The Otto Aufranc Award: Does Hip Arthroscopy at the Time of Periacetabular Osteotomy Improve the Clinical Outcome for the Treatment of Hip Dysplasia? A Multi-Center Randomized Clinical Trial.

BACKGROUND: A periacetabular osteotomy (PAO) is often sufficient to treat the symptoms and improve quality of life for symptomatic hip dysplasia. However, acetabular cartilage and labral pathologies are very commonly present, and there is a lack of evidence examining the benefits of adjunct arthroscopy to treat these. The goal of this study was to compare the clinical outcome of patients undergoing PAO with and without arthroscopy, with the primary endpoint being the International Hip Outcome Tool-33 (iHOT-33) at one year. METHODS: In a multi-center study, two hundred and three patients who had symptomatic hip dysplasia were randomized: 97 patients undergoing an isolated PAO (mean age 27 years (range, 16 to 44); mean Body Mass Index (BMI) of 25.1 (range, 18.3 to 37.2); 86% women) and 91 patients undergoing PAO who had an arthroscopy [mean age 27 years (range, 16 to 49); mean BMI of 25.1 (17.5 to 25.1); 90% women]. RESULTS: At a mean follow up of 2.3 years (range, 1 to 5), all patients exhibited significant improvements in their functional score, with no significant differences between PAO plus arthroscopy versus PAO alone at 12 months post-surgery on all scores: pre-operative iHot-33 score of 31.2 (SD [standard deviation] 16.0) versus 36.4 (SD 15.9), and 12 months post-operative score of 72.4 (SD 23.4) versus 73.7 (SD 22.6)]. The pre-operative Hip disability and Osteoarthritis Outcome (HOOS)-pain score was 60.3 (SD 19.6) versus 66.1 (SD 20.0)] and 12 months post-operative [88.2 (SD 15.8) versus 88.4 (SD 18.3)]. The mean pre-operative physical health Patient-Reported Outcomes Measurement Information System (PROMIS) score was 42.5 (SD 8.0) versus 44.2 (SD 8.8) and 12 months post-operative [48.7 (SD 8.5) versus 52.0 (SD 10.6)]. There were four patients with PAO without arthroscopy who required an arthroscopy later to resolve persistent symptoms, and one patient from the PAO plus arthroscopy group required an additional arthroscopy. CONCLUSION: This Randomized Controlled Trial (RCT) has failed to show any significant clinical benefit in performing hip arthroscopy at the time of the PAO at one-year follow-up. Longer follow-up will be required to determine if hip arthroscopy provides added value to a PAO for symptomatic hip dysplasia.

First deployment of artificial intelligence recommendations in orthopedic surgery.

Scant research has delved into the non-clinical facets of artificial intelligence (AI), concentrating on leveraging data to enhance the efficiency of healthcare systems and operating rooms. Notably, there is a gap in the literature regarding the implementation and outcomes of AI solutions. The absence of published results demonstrating the practical application and effectiveness of AI in domains beyond clinical settings, particularly in the field of surgery, served as the impetus for our undertaking in this area. Within the realm of non-clinical strategies aimed at enhancing operating room efficiency, we characterize OR efficiency as the capacity to successfully perform four uncomplicated arthroplasty surgeries within an 8-h timeframe. This Community Case Study addresses this gap by presenting the results of incorporating AI recommendations at our clinical institute on 228 patient arthroplasty surgeries. The implementation of a prescriptive analytics system (PAS), utilizing supervised machine learning techniques, led to a significant improvement in the overall efficiency of the operating room, increasing it from 39 to 93%. This noteworthy achievement highlights the impact of AI in optimizing surgery workflows.

Prevalence of anemia and association with outcome in joint arthroplasty - is there a difference between primary and revision cases?

PURPOSE: Anemia has been shown to be a modifiable pre-operative, patient factor associated with outcome following arthroplasty. The aims of this retrospective study were to (1) ascertain the prevalence of preoperative anemia in patients undergoing primary and revision hip and knee arthroplasty at a tertiary referral center and (2) to test the association with outcome and whether it differs between primary and revision cases. METHODS: All hip and knee primary and revision arthroplasties performed at a Canadian academic, tertiary-care, arthroplasty center between 2012 and 2017 were included in this study. The study group consisted of 5944 patients, of which 5251 were primary Total Hip and Knee Arthroplasties or Hip Resurfacings and 693 were revision arthroplasties (65% hip revisions/35% knee revisions). Anemia was classified as per WHO definition (hemoglobin < 130 g/L for men and < 120 g/L for women). All anemic patients were grouped into mild, moderate or severe anemia. Length-of-stay, perioperative transfusion-rate, 90-day readmission, overall complication rate and reoperation rates were recorded. The effect of preoperative anemia and the effect of severity of the anemia was evaluated through multivariable regression analysis controlling for relevant covariates. RESULTS: Preoperatively, 15% (786/5251) of the primary patients and 47% (322/693) of the revision arthroplasty patients were anemic preoperatively. Anemic revision patients were 3.1 times more likely (95% CI: 1.47-6.33) to obtain blood transfusions during the hospital stay, compared to a 4.9 times higher risk in primary patients. The odds ratio to sustain any postoperative complication if anemic was 1.5 times higher (95% CI: 0.73-3.16) in revision patients and 1.7 in primary cases. In addition, the 90-day readmission rate among both groups was 1.6 times higher in anemic patients. Furthermore, anemic revision patients had a 5.3 days longer length of stay (95% CI: 2.63-7.91), compared to only 1 additional day in anemic primary patients (95% CI: 0.69-1.34). CONCLUSION: In this study cohort, the prevalence of anemia in patients awaiting revision arthroplasty was 3 times higher (46.6%) than in primary arthroplasty patients (18.7%). Preoperative anemia was associated with similarly, inferior outcomes in both groups. To reduce postoperative complications and the "burden" associated with anemia, these findings strongly recommend optimizing the preoperative hemoglobin in all arthroplasty patients. However, revision patients are affected more frequently, and particular attention must therefore be taken to this growing group in the future. LEVEL OF EVIDENCE: Level III.

Which Acetabular Measurements Most Accurately Differentiate Between Patients and Controls? A Comparative Study.

BACKGROUND: Acetabular morphology is an important determinant of hip biomechanics. To identify features of acetabular morphology that may be associated with the development of hip symptoms while accounting for spinopelvic characteristics, one needs to determine acetabular characteristics in a group of individuals older than 45 years without symptoms or signs of osteoarthritis. Previous studies have used patients with unknown physical status to define morphological thresholds to guide management. QUESTIONS/PURPOSES: (1) To determine acetabular morphological characteristics in males and females between 45 and 60 years old with a high Oxford hip score (OHS) and no signs of osteoarthritis; (2) to compare these characteristics with those of symptomatic hip patients treated with hip arthroscopy or periacetabular osteotomy (PAO) for various kinds of hip pathology (dysplasia, retroversion, and cam femoroacetabular impingement); and (3) to assess which radiographic or CT parameters most accurately differentiate between patients who had symptomatic hips and those who did not, and thus, define thresholds that can guide management. METHODS: Between January 2018 and December 2018, 1358 patients underwent an abdominopelvic CT scan in our institution for nonorthopaedic conditions. Of those, we considered 5% (73) of patients as potentially eligible as controls based on the absence of major hip osteoarthritis, trauma, or deformity. Patients were excluded if their OHS was 43 or less (2% [ 28 ]), if they had a PROMIS less than 50 (1% [ 18 ]), or their Tönnis score was higher than 1 (0.4% [ 6 ]). Another eight patients were excluded because of insufficient datasets. After randomly selecting one side for each control, 40 hips were left for analysis (age 55 ± 5 years; 48% [19 of 40] were in females). In this comparative study, this asymptomatic group was compared with a group of patients treated with hip arthroscopy or PAO. Between January 2013 and December 2020, 221 hips underwent hip preservation surgery. Of those, eight were excluded because of previous pelvic surgery, and 102 because of insufficient CT scans. One side was randomly selected in patients who underwent bilateral procedure, leaving 48% (107 of 221) of hips for analysis (age 31 ± 8 years; 54% [58 of 107] were in females). Detailed radiographic and CT assessments (including segmentation) were performed to determine acetabular (depth, cartilage coverage, subtended angles, anteversion, and inclination) and spinopelvic (pelvic tilt and incidence) parameters. Receiver operating characteristics (ROC) analysis was used to assess diagnostic accuracy and determine which morphological parameters (and their threshold) differentiate most accurately between symptomatic patients and asymptomatic controls. RESULTS: Acetabular morphology in asymptomatic hips was characterized by a mean depth of 22 ± 2 mm, with an articular cartilage surface of 2619 ± 415 mm 2 , covering 70% ± 6% of the articular surface, a mean acetabular inclination of 48° ± 6°, and a minimal difference between anatomical (24° ± 7°) and functional (22° ± 6°) anteversion. Patients with symptomatic hips generally had less acetabular depth (20 ± 4 mm versus 22 ± 2 mm, mean difference 3 mm [95% CI 1 to 4]; p < 0.001). Hips with dysplasia (67% ± 5% versus 70% ± 6%, mean difference 6% [95% CI 0% to 12%]; p = 0.03) or retroversion (67% ± 5% versus 70% ± 6%, mean difference 6% [95% CI 1% to 12%]; p = 0.04) had a slightly lower relative cartilage area compared with asymptomatic hips. There was no difference in acetabular inclination (48° ± 6° versus 47° ± 7°, mean difference 0.5° [95% CI -2° to 3°]; p = 0.35), but asymptomatic hips had higher anatomic anteversion (24° ± 7° versus 19° ± 8°, mean difference 6° [95% CI 3° to 9°]; p < 0.001) and functional anteversion (22° ± 6° versus 13°± 9°, mean difference 9° [95% CI 6° to 12°]; p < 0.001). Subtended angles were higher in asymptomatic at 105° (124° ± 7° versus 114° ± 12°, mean difference 11° [95% CI 3° to 17°]; p < 0.001), 135° (122° ± 9° versus 111° ± 12°, mean difference 10° [95% CI 2° to 15°]; p < 0.001), and 165° (112° ± 9° versus 102° ± 11°, mean difference 10° [95% CI 2° to 14°]; p < 0.001) around the acetabular clockface. Symptomatic hips had a lower pelvic tilt (8° ± 8° versus 11° ± 5°, mean difference 3° [95% CI 1° to 5°]; p = 0.007). The posterior wall index had the highest discriminatory ability of all measured parameters, with a cutoff value of less than 0.9 (area under the curve [AUC] 0.84 [95% CI 0.76 to 0.91]) for a symptomatic acetabulum (sensitivity 72%, specificity 78%). Diagnostically useful parameters on CT scan to differentiate between symptomatic and asymptomatic hips were acetabular depth less than 22 mm (AUC 0.74 [95% CI 0.66 to 0.83]) and functional anteversion less than 19° (AUC 0.79 [95% CI 0.72 to 0.87]). Subtended angles with the highest accuracy to differentiate between symptomatic and asymptomatic hips were those at 105° (AUC 0.76 [95% CI 0.65 to 0.88]), 135° (AUC 0.78 [95% CI 0.70 to 0.86]), and 165° (AUC 0.77 [95% CI 0.69 to 0.85]) of the acetabular clockface. CONCLUSION: An anatomical and functional acetabular anteversion of 24° and 22°, with a pelvic tilt of 10°, increases the acetabular opening and allows for more impingement-free flexion while providing sufficient posterosuperior coverage for loading. Hips with lower anteversion or a larger difference between anatomic and functional anteversion were more likely to be symptomatic. The importance of sufficient posterior coverage was also illustrated by the posterior wall indices and subtended angles at 105°, 135°, and 165° of the acetabular clockface having a high discriminatory ability to differentiate between symptomatic and asymptomatic hips. Future research should confirm whether integrating these parameters when selecting patients for hip preservation procedures can improve postoperative outcomes.Level of Evidence Level III, prognostic study.

The Effect of Surgical Approach and Hip Offset Reconstruction on Gait Biomechanics Following Total Hip Arthroplasty.

BACKGROUND: This study aimed to examine how hip offset (HO) and surgical approach affect gait biomechanics following total hip arthroplasty (THA). METHODS: There were 55 THA patients assigned to 3 groups based on surgical approach (ANT: anterior, LAT: lateral, or POS: posterior) and HO difference (large HO: >5 millimeters (mm), small HO; <5 mm, or normal; between +3 mm and -3 mm). Kinematics and kinetics were recorded using motion capture and force plate data. Group differences were assessed using statistical parametric mapping. RESULTS: The ANT group demonstrated more normal sagittal plane kinematics and kinetics. No frontal plane kinematic differences were found, but the LAT group displayed more normal frontal plane kinetics. The LAT group displayed a slower walking speed than the ANT group, and the LAT and POS groups used a shorter stride/step length than the control group. The large HO group showed fewer differences in sagittal plane kinematics and kinetics than the small HO and normal groups. No frontal plane kinematic differences were observed, but the normal group demonstrated more significant differences than the large HO and small HO groups. No significant differences were found between any of the HO patient groups. CONCLUSION: Anterior and lateral approaches led to more normal gait biomechanics in sagittal kinematics and frontal kinetics, respectively, but only the ANT group exhibited spatiotemporal gait parameters within normal ranges. Hip offset differences greater or less than 5 mm do not significantly change gait patterns. Surgical approach plays a greater role than HO reconstruction in producing more normal gait biomechanics following THA.

Periprosthetic fracture following anterior approach or dislocation after posterior approach: which one is the lesser evil?

INTRODUCTION: The most common approaches in total hip arthroplasty (THA) have different complication profiles; anterior-approach (AA-THA) has an increased risk of periprosthetic fractures (PPF); posterior-approach (PA-THA) is associated with higher dislocation risk. However, the relative severity of one versus the other is unknown. This study aims to compare outcome of patients who suffered PPF after AA-THA with those that sustained dislocation after PA-THA. METHODS: This is a retrospective, single-center, multi-surgeon, consecutive case-series of primary THA patients. In a cohort of 9867 patients who underwent THA, 79 fulfilled the approach-specific, post-operative complication criteria, of which 44 were PPF after AA-THA and 35 with dislocation after PA-THA (age 67.9 years (range: 38.0-88.1), 58.2% women). Outcome included complication- and revision- rates, and patient-reported outcomes including Oxford Hip Score (OHS). RESULTS: At 5.8 years follow-up (range: 2.0-18.5), reoperation was more common in the dislocation after PA-THA group (23/35 vs. 20/44; p = 0.072). Change of surgical approach occurred in 15/20 of patients with PPF after AA-THA, but none in those with dislocation after PA-THA. Following re-operation, complication rate was greater in the PPF group (9/20 vs. 4/23; p = 0.049). At latest follow-up, OHS were superior in the PPF after AA-THA group [42.6 (range: 25.0-48.0) vs. 36.6 (range: 21.0-47.0); p = 0.006]. CONCLUSION: Dislocation following PA-THA is more likely to require revision. However, PPF following AA-THA requires more often a different surgical approach and is at higher risk of complications. Despite the increased surgical burden post-operative PROMs are better in the peri-prosthetic fracture group, especially in cases not requiring reoperation. LEVEL OF EVIDENCE: III, case-control study.

Prevalence of Lumbosacral Transitional Vertebral Anomalies Among Healthy Volunteers and Patients with Hip Pathology: Association with Spinopelvic Characteristics.

A lumbosacral transitional vertebra (LSTV) has been reported to be prevalent among patients with hip dysplasia. The aims of this study were to determine the (1) prevalence of an LSTV in young patients presenting with hip pain and a group of asymptomatic volunteers, (2) effect of an LSTV on spinopelvic characteristics, and (3) presence of low back pain among patients with an LSTV. Methods: This cross-sectional study included 102 patients with hip pathology and 51 asymptomatic volunteers (mean age, 33.9 ± 7.3 years; mean body mass index, 26.0 ± 5.0 kg/m2; 57.5% female). Participants underwent radiographic assessment of the lumbar spine and pelvis in standing and deep-seated positions. LSTV occurrence was classified according to the Castellvi system. Spinopelvic characteristics included lumbar lordosis (including segmental lumbar angles), pelvic tilt, and hip flexion (pelvic-femoral angle). Differences between standing and deep-seated values were calculated. Low back pain was assessed using the Oswestry Disability Index. Results: The prevalence of LSTV type ≥II was 8.5%, with no difference between patients and volunteers (p = 0.386). Individuals with an LSTV had a greater standing L1-L5 angle (mean, 51.6° ± 11.7° versus 38.9° ± 9.3°; p < 0.001). The overall spinal flexion (change in L1-S1 angle between the standing and deep-seated positions) in individuals with an LSTV was similar to that in individuals without an LSTV; restricted L5-S1 mobility was compensated for at L1-L2 (10.2° ± 5.8° in those with versus 8.4° ± 4.1° in those without an LSTV; p = 0.070). No significant difference in the presence of low back pain was found (p = 0.250). Conclusions: An LSTV was found in 8.5% of young adults, with no difference between patients with hip pathology and controls. Individuals with an LSTV have greater standing lumbar lordosis, with altered mechanics at the cephalad adjacent level, which may predispose these individuals to degenerative changes at this level. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Patient-clinician digital health interventions for the hip fracture population: a scoping review.

INTRODUCTION: Older adults with hip fracture often require extensive post-surgery care across multiple sectors, making follow-up care even more important to ensure an ideal recovery. With the increased adoption of technology, patient-clinician digital health interventions can potentially improve post-surgery outcomes of hip fracture patients by helping them and their caregivers better understand the various aspects of their care, post-hip fracture surgery. The purpose of this study was to examine the available literature on the impact of hip fracture-specific, patient-clinician digital health interventions on patient outcomes and health care delivery processes. We also aimed to identify the barriers and enablers to the uptake and implementation of these technologies and to provide strategies for improved use of these digital health interventions. METHODS: We conducted a scoping review following the six stages of Arksey and O'Malley's framework and following the PRISMA-ScR reporting format. Searches were conducted in five databases. In addition to hand searching for relevant studies from the references of all included studies, we also conducted a grey literature search to identify relevant primary studies. Screening of titles and abstracts as well as full texts were performed independently by two reviewers. Two reviewers also performed the data extraction of the included studies. RESULTS: After screening 3,638 records, 20 articles met the criteria and 1 article was identified through hand searching. Various patient-clinician digital health interventions were described including telehealth /telerehabilitation programs (n = 6), care transition /follow-up interventions (n = 5), online resources (n = 2), and wearable devices /sensor monitoring (n = 1). Outcomes were varied and included functional status, gait/mobility, quality of life, psychological factors, satisfaction, survival/complications, caregiver outcomes, compliance, technology-user interactions, and feedback on the use of the digital health interventions. For clinicians, a key barrier to the use of the digital health interventions was the acceptability of the technology. However, the usefulness of the digital health intervention by clinicians was seen as both a barrier and an enabler. For patients and caregivers, all the themes were seen as both a barrier and an enabler depending on the study. These themes included: 1) availability and access, 2) usability, 3) knowledge and skills, 4) acceptability, and 5) usefulness of the digital health intervention. CONCLUSION: Many behavioural factors affect the use of patient-clinician digital health interventions. However, a specific attention should be focused on the acceptability of the technology by the clinicians to encourage uptake of the digital health interventions. The results of this scoping review can help to better understand the factors that may be targeted to increase the use of these technologies by clinicians, patients, and caregivers.

Outcome of hip resurfacing revision through the Hueter-anterior approach.

BACKGROUND: The Hueter-Anterior Approach (HAA) with its limited soft tissue and internervous dissection has been shown to be an effective approach for primary total hip and hip resurfacing arthroplasty (HRA). The purpose of this study is to evaluate the clinical outcome of patients requiring revision of HRA to total hip replacement using the HAA, assessing function and complications. METHODS: We performed a retrospective review of a prospectively maintained research database. Between 2006 and 2015, 555 primary metal-on-metal (MoM) HRAs were performed via the HAA; we identified 33 hips in 30 patients that required revisions for aseptic causes to THA: aseptic loosening of acetabulum in 12 and femoral in 7, 10 for pseudotumour/ALTR, 4 for femoral neck fracture. All revision surgeries were performed through a HAA by a single surgeon who had also performed the index operation. PROMs were collected preoperatively and yearly at various timepoints postoperatively. RESULTS: The mean age at time of revision was 48.9 years (±5.3 SD) for 22 males (67%) and 11 females (33%). The mean time to revision surgery/failure of hip resurfacing was 3.3 years (±2.4 SD). There were 5 major reoperations with 3 infections, 1 acetabular loosening and 1 trunnionosis. There were significant improvements in multiple PROMs. CONCLUSIONS: The HAA is a viable surgical approach for revision of HRA with smaller initial HRA acetabular components generally requiring a relatively larger acetabular compoent at time of revision. Patients reported improvement in symptoms and function and a lower risk of subsequent reoperation than what has previously been reported for failed MoM bearings.

Leveraging machine learning and prescriptive analytics to improve operating room throughput.

Successful days are defined as days when four cases were completed before 3:45pm, and overtime hours are defined as time spent after 3:45pm. Based on these definitions and the 460 unsuccessful days isolated from the dataset, 465 hours, 22 minutes, and 30 seconds total overtime hours were calculated. To reduce the increasing wait lists for hip and knee surgeries, we aim to verify whether it is possible to add a 5th surgery, to the typical 4 arthroplasty surgery per day schedule, without adding extra overtime hours and cost at our clinical institution. To predict 5th cases, 301 successful days were isolated and used to fit linear regression models for each individual day. After using the models' predictions, it was determined that increasing performance to a 77% success rate can lead to approximately 35 extra cases per year, while performing optimally at a 100% success rate can translate to 56 extra cases per year at no extra cost. Overall, this shows the extent of resources wasted by overtime costs, and the potential for their use in reducing long wait times. Future work can explore optimal staffing procedures to account for these extra cases.

Acetabular Sector Angles in Asymptomatic and Dysplastic Hips: Defining Dysplasia and Thresholds to Guide Management.

BACKGROUND: Radiographic evaluation plays an important role in detecting and grading hip dysplasia. Acetabular sector angles (ASAs) measure the degree of femoral head coverage provided by the acetabulum on computed tomographic (CT) scans. In this study, we aimed to determine ASA values at different axial levels in a control cohort with asymptomatic, high-functioning hips without underlying hip pathology and a study group with symptomatic, dysplastic hips that underwent periacetabular osteotomy (PAO), thereby defining the ASA thresholds for hip dysplasia. METHODS: This was a cross-sectional study evaluating a control group of 51 patients (102 hips) and a study group of 66 patients (72 hips). The control group was high-functioning and asymptomatic, with an Oxford Hip Score of >43, did not have osteoarthritis (Tönnis grade ≤1), underwent a pelvic CT scan, had a mean age (and standard deviation) of 52.1 ± 5.5 years, and was 52.9% female. The study group had symptomatic hip dysplasia treated with PAO, had a mean age of 29.5 ± 7.3 years, and 83.3% was female. Anterior ASA (AASA) and posterior ASA (PASA) were measured at 3 axial CT levels to determine equatorial, intermediate, and proximal ASA. The thresholds for dysplasia were determined using receiver operating characteristic (ROC) curve analysis, including the area under the curve (AUC). RESULTS: Patients with dysplasia had significantly smaller ASAs compared with the control group; the differences were most pronounced for proximal AASAs and proximal and intermediate PASAs. The control group had a mean proximal PASA of 162° ± 17°, yielding a threshold for dysplasia of 137° (AUC, 0.908). The mean intermediate PASA for the control group was 117° ± 11°, yielding a threshold of 107° (AUC, 0.904). The threshold for anterior dysplasia was 133° for proximal AASA (AUC, 0.859) and 57° for equatorial AASA (AUC, 0.868). The threshold for posterior dysplasia was 102° for intermediate PASA (AUC, 0.933). CONCLUSIONS: Measurement of ASA is a reliable tool to identify focal acetabular deficiency with high accuracy, aiding diagnosis and management. A proximal PASA of <137° or an intermediate PASA of <107° should alert clinicians to the presence of dysplasia. LEVEL OF EVIDENCE: Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.

The Impact of Age on Clinical Outcomes of Acetabular Microfracture During FAI Surgery.

BACKGROUND: Full-thickness acetabular cartilage lesions are common findings during primary surgical treatment of femoroacetabular impingement (FAI). PURPOSE: To evaluate clinical outcomes after acetabular microfracture performed during FAI surgery in a prospective, multicenter cohort. STUDY DESIGN: Cohort Study; Level of evidence, 3. METHODS: Patients with FAI who had failed nonoperative management were prospectively enrolled in a multicenter cohort. Preoperative and postoperative (mean follow-up, 4.3 years) patient-reported outcome measures were obtained with a follow-up rate of 81.6% (621/761 hips), including 54 patients who underwent acetabular microfracture. Patient characteristics, radiographic parameters, intraoperative disease severity, and operative procedures were analyzed. Propensity matching using linear regression was used to match 54 hips with microfracture to 162 control hips (1:3) to control for confounding variables. Subanalyses of hips ≤35 and >35 years of age with propensity matching were also performed. RESULTS: Patients who underwent acetabular microfracture were more likely to be male (81.8% vs 40.9%; P < .001), be older in age (35.0 vs 29.9 years; P = .001), have a higher body mass index (27.2 vs 25.0; P = .001), and have a greater alpha angle (69.6° vs 62.3°; P < .001) compared with the nonmicrofracture cohort (n = 533). After propensity matching to control for covariates, patients treated with microfracture displayed no differences in the modified Harris Hip Score or Hip Disability and Osteoarthritis Outcome Score (P = .22-.95) but were more likely to undergo total hip arthroplasty (THA) (13% [7/54] compared with 4% [6/162] in the control group; P = .002), and age >35 years was associated with conversion to THA after microfracture. Microfracture performed at or before 35 years of age portended good outcomes with no significant risk of conversion to THA at the most recent follow-up. CONCLUSION: Microfracture of acetabular cartilage defects appears to be safe and associated with reliably improved short- to mid-term results in younger patients; modified expectations should be realized when full-thickness chondral lesions are identified in patients >35 years of age.

In meeting the increasing demands for total knee arthroplasty, can we achieve high levels of quality care in a small community hospital? A mixed-methods study.

Purpose: Small community hospitals (SCHs) help meet the demand for total knee arthroplasty (TKA). This mixed-methods study compares outcomes and analyses of environmental differences following TKA at a SCH and a tertiary care hospital (TCH). Methods: Quantitative: A retrospective review of 352 propensity-matched primary TKA procedures at both a SCH and a TCH, based on age, body mass index, and American Society of Anesthesiologists class, was completed. Groups were compared by length of stay (LOS), 90-day emergency department visits, 90-day readmissions, reoperations, and mortality. Qualitative: Based on the Theoretical Domains Framework, seven prospective semistructured interviews were performed. Interview transcripts were coded and belief statements were generated and summarized by two reviewers. Discrepancies were resolved by a third reviewer. Results: Quantitative: The average LOS for the SCH was significantly shorter than that for the TCH (2.0 ± 0.2 vs. 3.6 ± 2.7 days; p < 0.001), a difference that persisted following a subgroup analysis of ASA I/II patients (2.0 ± 0.2 vs. 3.2 ± 2.2; p < 0.001). There were no significant differences in other outcomes. Qualitative: The main themes that revolved around a higher case load for physiotherapy at the TCH resulted in patients waiting longer to be mobilized after surgery. Patient disposition also affected their discharge rates. Conclusion: Given the increasing demand for TKA, the SCH represents a viable option to increase capacity, while reducing LOS. Future directions to reduce LOS include addressing social barriers to discharge and patient prioritization for assessment by allied health services. When TKA is performed by the same set of surgeons, the SCH provides quality care with a shorter LOS and comparable with urban hospitals, and this can be attributed to the differences in resource utilization in the two hospital settings.

Impact of Anesthetic Choice on Time to Discharge for Same-Day Discharge Joints.

BACKGROUND: As total joint arthroplasty programs continue to move towards same-day discharge (SDD), time to discharge is an increasingly important performance indicator. The primary objective of this study was to determine the impact of the choice of anesthetic on the time to discharge after SDD primary hip and knee arthroplasty. METHODS: A retrospective chart review was conducted within our SDD arthroplasty program, with 261 patients identified for analysis. Baseline characteristics, length of surgery, anesthetic drug, dose, and perioperative complications were extracted and recorded. The time from the patient leaving the operating room to physiotherapy assessment and from the operating room to discharge were recorded. These were referred to as ambulation time and discharge time, respectively. RESULTS: The ambulation time was significantly reduced when hypobaric lidocaine was used in a spinal block compared to isobaric or hyperbaric bupivacaine-135 minutes (range, 39 to 286), 305 minutes (range, 46 to 591), and 227 minutes (range, 77 to 387), respectively-(P < .0001). Similarly, the discharge time was also significantly lower with hypobaric lidocaine compared to isobaric bupivacaine, hyperbaric bupivacaine, and general anesthesia-276 minutes (range, 179 to 461), 426 minutes (range, 267 to 623), 375 minutes (range, 221 to 511), and 371 minutes (range, 217 to 570), respectively-(P < .0001). No cases of transient neurologic symptoms were reported. CONCLUSION: Patients receiving a hypobaric lidocaine spinal block experienced significantly reduced ambulation time and time to discharge compared to other anesthetics. Surgical teams should feel confident in using hypobaric lidocaine during spinal anesthesia as it is rapid and efficacious.

Use of multidisciplinary positive deviance seminars to improve efficiency in a high-volume arthroplasty practice: a pilot study.

BACKGROUND: Positive deviance (PD) seminars, which have shown excellent results in improving the quality of surgical practices, use individual performance feedback to identify team members who outperform their peers; the strategies from those with exemplary performance are used to improve team members' practices. Our study aimed to use the PD approach with arthroplasty surgeons and nurses to identify multidisciplinary strategies and recommendations to improve operating room (OR) efficiency. METHODS: We recruited 5 surgeons who performed high-volume primary arthroplasty and had participated in 4-joint rooms since 2012, and 29 nurses who had participated in 4-joint rooms and in at least 16 cases in our data set. Three 1-hour PD sessions were held in February and March 2021: 1 with surgeons, 1 with nurses, and 1 with both surgeons and nurses to select recommendations for implementation. The sessions were led by a member of the nonorthopedic surgical faculty who was familiar with the subjects discussed and with PD seminars. To determine the success of the recommendations, we compared OR efficiency before and after implementation. We defined success as performance of 4 joint procedures within 8 hours. RESULTS: Eleven recommendations were recorded from the session with nurses and 7 from the session with surgeons, of which 11 were selected for implementation. During the month after implementation, there were great improvements across all time intervals of surgical procedures, with the greatest improvements seen in mean anesthesia preparation time in the room (4.51 min [26.3%]), mean procedure duration (9.75 min [14.0%]) and mean anesthesia finish time (5.78 min [44.0%]) (all p < 0.001). The total time saved per day was 49.84 minutes; this led to a success rate of 69.0%, a relative increase of 73.8% from our 2012-2020 success rate of 39.7% (p < 0.001). CONCLUSION: The recommendations and increased motivation owing to the individualized feedback reduced time spent per case, allowing more days to finish on time. Positive deviance seminars offer an inexpensive, efficient and collegial means for process improvement in the OR.

Artificial intelligence-driven prescriptive model to optimize team efficiency in a high-volume primary arthroplasty practice.

PURPOSE: We aimed to improve OR efficiency using machine learning (ML) to find relevant metrics influencing surgery time success and team performance on efficiency to create a model which incorporated team, patient, and surgery-related factors. METHODS: From 2012 to 2020, five surgeons, 44 nurses, and 152 anesthesiologists participated in 1199 four joint days (4796 cases): 1461 THA, 1496 TKA, 652 HR, 242 UKA, and 945 others. Patients were 2461f:2335 m; age, 64.1; BMI, 29.93; and ASA, 2.45. Surgical Success was defined as completing four joints within an eight hour shift using one OR. Time data was recorded prospectively using Surgical Information Management Systems. Hospital records provided team, patient demographics, adverse events, and anesthetic. Data mining identified patterns and relationships in higher dimensions. Predictive analytics used ML ranking algorithm to identify important metrics and created decision tree models for benchmarks and success probability. RESULTS: Five variables predicted success: anaesthesia preparation time, surgical preparation time, time of procedure, anesthesia finish time, and type of joint replacement. The model determined success rate with accuracy of 72% and AUC = 0.72. Probability of success based on mean performance was 77-89% (mean-median) if APT 14-15 minutes, PT 68-70 minutes, AFT four to five minutes, and turnover 25-27 minutes. With the above benchmarks maintained, success rate was 59% if surgeon exceeded 71.5-minutes PT or 89% if 64-minutes procedure time or 66% when anesthesiologist spent 17-19.5 minutes on APT. CONCLUSION: AI-ML predicted OR success without increasing resources. Benchmarks track OR performance, demonstrate effects of strategic changes, guide decisions, and provide teamwork improvement opportunities.

Does pelvic tilt change with a peri-acetabular osteotomy?

Change in pelvic tilt (PT) during and after peri-acetabular osteotomy (PAO) is important for surgical planning. The aims of this study were to (i) determine how PT varies throughout the course of treatment in patients undergoing PAO, (ii) test what factors influence the change in PT and (iii) assess whether changes in PT influenced achieved correction. This is an retrospective, single-centre, consecutive case series of 111 patients treated with PAO for global (n = 79), posterior (n = 49) or anterior dysplasia (n = 6) (mean age: 27.3 ± 7.7 years; 85% females). PT was determined on supine, anteroposterior pelvic radiographs pre-, intra-, 1 day, 6 weeks and 1 year post-operatively, using the sacro-femoral-pubic (SFP) angle, a validated, surrogate marker of PT. An optimal acetabular correction was based on the lateral centre-edge angle (25°-40°), acetabular index (-5° to 10°) and cross-over ratio (<20%). There was a significant difference across pre- (70.1° ± 4.8°), 1-day (71.7° ± 4.3°; P < 0.001) and early post-operative SFP (70.6° ± 4.7°; P = 0.004). The difference in SPF between pre-operative and 1-year post-operative was -0.5° ± 3.1° (P = 0.043), with 9% of cases having a difference of >5°. The difference in SFP did not correlate with age, sex, body mass index, type of dysplasia or achievement of optimal acetabular correction (P = 0.1-0.9). In the early post-operative period, PT is reduced, leading to a relative appearance of acetabular retroversion, which gradually corrects and is restored by annual follow-up. The degree of change in PT during PAO did not adversely affect fragment orientation. PT does not significantly change in most patients undergoing PAO and therefore does not appear to be a compensatory mechanism.

Factors influencing delays and overtime during surgery: a descriptive analytics for high volume arthroplasty procedures.

The aim of this article is to analyze factors influencing delays and overtime during surgery. We utilized descriptive analytics and divided the factors into three levels. In level one, we analyzed each surgical metrics individually and how it may influence the Surgical Success Rate (SSR) of each operating day. In level two, we compared up to three metrics at once, and in level three, we analyzed four metrics to identify more complex patterns in data including correlations. Within each level, factors were categorized as patient, surgical team, and time specific. Retrospective data on 788 high volume arthroplasty procedures was compiled and analyzed from the 4-joint arthroplasty operating room at our institution. Results demonstrated that surgical team performance had the highest impact on SSR whereas patient metrics had the least influence on SSR. Additionally, beginning the surgical day on time has a prominent effect on the SSR. Finally, the experience of the surgeon had almost no impact on the SSR. In conclusion, we gathered a list of insights that can help influence the re-allocation of resources in daily clinical practice to offset inefficiencies in arthroplasty surgeries.

Postsurgery paths and outcomes for hip fracture patients (POST-OP HIP PATHS): a population-based retrospective cohort study protocol.

INTRODUCTION: Hip fracture patients receive varying levels of support posthip fracture surgery and often experience significant disability and increased risk of mortality. Best practice guidelines recommend that all hip fracture patients receive active rehabilitation following their acute care stay, with rehabilitation beginning no later than 6 days following surgery. Nevertheless, patients frequently experience gaps in care including delays and variation in rehabilitation services they receive. We aim to understand the factors that drive these practice variations for older adults following hip fracture surgery, and their impact on patient outcomes. METHODS AND ANALYSIS: We will conduct a retrospective population-based cohort study using routinely collected health administrative data housed at ICES. The study population will include all individuals with a unilateral hip fracture aged 50 and older who underwent surgical repair in Ontario, Canada between 1 January 2015 and 31 December 2018. We will use unadjusted and multilevel, multivariable adjusted regression models to identify predictors of rehabilitation setting, time to rehabilitation and length of rehabilitation, with predictors prespecified including patient sociodemographics, baseline health and characteristics of the acute (surgical) episode. We will examine outcomes after rehabilitation, including place of care/residence at 6 and 12 months postrehabilitation, as well as other short-term and long-term outcomes. ETHICS AND DISSEMINATION: The use of the data in this project is authorised under section 45 of Ontario's Personal Health Information Protection Act and does not require review by a Research Ethics Board. Results will be disseminated through conference presentations and in peer-reviewed journals.

Comparing Intramedullary Nails Versus Dynamic Hip Screws in the Treatment of Intertrochanteric Hip Fractures on Post-operative Rehabilitation Outcomes:A Systematic Review Protocol.

Background: Intertrochanteric hip fractures are treated by fixation with either an intramedullary (IM) Nail or Dynamic Hip Screw (DHS). It is unknown whether one surgery type has better post-operative rehabilitative outcomes for the hip fracture population. This systematic review aims to compare post-operative rehabilitation outcomes of intertrochanteric hip fractures treated via IM Nails versus DHS. Methods: We will conduct a systematic review following the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) format. A search strategy will be developed, and the following databases will be searched: MEDLINE, EMBASE, Cochrane Library, and Web of Science. Two reviewers will perform a two-step screening process and data extraction of included studies. Any disagreement will be resolved with a discussion or a third reviewer. Risk of bias and the quality of the studies will also be assessed. A narrative synthesis will be used for the data analysis. Conclusion: This systematic review will provide evidence for orthopaedic surgeons and rehabilitation clinicians to further improve patient rehabilitation outcomes post-hip fracture surgery.