The Impact of Experience Versus Decision Aids on Patient Preference Toward Virtual Care.

Introduction: Virtual care utilization has increased in recent years bringing questions of how to best inform patients regarding their use. Decision aids (DAs) are tools created to assist patients in making informed decisions about their health care. This study seeks to determine whether a DA or previous experience could better educate and influence patient's preference on virtual care. Methods: One hundred fifty participants from an orthopedic clinic of a multi-hospital system were divided into three groups. Group 1 (Virtual Care Cohort) had at least one previous virtual care visit and was surveyed with the Telemedicine Satisfaction Questionnaire (TSQ). Group 2 (In-person with Decision Aid) and Group 3 (In-person without Decision Aid) had no virtual care experience. Group 2 received a validated virtual care DA with a knowledge test. Both groups were also administered the TSQ. Results: After the DA, patients improved their score on 3 of 4 virtual care knowledge questions. Each cohort demonstrated a positive perception of virtual care; however, the specific reasons for their favorable views varied. The DA cohort did not show increased preference toward virtual care compared with the non-DA group and only responded significantly higher regarding encounter comfort. Patients with previous experience in virtual care responded most favorably to the majority of survey questions regarding their virtual care preferences when compared with both virtual care naive cohorts. Discussion and Conclusion: We found that patient experience was the most important factor in influencing patient preference toward virtual care. Although the DA increased their virtual care knowledge it did not increase their preference; therefore, efforts should be placed at encouraging patient to experience virtual care.

The AAHKS Clinical Research Award: Oral Dexamethasone Following Total Knee Arthroplasty: A Double-Blind, Randomized Controlled Trial.

BACKGROUND: Intravenous dexamethasone has been shown to reduce pain in total joint arthroplasty. This double-blind, randomized, placebo-controlled trial investigated the postoperative effects and safety of oral dexamethasone as a potential augment to multimodal pain management in outpatient knee arthroplasty. METHODS: The authors prospectively randomized 109 consecutive patients undergoing primary total knee arthroplasty. Patients assigned to Group A (57 patients) received 4 mg of dexamethasone by mouth twice per day starting postoperative day (POD) 1 for 4 days and those assigned to Group B received placebo capsules. All healthcare professionals and patients were blinded to group allocation. The primary outcome was defined as postoperative pain scores. Secondary outcomes included 90-day postoperative complications, nausea and vomiting, daily opioid usage, assistance for ambulation, difficulty sleeping, and early patient reported outcomes. Demographics were similar between groups. RESULTS: The patients who received dexamethasone had a statistically significant decrease in VAS scores when averaging POD 1 to 4 (P = .01). The average VAS scores among individual days were significantly lower with dexamethasone on POD 2, 3, and 4. While taking dexamethasone, morning and mid-day VAS scores were significantly lower. There was no difference between the groups with opioid use, nausea or vomiting, 90-day complications, ability to walk with/without assistance, difficulty sleeping, and early patient reported outcomes. CONCLUSION: This double-blind, randomized, placebo-controlled trial demonstrated that oral dexamethasone following primary total knee arthroplasty can reduce postoperative pain. This may be a beneficial option in ambulatory surgery where intravenous limitations exist, but larger series are needed to further evaluate the safety profile in this population.

Increased Accuracy in Templating for Total Knee Arthroplasty Using 3D Models Generated from Radiographs.

Templating prior to total hip arthroplasty is a widely adopted practice that aims to improve operative efficiency and reduce clinical outliers. Predicting implant size before total knee arthroplasty (TKA), although less common, could increase operating room efficiency by reducing necessary equipment needed for the procedure. This study compared templating accuracy in TKA using two-dimensional (2D) digital radiographs to a novel imaging technology that generates a three-dimensional (3D) model from these 2D radiographs. Two hundred and two robotic-assisted primary TKA surgical cases using Persona Knee System (Zimmer Biomet, Warsaw, IN) were retrospectively analyzed. For all cases, 3D templating was completed preoperatively using a novel radiographic image acquisition protocol. Using the same radiographs, the knee was templated using a 2D digital templating program. All surgeons were blinded to the final implant sizes, and all templating was done independently. The accuracy of predictions within ± 1 from the final implant size was determined for the femoral and tibial components. The accuracy (within 1 size) of tibial size predictions was comparable between attending surgeons and residents (87 vs. 82%, p = 0.08), but attending surgeons more accurately predicted the femoral size (77 vs. 60%, p < 0.05). The 2D to 3D imaging technology more accurately predicted both tibial and femoral sizes compared with the attending surgeons (99.5 vs. 87%, p < 0.05; 84% vs. 77%, p < 0.05). However, the imaging technology, attending surgeons, and residents were all more likely to overestimate femur size (p < 0.05). Moreover, the 3D imaging technology predicted the exact tibial component size in 93.1% of cases, which was significantly greater compared with residents (40%, p < 0.01) and attending surgeons (53%, p < 0.01). The 2D to 3D imaging technology more accurately predicted tibial and femoral component sizes compared with 2D digital templating done by surgeons. All templating predictions were more accurate for the tibial implant size than for the femoral size. The increased accuracy of implant size predictions from this 3D templating technology has the potential to improve intraoperative efficiency and minimize costs and surgical time.

Preoperative Patient-Reported Outcomes Measurement Information System Global Health Scores Predict Patients Achieving the Minimal Clinically Important Difference in the Early Postoperative Time Period After Total Knee Arthroplasty.

INTRODUCTION: The patient-specific factors influencing postoperative improvement after total knee arthroplasty (TKA) are important considerations for the surgeon and patient. The primary purpose of this study was to determine which patient demographic factors influence the postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health (GH) scores. In addition, we aimed to compare the prognostic utility of preoperative PROMIS-GH scores and the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) in predicting postoperative improvement. METHODS: This retrospective cohort study of a consecutive series of patients who underwent primary, unilateral TKA analyzed prospectively collected KOOS-JR and PROMIS-GH surveys. PROMIS-GH includes physical health (PH) and mental health scores. Patient demographic and presurgical characteristics were evaluated for prognostic capability in predicting postoperative improvement in the PROMIS scores and achievement of the minimal clinically important difference (MCID). Receiver operating characteristic curves were used to understand the prognostic thresholds of the preoperative PROMIS score and KOOS-JR for predicting MCID achievement. RESULTS: A total of 872 patients were included. Although unadjusted analyses showed associations between patient demographic factors and PROMIS-PH scores, multivariable regression analysis for predictors of MCID achievement demonstrated that PROMIS-PH was the only significant preoperative variable. Receiver operating characteristic analysis revealed that the area under the curve of PROMIS-PH (0.70; 95% CI, 0.67 to 0.74) was less than that of the KOOS-JR (0.77; 95% CI, 0.73 to 0.81; P = 0.032). Sensitivity and specificity for achieving the MCID were maximized for preoperative PROMIS-PH scores of ≤ 38 (59% and 70%) and for preoperative KOOS-JR ≤ 51 (71% and 69%). CONCLUSIONS: Preoperative KOOS-JR and PROMIS-PH scores predict clinically meaningful improvement after TKA. The KOOS-JR has greater prognostic utility in the early postoperative period. LEVEL OF EVIDENCE: Level III, Prognostic Study.

Minimal Clinically Important Difference in Robotic-Assisted Total Knee Arthroplasty Versus Standard Manual Total Knee Arthroplasty.

BACKGROUND: The purpose of this study was to determine whether robotic total knee arthroplasty (R-TKA) demonstrated evidence of improvement in minimal clinically important difference (MCID) in early (<4 weeks) and intermittent (4-8 month) patient-reported outcomes compared with manual total knee arthroplasty (M-TKA). METHODS: A prospectively collected database was reviewed of 1160 consecutive patients undergoing R-TKA or M-TKA from December 2017 to October 2019. Primary outcomes consisted of Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) and Patient-Reported Outcomes Measurement Information System Global Health Measures of Physical Health (PH) and Mental Health (MH). Statistical analysis included MCID via the distribution method. RESULTS: Univariate analysis demonstrated conflicting results for early MCID achievement favoring M-TKA (4-week KOOS-JR, P = .03) for the multisurgeon cohort, but favored R-TKA (4-week Patient-Reported Outcomes Measurement Information System-PH, P = .04) in the single-surgeon analysis, and the remaining outcome scores were similar. Ultimately, multivariate analysis demonstrated similar 4-week and 6-month MCID achievement in all measures. Lower preoperative scores consistently achieved MCID at a higher rate in M-TKA, although in R-TKA, the higher baseline scores improved at a rate comparable with those with lower scores in all but the short-term postoperative KOOS-JR. CONCLUSION: R-TKA demonstrated comparable MCID achievement to M-TKA across the larger cohort. Single-surgeon comparison did show some early benefit. Confounding variables such as surgical technique, implant fixation, and responsiveness of an outcome measure may be as important as simply what tools are used during surgery. Such granular data should be sought out in future studies.

Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health Short Forms Demonstrate Responsiveness in Patients Undergoing Knee Arthroplasty.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) is an alternative to legacy outcome metrics. We investigated the relationship between Knee Injury and Osteoarthritis Outcomes Score for Joint Replacement (KOOS-JR) and PROMIS Global Health forms of Physical Health (PH) and Mental Health (MH) in knee arthroplasty patients. METHODS: This is a retrospective cohort study of knee arthroplasty patients from December 2017 through April 2019 who had surveys collected preoperatively and postoperatively. We excluded patients undergoing revision surgery. Outcome scores were analyzed for responsiveness, effect size index (ESI), minimal clinically important difference (MCID), and correlation with each other through 12 months postoperatively. RESULTS: A total of 875 patients were included. Floor and ceiling effects were 0% for PROMIS-PH. Postoperative PROMIS-PH and KOOS-JR scores significantly correlated with one another and increased from baseline at each postoperative time point (P < .001 for all). PROMIS-MH did not change between time points (P > .05). PROMIS-PH showed moderate responsiveness at 1 and 3 months (ESI >0.2) and excellent responsiveness at 6 and 12 months (ESI >0.8), whereas KOOS-JR was responsive at all time points (ESI >0.8). The MCID of PROMIS-PH correlated significantly with KOOS-JR, and a preoperative PROMIS-PH score of less than 32.5 predicted achieving MCID with 97% specificity. CONCLUSION: PROMIS global health forms are a valid metric which capture patient outcomes and correlate with KOOS-JR scores after knee arthroplasty. Although KOOS-JR may be more responsive in the early postoperative time period, both measures show excellent responsiveness at 6 and 12 months after knee arthroplasty.

Peer-to-Peer Collaboration Adds Value for Surgical Colleagues.

BACKGROUND: Peer-to-peer advisory among colleagues in orthopedic surgery is commonplace in academic medical centers. In the private practice setting, however, it becomes more difficult for surgeons to discuss complex cases among peers. PURPOSE/QUESTIONS: We sought to study the effect of peer-to-peer mentorship on surgeons' decision-making and on patient care across academic and private adult joint reconstruction practices via the use of group secured messages. METHODS: From 2013 to 2016, we established a messaging system that was compliant with the Health Insurance Portability and Accountability Act (HIPAA) among five previous adult hip and knee reconstruction co-fellows in order to discuss complex cases. Data collected from each case included patient demographics (age and sex), history and physical examination, relevant imaging in orthogonal planes, and preliminary diagnosis and treatment plans. Data collected from group responses included nature of additional inquiries, literature citations, operative recommendations, and sample imaging of similar cases previously treated. RESULTS: The group consisted of two private practice surgeons and three academic surgeons. Data was collected on 283 cases discussed during the study period. None of the patients had any HIPAA violations. The mean number of reviewers who commented on a case was 2.4, with at least one response in 97% of cases. In 33% of the cases, the peers confirmed the initial treatment plan, and in 67% of the cases, an alternative treatment plan was recommended and executed. The case distribution was 94 primary and 189 revision procedures, including 173 hips, 103 knees, three ankles, two shoulders, and two pelvises. CONCLUSION: In the majority of cases exchanged between young surgeons via a group messaging system, a significant impact on patient care was appreciated. In a technology-driven era, peer-to-peer advisory for difficult cases via a rapid feedback method may allow for substantial improvement in patient care, particularly for surgeons not practicing at a large academic medical center with access to several partners and multiple opinions.

Cutibacteriumacnes Septic Arthritis of the Nonoperated Knee: A Case Report.

Cutibacterium (Propionibacterium) acnes , a gram-positive bacillus with low pathogenicity, is an uncommon but known cause of prosthetic joint infections, particularly related to shoulder surgery. C. acnes , however, is an extremely rare pathogen in the nonoperated knee joint. This report details an uncommon case of C. acnes septic knee arthritis after multiple intra-articular steroid injections in a 56-year-old male patient. After an indolent presentation and late diagnosis, the patient underwent surgical debridement with IV antibiotic management. This case illustrates that intra-articular corticosteroid injections for the management of osteoarthritis are not without risk. Literature supporting their use remains limited and clinicians should use proficient clinical judgment for appropriate patient selection for these injections. Vigilance following injections or aspirations of the knee should be maintained to identify the indolent clinical presentation of C. acnes septic arthritis.

Preoperative predictors of postoperative opioid usage, pain scores, and referral to a pain management service in total knee arthroplasty.

BACKGROUND: Little is known about preoperative predictors of postoperative pain and referral to a recuperative pain management service after total knee arthroplasty (TKA). QUESTIONS/PURPOSES: We sought to identify the preoperative predictors of postoperative pain scores, referral to a pain management service, and narcotic usage in patients undergoing primary total knee arthroplasty. METHODS: We performed a prospective cohort study of 97 TKAs from a single surgeon. Pre and 6-week postoperative WOMAC, visual analog pain scale (VAS) scores, narcotic usage, and catastrophizing pain scores were collected. RESULTS: After adjusting for all other variables, higher age and catastrophizing pain scores were associated with lower odds of postoperative opioid usage. Increasing age and BMI were associated with lower odds of being referred to pain management. There was no relationship between self-reported preoperative pain tolerance and postoperative change in WOMAC or VAS pain scores. CONCLUSIONS: This information may help surgeons advise their patients preoperatively and set expectations during the recovery period.

Early intraprosthetic dislocation in a revision dual-mobility hip prosthesis.

This article presents a case of early intraprosthetic dislocation of a dual-mobility hip prosthesis after revision total hip arthroplasty for instability. A 70-year-old woman was revised to a dual-mobility cup for multiple hip dislocations. She dislocated the dual-mobility construct twice, which was closed reduced. Postreduction radiographs after the second closed reduction showed that the femoral head was eccentrically positioned within the acetabular shell, raising suspicion for intraprosthetic dislocation or disassociation between the femoral head and the mobile polyethylene liner. After closed reduction, the patient reported a mobile, golf ball-size mass deep to the posterior lateral incision and new onset of crepitus. Magnetic resonance imaging verified complete intraprosthetic dissociation between the femoral head and mobile polyethylene liner, which was located between the gluteus medius and minimus. The dual-mobility cup was revised to a constrained socket with retention of the femoral stem. The patient recovered uneventfully without further instability.

Clinical outcomes of patients with non-fatal VTE after total knee arthroplasty.

Venous thromboembolism (VTE) continues to be one of the most important, and highly controversial, topics in orthopaedics. While many surgeons have discussed the incidence and treatment of this potentially life-threatening complication, little has been published about the clinical outcomes of patients who receive treatment and recover from these conditions. We evaluated the clinical outcomes of patients who suffered non-fatal VTE and compared them to a matched cohort with no complications after total knee arthroplasty using our institution's joint arthroplasty registry. At two years, the patient-reported clinical outcomes were equivalent between the groups. While VTE remains an important consideration in total knee arthroplasty, it is helpful for surgeons to know that patient outcomes are not negatively affected after appropriate treatment of these complications.

2011 Mid-America Orthopaedic Association Dallas B. Phemister Physician in Training Award: Can musculoskeletal tumors be diagnosed with ultrasound fusion-guided biopsy?

BACKGROUND: Percutaneous biopsy for musculoskeletal tumors commonly relies on imaging adjuncts including ultrasound (US), CT, or MRI. These modalities however have disadvantages (US) or are cumbersome, not universally available, and costly (CT and MRI). US fusion is a novel technique that fuses previously obtained CT or MRI data with real-time US, which allows biopsies to be performed in an US suite. It has proven useful in various body systems but musculoskeletal applications remain scarce. Our goal is to evaluate the fusion technology and determine its ability to diagnose musculoskeletal tumors. QUESTIONS/PURPOSES: We determined whether biopsies performed via US fusion compared with CT guidance provide equivalent diagnostic yield and accuracy and allow quicker biopsy scheduling and procedure times. METHODS: Forty-seven patients were assigned to undergo either US fusion (with MR, n = 16 or CT, n = 15) or CT-guided biopsies (n = 16). We evaluated adequacy of the histologic specimen (diagnostic yield) and correlation with surgical pathology (diagnostic accuracy). We determined scheduling times and lengths of the biopsy. RESULTS: US fusion and CT-guided biopsy groups had comparable diagnostic yields (CT = 94%; US/MRI = 94%; US/CT = 93%) and accuracy (CT = 83%; US/MRI = 90%; US/CT = 100%). US fusion biopsies were faster to schedule and perform. All procedures were safe with minimal complications. CONCLUSIONS: US fusion provides a high diagnostic yield and accuracy comparable to CT-guided biopsy while performed in the convenience of an US suite. This may have resulted in the observed faster scheduling and biopsy times. LEVEL OF EVIDENCE: Level II, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.