes in fear of re-injury throughout concussion recovery, and compared changes in neurocognitive, symptom, vestibular/ocular motor, and recovery time outcomes between concussed adolescent athletes who endorsed high and low fear of re-injury. Individuals with high fear of re-injury were more symptomatic and more likely to exhibit vestibular/ocular motor symptoms over clinical cutoffs than those with low fear of re-injury. Recovery time was not significantly different between the groups. These findings may help explain performance on more subjective concussion assessments.

Motion Sickness Susceptibility and Baseline Vestibular and Ocular-Motor Performance in Adolescent Athletes.

CONTEXT: High school athletes with a history of motion sickness susceptibility exhibit higher baseline vestibular and ocular-motor scores than those without a history of motion sickness susceptibility. OBJECTIVE: To examine the effects of motion sickness susceptibility on baseline vestibular and ocular-motor functioning, neurocognitive performance, and symptom scores. DESIGN: Cross-sectional study. SETTING: Preseason concussion testing. PATIENTS OR OTHER PARTICIPANTS: A convenience sample of high school athletes (N = 308, age = 15.13 ± 1.21 years) involved in a variety of sports. MAIN OUTCOME MEASURE(S): Vestibular/Ocular Motor Screening, computerized neurocognitive assessment, symptom scale, and Motion Sickness Susceptibility Questionnaire-Short Form (MSSQ-S). RESULTS: Participants were categorized into 3 groups based on a median split of the scores (eg, NONE, LOW, and HIGH). The LOW (n = 95) and HIGH (n = 92) groups (ie, MSSQ-S score > 0) were 2.64 times more likely (χ21,257 = 7.94, P = .01, 95% confidence interval = 1.32, 5.26) to have baseline Vestibular/Ocular Motor Screening scores larger than the clinical cutoffs for the NONE group (n = 70). No between-groups main effects were present for the NONE (n = 52), LOW (n = 89), and HIGH (n = 90) MSSQ-S groups for verbal (F2,230 = .09, P = .91, η2 = .001) and visual (F2,230 = .15, P = .86, η2 = .001) memory, processing speed (F2,230 = .78, P = .46, η2 = .007), or reaction time (F2,230 = 2.21, P = .11, η2 = .002). The HIGH group exhibited higher total baseline symptom scores than the LOW (U = 3325.50, z = -1.99, P = .05, r = .15) and NONE (U = 1647.50, z = -2.83, P = .005, r = .24) groups. CONCLUSIONS: Motion sickness should be considered a preexisting risk factor that might influence specific domains of the baseline concussion assessment and postinjury management.