Ten Year Outcomes of Contemporary Total Hip Arthroplasty in Adolescent and Young Adult Patients are Favorable.

BACKGROUND: The purpose of this study was to assess 10-year patient-reported outcome measures, complications, polyethylene wear-rates, and implant survivorships in patients ≤30 years of age treated with contemporary total hip arthroplasty (THA). METHODS: We retrospectively assessed 121 patients (144 hips) who underwent THA at age ≤30 years (mean 23 [range, 11 to 30]) at an average follow-up duration of 10.7 years (range, 8 to 17). Highly-crosslinked polyethylene acetabular liners were used in all cases. Femoral heads were ceramic (74%) or cobalt-chrome (26%). There were 52 hips (36%) that had previous surgery and 31 hips (22%) were in patients who had associated major systemic comorbidities. We analyzed the modified Harris Hip scores, University of California Los Angeles Activity Scores, major complications, polyethylene wear-rates, and implant survivorships. RESULTS: At final follow-up, the average modified Harris Hip scores improved from 47 (±15.1) to 81 (±19.5) with an average 34-point improvement. The University of California Los Angeles scores improved from 4.0 (±2.3) to 6.0 (±2.4). The major complication rate was 5.6%. There were 6 hips (4.2%) that were revised. Indications for revision included instability (3, 2.1%), late infection (1, 0.7%), liner dissociation (1, 0.7%), and acetabular loosening (1, 0.7%). Mean linear (0.0438 mm/y) and volumetric (29.07 mm3/y) wear rates were low. No periprosthetic osteolysis was detected in any hip. Survivorship free from revision for any reason was 97.2, 95.8, and 95.8% at 5, 10, and 15 years. CONCLUSIONS: Contemporary THA in patients ≤30 years of age is associated with marked clinical improvements at 10-year follow-up and encouraging survivorship estimates at 15 years.

A Psycholgical Intervention Delivered by Automated Mobile Phone Messaging Stabilized Hip and Knee Function During the COVID-19 Pandemic: A Randomized Controlled Trial.

BACKGROUND: We conducted a randomized controlled trial to evaluate the effectiveness of acceptance and commitment therapy (ACT) delivered via a mobile phone messaging robot to patients who had their total hip arthroplasty or total knee arthroplasty procedures postponed due to the COVID-19 pandemic. METHODS: Ninety patients scheduled for total hip arthroplasty or total knee arthroplasty who experienced surgical delay due to the COVID-19 pandemic were randomized to the ACT group, receiving 14 days of twice daily automated mobile phone messages, or the control group, who received no messages. Minimal clinically important differences (MCIDs) in preintervention and postintervention patient-reported outcome measures were utilized to evaluate the intervention. RESULTS: Thirty-eight percent of ACT group participants improved and achieved MCID on the Patient-Reported Outcome Measure Information System Physical Health compared to 17.5% in the control group (P = .038; number needed to treat [NNT] 5). For the joint-specific Hip Disability and Osteoarthritis Outcome Score Joint Replacement and Knee Disability and Osteoarthritis Outcome Score Joint Replacement (KOOS JR), 24% of the ACT group achieved MCID compared to 2.5% in the control group (P = .004; NNT 5). An improvement in the KOOS JR was found in 29% of the ACT group compared to 4.2% in the control group (P = .028; NNT 5). Fourteen percent of the ACT group participants experienced a clinical important decline in the KOOS JR compared to 41.7% in the control group (P = .027; NNT 4). CONCLUSION: A psychological intervention delivered via a text messaging robot improved physical function and prevented decline in patient-reported outcome measures in patients who experienced an unexpected surgical delay during the COVID-19 pandemic. LEVEL OF EVIDENCE: 1.

Total Hip Arthroplasty in Patients With Osteoarthritis Associated With Legg-Calve-Perthes Disease: Perioperative Complications and Patient-Reported Outcomes.

BACKGROUND: Complications and patient-reported outcomes (PROs) of total hip arthroplasty (THA) in patients with Legg-Calve-Perthes disease (LCPD) have demonstrated variable results. The purpose of this study was to use a validated grading scheme to analyze complications associated with THA in patients with residual LCPD deformities. Second, we report PROs and intermediate-term survivorship in this patient population. METHODS: A retrospective, single-center review was performed on 61 hips in 61 patients who underwent THA for residual Perthes disease. Average patient age was 42 years and 26% of hips had previous surgery. Complications were determined and categorized using a validated grading scheme that included five grades based on the treatment required to manage the complication and on persistent disability. PROs were compared from preoperative to most recent follow-up time points. RESULTS: Major complications (grade III) occurred in three patients (5%) which each required a second surgical intervention. The most common minor grade I or II complications (11.5%) were asymptomatic heterotopic ossification (3.3%). Patients were lengthened on the surgical side an average of 1.4 cm with no nerve palsies. All patient PROs improved from preoperative to postoperative time points with the modified Harris Hip Score improving from 46.9 preoperatively to 85.4 postoperatively (P < .01). Patients free from revision for any reason at final follow-up (5.6 years; range 2-13 years) was 98.4% with one patient needing a revision of their femoral component. CONCLUSIONS: THA for the sequelae of the LCPD has an acceptable complication rate and provides excellent patient reported outcomes at mid-term follow-up.

Diabetic Foot Surveillance Using Mobile Phones and Automated Software Messaging, a Randomized Observational Trial.

Background: Early detection of diabetic foot ulcers can improve outcomes. However, patients do not always monitor their feet or seek medical attention when ulcers worsen. New approaches for diabetic-foot surveillance are needed. The goal of this study was to determine if patients would be willing and able to regularly photograph their feet; evaluate different foot-imaging approaches; and determine clinical adequacy of the resulting pictures. Methods: We recruited adults with diabetes and assigned them to Self Photo (SP), Assistive Device (AD), or Other Party (OP) groups. The SP group photographed their own feet, while the AD group used a selfie stick; the OP group required another adult to photograph the patient's foot. For 8 weeks, we texted all patients requesting that they text us a photo of each foot. The collected images were evaluated for clinical adequacy. Numbers of (i) submitted and (ii) clinically useful images were compared among groups using generalized linear models and generalized linear mixed models. Results: A total of 96 patients consented and 88 participated. There were 30 patients in SP, 29 in AD, and 29 in OP. The completion rate was 77%, with no significant differences among groups. However, 74.1% of photographs in SC, 83.7% in AD, 92.6% in OP were determined to be clinically adequate, and these differed statistically significantly. Conclusions: Patients with diabetes are willing and able to take photographs of their feet, but using selfie sticks or having another adult take the photographs increases the clinical adequacy of the photographs.Level of Evidence: II.

Obtaining Imaging Cost and Quality Information in Femoroacetabular Impingement: The Patient Experience.

Background: Recent changes in healthcare have placed increased emphasis on price transparency, quality measures, and improving the patient experience. However, limited information is available for patient cost of obtaining a hip MRI and factors associated with cost variability. For a patient with femoroacetabular impingement (FAI), this study sought to report (1) the availability of pricing and quality information for a hip magnetic resonance imaging (MRI) in the state of Iowa, (2) the time investment required to obtain pricing and quality information, and (3) factors that influence hip MRI cost, quality and the time investment required for patients to obtain cost and quality information. Methods: Within the state of Iowa, 126 unique hospital institutions and 30 active, private orthopaedic practices were identified. All 156 providers were contacted via telephone using a standardized script of a hypothetical 25-year-old adult male patient with FAI requesting a quote for a hip MRI. Cost of the MRI and its components, availability of payment discounts, and MRI magnet tesla (T) were requested. A final bundled cost (FBC) was calculated for each MRI provider with all available services and discounts applied. The total amount of time needed to obtain a quote from each location was recorded. Results: One hundred and thirty-six of the 156 institutions contacted provided hip MRI services (87%). Median call duration was 9.1 minutes (Range 2.3-25.6). Median FBC was $2,114.00 (Range $484.75-4,463.00) across all providers. Hospital median FBC was $2,261.70 (Range $909.62-4,463.00) versus $1,225.13 (Range $484.75-2,218.40) for independent imaging centers (P<0.0001). No difference in median cost was observed between nine available 3.0 T machines and eighty-nine 1.5 T machines (P=0.2655). Conclusions: MRI cost varies widely across the state of Iowa and within individual metropolitan areas. Hip MRIs cost less at independent imaging centers compared to hospital locations. The amount of time required to obtain quality and cost data for a hip MRI presents a substantial time burden for patients with FAI. Surgeons, healthcare systems, and policy makers should be cognizant of the large price differences for a hip MRI and the time burden placed on patients with FAI to obtain this information.Level of Evidence: IV.

Acceptance and Commitment Therapy Delivered via a Mobile Phone Messaging Robot to Decrease Postoperative Opioid Use in Patients With Orthopedic Trauma: Randomized Controlled Trial.

BACKGROUND: Acceptance and commitment therapy (ACT) is a pragmatic approach to help individuals decrease avoidable pain. OBJECTIVE: This study aims to evaluate the effects of ACT delivered via an automated mobile messaging robot on postoperative opioid use and patient-reported outcomes (PROs) in patients with orthopedic trauma who underwent operative intervention for their injuries. METHODS: Adult patients presenting to a level 1 trauma center who underwent operative fixation of a traumatic upper or lower extremity fracture and who used mobile phone text messaging were eligible for the study. Patients were randomized in a 1:1 ratio to either the intervention group, who received twice-daily mobile phone messages communicating an ACT-based intervention for the first 2 weeks after surgery, or the control group, who received no messages. Baseline PROs were completed. Two weeks after the operative intervention, follow-up was performed in the form of an opioid medication pill count and postoperative administration of PROs. The mean number of opioid tablets used by patients was calculated and compared between groups. The mean PRO scores were also compared between the groups. RESULTS: A total of 82 subjects were enrolled in the study. Of the 82 participants, 76 (38 ACT and 38 controls) completed the study. No differences between groups in demographic factors were identified. The intervention group used an average of 26.1 (SD 21.4) opioid tablets, whereas the control group used 41.1 (SD 22.0) tablets, resulting in 36.5% ([41.1-26.1]/41.1) less tablets used by subjects receiving the mobile phone-based ACT intervention (P=.004). The intervention group subjects reported a lower postoperative Patient-Reported Outcome Measure Information System Pain Intensity score (mean 45.9, SD 7.2) than control group subjects (mean 49.7, SD 8.8; P=.04). CONCLUSIONS: In this study, the delivery of an ACT-based intervention via an automated mobile messaging robot in the acute postoperative period decreased opioid use in selected patients with orthopedic trauma. Participants receiving the ACT-based intervention also reported lower pain intensity after 2 weeks, although this may not represent a clinically important difference. TRIAL REGISTRATION: ClinicalTrials.gov NCT03991546; https://clinicaltrials.gov/ct2/show/NCT03991546.

Efficacy of Multimodal Analgesic Injections in Operatively Treated Ankle Fractures: A Randomized Controlled Trial.

BACKGROUND: Pain management following surgical treatment of an ankle fracture is an under-studied area of clinical practice. The present study evaluated the efficacy of a multimodal surgical-site injection as an adjunct to postoperative pain management in patients with an operatively treated, closed, rotational ankle fracture. METHODS: Patients indicated for operative fixation of a rotational ankle fracture were randomized to receive multimodal surgical-site injection (ropivacaine 200 mg, epinephrine 0.6 mg, and morphine 5 mg) or no injection (control). Visual analog scale (VAS) pain and opioid consumption data were collected every 4 hours until discharge from the hospital. Length of stay and discharge destination were recorded. Patients were sent automated text messages to report VAS pain and opioid usage during the first 2 weeks after discharge. RESULTS: One hundred patients (49 injection and 51 control) were enrolled. Demographic data were similar between the 2 groups. Mean VAS scores over the first 24 and 48 hours postoperatively were slightly lower in the injection group (42 ± 3 and 41 ± 3, respectively) compared with the control group (52 ± 3 and 50 ± 3, respectively; p = 0.01 and p < 0.01, respectively). The median opioid usage, in terms of morphine equivalent dose, was similar over the first 24 hours between the injection group (25.5; range, 0 to 74.7) and the control group (28.3; range, 2.5 to 91.0; p = 0.35). The median opioid usage from recovery room admission to discharge was also similar between the injection group (29.0; range, 0 to 85.3) and the control group (32.7; range, 4.3 to 215.0; p = 0.35). There were no differences in outpatient VAS scores or opioid consumption during the first 2 weeks postoperatively as assessed with use of automated text messaging. Median length of stay was 22.3 hours (range, 1.7 to 182.3 hours) for the injection group and 22.5 hours (range, 2.2 to 123.3 hours) for the control group (p = 0.71). The response rate for the post-discharge automated text messages was 85.1%. Complication rates were similar. CONCLUSIONS: The use of multimodal surgical-site injections in operatively treated rotational ankle fractures is associated with a reduction in immediate in-hospital pain scores that is statistically significant but below the minimal clinically important difference. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

A texting-based blood pressure surveillance intervention.

The authors examined whether using home BP measurements collected via a custom-built bi-directional-texting platform incorporated into patients' electronic medical records would lead to treatment calibration and improved BP management. Patients were randomized to either the intervention group and collected home measurements based on reminders and reported via bi-directional texting, or to the control group, with home BP measurement reporting via standard practice (eg, phone, electronic medical record portal) and instructed to return 7 morning and 7 evening BP measurements. Outcomes included number of BP measurements submitted, the number of medication changes, reduction in BP, and BP control. 72% of the intervention group submitted at least 14 readings, compared with 45% of the control group. BP control improved in both groups. However, the authors found no statistically significant difference in BP or the number of BP-medication changes at 1, 3, or 6 months compared with the control group.

Performance of the PROMIS in Patients Undergoing 3 Common Elbow Procedures.

BACKGROUND: Ulnar collateral ligament (UCL) reconstruction, distal biceps tendon repair, and elbow arthroscopic surgery are common elbow procedures performed in active patients. HYPOTHESIS: We hypothesized (1) good to excellent correlation between Patient-Reported Outcomes Measurement Information System (PROMIS) instruments and traditional orthopaedic upper extremity patient-reported outcome (PRO) measures; (2) that PROMIS instruments would demonstrate ceiling effects; and (3) that the PROMIS physical function computer adaptive test (PF CAT) would demonstrate a low question burden compared with other PRO instruments. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A total of 76 patients undergoing UCL repair/reconstruction, distal biceps tendon repair, or elbow arthroscopic surgery filled out the Short Form-36 Health Survey (SF-36) Physical Function subscale, EuroQol-5 Dimensions (EQ-5D) questionnaire, PROMIS PF CAT, and PROMIS upper extremity item bank (UE). Excellent correlation between PROs was defined as ≥.70. RESULTS: The PROMIS PF CAT had excellent correlation with the SF-36 (r = 0.74; P < .0001), Disabilities of the Arm, Shoulder and Hand (DASH) survey (r = -0.76; P < .0001), and PROMIS UE (r = 0.73; P < .0001). The PROMIS UE demonstrated excellent correlation with the SF-36 (r = 0.73; P < .0001) and DASH survey (r = -0.81; P < .0001). The PROMIS UE had ceiling effects in 33% of patients. The SF-36 showed ceiling effects in 20% of patients. On average, patients answered 5.1 ± 2.2 questions on the PROMIS PF CAT. CONCLUSION: The PROMIS PF CAT and PROMIS UE are valid in patients undergoing distal biceps tendon repair, elbow arthroscopic surgery, and UCL repair. The PROMIS UE demonstrated high ceiling effects in younger, higher functioning patients and should be used with caution in this group. A further evaluation and modification of the PROMIS UE in younger, high-functioning patients are warranted. Finally, the PROMIS PF CAT exhibited a low question burden relative to traditional PRO instruments without the loss of reliability.

Opioid Prescription Refills After Osteochondral Procedures of the Knee.

PURPOSE: (1) To assess the incidence of postoperative opioid prescription refills in patients undergoing osteochondral autograft transplant (OAT) and osteochondral allograft transplant (OCA) procedures of the knee; (2) to evaluate the effect of filling preoperative opioid prescriptions on the incidence of postoperative filling; and (3) to assess the impact of age, sex, and diagnosis of low-back pain on postoperative opioid prescription filling. METHODS: The Humana administrative claims database was queried for patients undergoing knee OAT and OCA procedures between 2007 and 2017 by use of Current Procedural Terminology codes. Patients were stratified by age, diagnosis of low-back pain, preoperative opioid use, autograft and allograft procedures, and open and arthroscopic procedures. Preoperative opioid users were defined as those having filled an opioid prescription within 3 months before surgery. The relative risk (risk ratio) for opioid prescription refills was calculated monthly for 12 months. Multivariate logistic regression analysis was performed to determine odds ratios (ORs) at 3, 6, and 12 months. RESULTS: We identified 300 patients: 133 (44%) underwent OAT and 167 (56%) underwent OCA procedures. Of the patients, 236 (79%) were aged 49 years or younger, and 31% of patients filled opioid prescriptions preoperatively. Of those who filled preoperative opioid prescriptions, 28% were still filling prescriptions 12 months after surgery. Multivariate analysis showed an increased risk of opioid prescription filling at 3 months (OR, 7.46 [95% confidence interval (CI), 3.26-17.38]), 6 months (OR, 15.41 [95% CI, 5.52-41.99]), and 12 months (OR, 13.45 [95% CI, 5.41-33.75]) postoperatively in preoperative opioid users. CONCLUSIONS: Filling opioid prescriptions preoperatively increased the risk of postoperative filling of opioid prescriptions after cartilage restoration procedures of the knee. Over 30% of patients were found to have filled an opioid prescription preoperatively. Univariate analysis showed that age of 50 years or older and low-back pain increased the risk of postoperative prescription refilling, but only age of 50 years or older provided a significantly increased risk at 3 months postoperatively using a multivariate analysis. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

Postoperative Pain and Opioid Use in Children with Supracondylar Humeral Fractures: Balancing Analgesia and Opioid Stewardship.

BACKGROUND: Effective postoperative analgesia remains a priority in orthopaedic surgery, but concerns with regard to opioid diversion and misuse have brought overdue attention to improving opioid stewardship. Normative data for postoperative pain and opioid use are needed to guide and balance these dual priorities. We aimed to characterize postoperative pain and opioid use for an archetypal pediatric orthopaedic procedure: closed reduction and percutaneous pinning of a supracondylar humeral fracture. METHODS: Children at a single pediatric trauma center who underwent closed reduction and percutaneous pinning of a supracondylar humeral fracture were enrolled and were prospectively followed. Validated pain scores (Wong-Baker FACES Pain Rating Scale) and opioid utilization data were collected using an automated text message-based protocol on postoperative days 1 to 7, 10, 14, and 21. Data were analyzed with descriptive and univariate statistics. RESULTS: Eighty-one patients with a mean age (and standard deviation) of 6.1 ± 2.1 years (62% of whom were male) were enrolled, including 53.1% who had Type-II fractures and 46.9% who had Type-III fractures. The mean pain ratings were highest on arrival to the emergency department (3.5 ± 3.5 points) and the morning of postoperative day 1 (3.5 ± 2.4 points). By postoperative day 3, the mean pain rating decreased to <2 (1.8 ± 1.8 points) and the mean opioid doses decreased to <1 dose (0.8 ± 1.2 doses). Postoperative opioid use decreased in parallel to reported pain (r = 0.972; p < 0.001). The interquartile range of opioid use was 1 to 7 doses, and patients used only 24.1% of the prescribed opioids (mean, 4.8 ± 5.6 doses used and 19.8 ± 7.1 doses prescribed). There was no significant difference (p > 0.05) in pain ratings or opioid use by fracture classification, age, or sex. CONCLUSIONS: Following closed reduction and percutaneous pinning for supracondylar humeral fracture, pain levels and opioid usage decrease to a clinically unimportant level by postoperative day 3. Patients who report pain scores of ≥6 points following discharge are outliers and should be screened for compartment syndrome or ischemia. Patients used <25% of prescribed opioid medication, suggesting the potential for overprescription and opioid diversion. A prescription for 7 opioid doses after discharge should allow adequate postoperative analgesia in the majority of patients while improving narcotic stewardship. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

PROMIS: a valid and efficient outcomes instrument for patients with ACL tears.

PURPOSE: The current study compares the Patient Reported Outcomes Information System Physical Function Computer Adaptive Test (PROMIS PF CAT) to traditional knee PRO instruments in a healthy population undergoing surgery for ACL injuries with the following objectives: (1) identify and determine the strength of any correlations between the scores of PROMIS PF CAT and current knee PROs or their subscales that measure physical function; (2) evaluate PROMIS PF CAT's test burden; and (3) determine if PROMIS PF CAT has any floor or ceiling effects in this population. METHODS: Patients indicated for ACL surgery completed the Short Form-36 Physical Function (SF-36 PF), Knee Injury and Osteoarthritis Outcome Score (KOOS), Marx Knee Activity Rating Scale (Marx), the EuroQol 5-dimensions Questionnaire (EQ-5D), and PROMIS PF CAT. Correlations between PROs were defined as follows: High (≥ 0.7); high-moderate (0.61-0.69); moderate (0.4-0.6); moderate-weak (0.31-0.39); and weak (≤ 0.3). Floor or ceiling effects were considered significant if 15% or more patients reported the lowest or highest possible total score, respectively. RESULTS: 100 patients participated with a mean age of 26 years (range 11-57). The PROMIS PF CAT demonstrated high correlations with SF-36 PF (r = 0.82, p < 0.01), EQ-5D (r = - 0.70, p < 0.01) KOOS ADL (r = 0.74, p < 0.01), and KOOS Sport (r = 0.70, p < 0.01). There were no ceiling or floor effects for PROMIS PF CAT (0%). The mean number of items completed for the PROMIS PF CAT was 4.2 (median 4; range 4-11). CONCLUSIONS: The PROMIS PF CAT shows a high correlation with commonly employed PROs that also measure physical function with low test burden and without ceiling effects in this relatively young and healthy population.

Automated Mobile Phone Messaging Utilizing a Cognitive Behavioral Intervention: A Pilot Investigation.

Background: In the setting of outpatient orthopaedic surgery, this pilot study utilized automated mobile messaging to assess (1) the feasibility of and interaction rates with a software delivered cognitive behavior therapy (CBT) intervention for postoperative opioid utilization, (2) the reliability of patient reported opioid utilization through our platform, (3) daily patient reported pain and opioid utilization within the first two postoperative weeks, and (4) the effect of software delivered CBT intervention on patient reported opioid utilization. Methods: Musculoskeletal tumor patients scheduled for outpatient surgery were randomized into two study groups. Control patients received standard postoperative communication limited to a two-week postoperative follow-up visit. The intervention group received automated daily text-messages regarding pain, opioid utilization, and a daily CBT intervention. Interventional group patients also completed a patient satisfaction questionnaire at their two-week follow-up. Completion rates of all software delivered questions were determined in the interventional group. Median values of opioid utilization and interquartile range (IQR) were determined to compare utilization between groups. Spearman correlation coefficients were used to determine reliability of patient reported opioid utilization in the interventional group. Results: Fourteen patients completed the pilot study (seven controls, seven intervention). Patients in the intervention arm completed 90% of pain and opioid questions. Intervention group patients utilized less of their daily prescribed opioid medication (20%, IQR:10%-27%) compared to controls (50%, IQR:4%-68%). Correlation between in-office pill counts and patient reported opioid medication utilization via our software messaging system was high (r=0.90, p=0.037). Conclusion: Automated mobile phone messaging in outpatient tumor surgery yielded high interaction rates. Patient reported opioid utilization obtained through our platform demonstrated a high correlation with in-office pill counts. CBT delivered via automated mobile phone messaging demonstrated decreased opioid utilization in this pilot investigation.Level of evidence: II.

Detailing postoperative pain and opioid utilization after periacetabular osteotomy with automated mobile messaging.

In the setting of periacetabular osteotomy (PAO), this investigation sought to (i) describe patient-reported pain scores and opioid utilization in the first 6 weeks following surgery and (ii) evaluate the effectiveness of postoperative communication using a robotic mobile messaging platform. Subjects indicated for PAO were enrolled from a young adult hip clinic. For the first 2 weeks after surgery, subjects received daily mobile messages inquiring about pain level on a 0-10 scale and the number of opioid pain medication tablets they consumed in the previous 24 h. Messaging frequency decreased to 3 per week in Weeks 3-6. Pain scores, opioid utilization and response rates with our mobile messaging platform were quantified for the 6-week postoperative period. Twenty-nine subjects underwent PAO. Twenty-one had concurrent hip arthroscopy. Average daily pain scores decreased over the first four postoperative days. Average pain scores reported were 5.9 ± 1.9, 4.1 ± 3.3 and 3.0 ± 3.5 on Day 1, Day 14 and Week 6, respectively. Reported opioid tablet utilization was 5.0 ± 3.2, 2.2 ± 2.0 and 0.0 ± 0.0 on Days 1 and 14 and at 6 weeks. Response rate for participants completing the 6-week messaging protocol was 84.1%. Patient-reported pain scores decreased over the first two postoperative weeks following PAO before plateauing in weeks 3-6. Opioid pain medication utilization increased in the first postoperative week before gradually declining to no tabs consumed at 6 weeks after PAO. Automated mobile messaging is an effective method of perioperative communication for the collection of pain scores and opioid utilization in patients undergoing PAO.

Use of an Automated Mobile Phone Messaging Robot in Postoperative Patient Monitoring.

BACKGROUND: Mobile phone messaging software robots allow clinicians and healthcare systems to communicate with patients without the need for human intervention. The purpose of this study was to (1) describe a method for communicating with patients postoperatively outside of the traditional healthcare setting by utilizing an automated software and mobile phone messaging platform and to (2) evaluate the first week of postoperative pain and opioid use after common ambulatory hand surgery procedures. MATERIALS AND METHODS: The investigation was a prospective, multicenter investigation of patient-reported pain and opioid usage after ambulatory hand surgery. Inclusion criteria included any adult with a mobile phone capable of text messaging, who was undergoing a common ambulatory hand surgical procedure at one of three tertiary care institutions. Participants received daily, automated text messages inquiring about their pain level and how many tablets of prescription pain medication they had taken in the past 24 h. Initial 1-week response rate was assessed and compared between different patient demographics. Patient-reported pain and opioid use were also quantified for the first postoperative week. Statistical significance was set as p < 0.05. RESULTS: Forty-seven (n = 47) patients were enrolled in this investigation. Total response rate of both pain and opioid medication questions through 7 days was 88.3%. Pain trended down on a daily basis for the first postoperative week, with the highest levels of pain being reported in the first 48 h after surgery. Patients reported an average use of 15.9 ± 14.8 tablets of prescription opioid pain medication. CONCLUSIONS: We find that a mobile phone messaging software robot allows for effective data collection of postoperative pain and pain medication use. Patients undergoing common ambulatory hand procedures utilized an average of 16 tablets of opioid medication in the first postoperative week.

Communication with Orthopedic Trauma Patients via an Automated Mobile Phone Messaging Robot.

BACKGROUND: Communication with orthopedic trauma patients is traditionally problematic with low response rates (RRs). The purpose of this investigation was to (1) evaluate the feasibility of communicating with orthopedic trauma patients postoperatively, utilizing an automated mobile phone messaging platform; and (2) assess the first 2 weeks of postoperative patient-reported pain and opioid use after lower extremity orthopedic trauma procedures. MATERIALS AND METHODS: This was a prospective investigation at a Level 1 trauma center in the United States. Adult patients who were capable of mobile phone messaging and were undergoing common, lower extremity orthopedic trauma procedures were enrolled in the study. Patients received a daily mobile phone message protocol inquiring about their current pain level and amount of opioid medication they had taken in the past 24 h starting on postoperative day (POD) 3 and continuing through POD 17. Our analysis considered (1) Patient completion rate of mobile phone questions, (2) Patient-reported pain level (0-10 scale), and (3) Number and percentage of daily prescribed opioid medication patients reported taking. RESULTS: Twenty-five patients were enrolled in this investigation. Patients responded to 87.5% of the pain and opioid medication inquiries they received over the 2-week study period. There were no differences in RRs by patient age, sex, or educational attainment. Patient-reported pain decreased over the initial 2-week study period from an average of 4.9 ± 1.7 on POD 3 to 3 ± 2.2 on POD 16-17. Patients took an average of 68% of their maximum daily narcotic prescription on POD 3 compared with 35% of their prescribed pain medication on POD 16-17. CONCLUSIONS: We found that in orthopedic trauma patients, an automated mobile phone messaging platform elicited a high patient RR that improved upon prior methods in the literature. This method may be used to reliably obtain pain and medication utilization data after trauma procedures.

The Seasonal Variability of Surgical Site Infections in Knee and Hip Arthroplasty.

BACKGROUND: Surgical site infections (SSIs) after total knee (TKA) and total hip (THA) arthroplasty are devastating to patients and costly to healthcare systems. The purpose of this study is to investigate the seasonality of TKA and THA SSIs at a national level. METHODS: All data were extracted from the National Readmission Database for 2013 and 2014. Patients were included if they had undergone TKA or THA. We modeled the odds of having a primary diagnosis of SSI as a function of discharge date by month, payer status, hospital size, and various patient co-morbidities. SSI status was defined as patients who were readmitted to the hospital with a primary diagnosis of SSI within 30 days of their arthroplasty procedure. RESULTS: There were 760,283 procedures (TKA 424,104, THA 336,179) in our sample. Our models indicate that SSI risk was highest for patients discharged from their surgery in June and lowest for December discharges. For TKA, the odds of a 30-day readmission for SSI were 30.5% higher at the peak compared to the nadir time (95% confidence interval [CI] 20-42). For THA, the seasonal increase in SSI was 19% (95% CI 9-30). Compared to Medicare, patients with Medicaid as the primary payer had a 49% higher odds of 30-day SSI after TKA (95% CI 32-68). CONCLUSION: SSIs following TKA and THA are seasonal peaking in summer months. Payer status was also a significant risk factor for SSIs. Future studies should investigate potential factors that could relate to the associations demonstrated in this study.

Brake Reaction Time After Ankle and Subtalar Arthroscopy.

PURPOSE: To evaluate preoperative and postoperative brake reaction time (BRT) of patients undergoing right-sided ankle or subtalar arthroscopy. METHODS: Patients who underwent right-sided ankle or subtalar arthroscopy were evaluated between May 2015 and February 2017. The inclusion criteria consisted of patients older than 18 years who possessed a valid driver's license, primarily drove vehicles that had automatic transmission, and used their right foot to depress the brake pedal. Patients were excluded if they had medical problems that precluded safe and legal driving. An automotive simulation device was used to calculate BRT from all participants. Each patient underwent testing on a computerized driving simulator preoperatively and then postoperatively at 2, 6, and 12 weeks or until their BRT was equal to or less than 0.7 seconds. BRT was defined as the time from stop stimulus until brake depression of 5%. RESULTS: The study enrolled 17 patients and 19 age-matched normal subjects. Patients showed an average BRT at 2 weeks postoperatively (0.57 ± 0.06 seconds) that was greater than the BRT in the control group (0.55 ± 0.06 seconds, P = .84) and lower than the patients' preoperative BRT (0.59 ± 0.06 seconds, P = .08). These BRTs were lower than the 0.70-second BRT threshold for safe driving in the United States. CONCLUSIONS: The results of this study show that emergency BRT after right-sided ankle or subtalar arthroscopy improves by 2 weeks after surgery and is under the previously set benchmark of 0.7 seconds. In patients who undergo right-sided ankle or subtalar arthroscopic procedures, it is not unsafe to drive a vehicle at 2 weeks. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Use of PROMIS for Patients Undergoing Primary Total Shoulder Arthroplasty.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) consists of question banks for health domains through computer adaptive testing (CAT). HYPOTHESIS: For patients with glenohumeral arthritis, (1) there would be high correlation between traditional patient-reported outcome (PRO) measures and the PROMIS upper extremity item bank (PROMIS UE) and PROMIS physical function CAT (PROMIS PF CAT), and (2) PROMIS PF CAT would not demonstrate ceiling effects. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: Sixty-one patients with glenohumeral osteoarthritis were included. Each patient completed the American Shoulder and Elbow Surgeons (ASES) assessment form, Marx Shoulder Activity Scale, Short Form-36 physical function scale (SF-36 PF), EuroQol 5 Dimensions (EQ-5D) questionnaire, Western Ontario Osteoarthritis Shoulder (WOOS) index, PROMIS PF CAT, and the PROMIS UE. Correlation was defined as high (>0.7), moderate (0.4-0.6), or weak (0.2-0.3). Significant floor and ceiling effects were present if more than 15% of individuals scored the lowest or highest possible total score on any PRO. RESULTS: The PROMIS PF demonstrated excellent correlation with the SF-36 PF (r = 0.81, P < .0001) and good correlation with the ASES (r = 0.62, P < .0001), EQ-5D (r = 0.64, P < .001), and WOOS index (r = 0.51, P < .01). The PROMIS PF demonstrated low correlation with the Marx scale (r = 0.29, P = .02). The PROMIS UE demonstrated good correlation with the ASES (r = 0.55, P < .0001), SF-36 (r = 0.53, P < .01), EQ-5D (r = 0.48, P < .01), and WOOS (r = 0.34, P <.01), and poor correlation with the Marx scale (r = 0.06, P = .62). There were no ceiling or floor effects observed. The mean number of items administered by the PROMIS PRO was 4. CONCLUSION: These data suggest that for a patient population with operative shoulder osteoarthritis, PROMIS UE and PROMIS PF CAT may be valid alternative PROs. Additionally, PROMIS PF CAT offers a decreased question burden with no ceiling effects.

Total Shoulder Arthroplasty: Is Less Time in the Hospital Better?

BACKGROUND: The incidence of total shoulder arthroplasty (TSA) has increased significantly over the last decade. Short-stay protocols for other highvolume procedures have been shown to be safe and effective but have yet to be fully explored for TSA. Our purpose in comparing short-stay and inpatient TSA was to determine: (1) patient demographics and comorbidities, (2) 30-day morbidity, mortality, and readmissions using a matched analysis, and (3) independent predictors of 30-day complications. METHODS: The American College of Surgeons National Surgical Quality Improvement (ACS NSQIP) database was queried and all patients undergoing elective, primary TSA between 2006 and 2013 were identified. Patients were categorized as short-stay or inpatient based on day of discharge. Propensity score matching was used to adjust for selection bias. Univariate and multivariate statistical analysis was used to compare 30-day morbidity and mortality between the two cohorts. RESULTS: Overall, 4,619 cases were available, with inpatient admission occurring in 65.7% of patients. Prior to propensity score matching, short-stay patients were significantly younger, more frequently male, with fewer comorbid conditions. After matching, inpatient admission was associated with increased rates of urinary tract infection (1.1% vs. 0.1%; p = 0.001), blood transfusion (5.3% vs. 0.8%; p < 0.001), and total complications (4.7% vs. 1.8%; p < 0.001). Multivariate analysis identified inpatient admission as an independent risk factor for 30-day complication following TSA. CONCLUSIONS: Short-stay TSA is a safe option for the appropriately selected patient. Inpatient admission was an independent risk factor for complication following TSA. Level of Evidence: III.