ABSTRACT
In response to the opioid epidemic in the United States, states have passed policies aimed at regulating how opioids are prescribed by physicians. For such policies to be effective, however, opioids must be prescribed to the patients for whom they are intended. Whether opioid prescriptions are written for those who are not intended to consume them is empirically difficult to show. In a commercially insured population, we examined opioid prescriptions written for and filled by spouses of patients undergoing outpatient surgery on the day of a patient's surgery compared with the surrounding days. Because patients may be unable to fill prescriptions themselves immediately after surgery, surgeons may prescribe opioids to a patient's spouse, which would be clinically inappropriate. Among 450,125 opioid-naïve couples studied, for patients who did not fill perioperative opioid prescriptions themselves, the rate of spousal fills on the day of surgery (DOS) was 2.39 fills per 1,000 surgeries compared with 0.44 fills on all other perioperative days (adjusted odds ratio (aOR), 5.5, 95% CI, 4.6-6.5). Increases in spousal opioid fills were not present for patients that filled opioid prescriptions themselves. These findings suggest intentional, clinically inappropriate prescribing of opioids.
Subject(s)
Epidemics , Physicians , Humans , Inappropriate Prescribing , Analgesics, Opioid/therapeutic use , PolicyABSTRACT
BACKGROUND: Periprosthetic femur fracture is a known complication after THA. The associated risk of cementless femoral component design for periprosthetic femur fracture in a registry population of patients older than 65 years has yet to be clearly identified. QUESTIONS/PURPOSES: (1) Is femoral stem geometry associated with the risk of periprosthetic femur fracture after cementless THA? (2) Is the presence or absence of a collar on cementless femoral implant designs associated with the risk of periprosthetic femur fracture after THA? METHODS: We analyzed American Joint Replacement Registry data from 2012 to March 2020. Unique to this registry is the high use of cementless femoral stems in patients 65 years and older. We identified 266,040 primary cementless THAs during the study period in patients with a diagnosis of osteoarthritis and surgeries linked to supplemental Centers for Medicare and Medicaid data where available. Patient demographics, procedure dates, and reoperation for periprosthetic femur fracture with revision or open reduction and internal fixation were recorded. The main analysis was performed comparing the Kheir and Chen classification: 42% (112,231 of 266,040) were single-wedge, 22% (57,758 of 266,040) were double-wedge, and 24% (62,983 of 266,040) were gradual taper/metadiaphyseal-filling cementless femoral components, which yielded a total of 232,972 primary cementless THAs. An additional analysis compared cementless stems with collars (20% [47,376 of 232,972]) with those with collarless designs (80% [185,596 of 232,972]). A Cox proportional hazard regression analysis with the competing risk of death was used to evaluate the association of design and fracture risk while adjusting for potential confounders. RESULTS: After controlling for the potentially confounding variables of age, sex, geographic region, osteoporosis or osteopenia diagnosis, hospital volume, and the competing risk of death, we found that compared with gradual taper/metadiaphyseal-filling stems, single-wedge designs were associated with a greater risk of periprosthetic femur fracture (HR 2.9 [95% confidence interval (CI) 2.2 to 3.9]; p < 0. 001). Compared with gradual taper/metadiaphyseal-filling stems, double-wedge designs showed an increased risk of periprosthetic femur fracture (HR 3.0 [95% CI 2.2 to 4.0]; p < 0. 001). Collarless stems showed an increased risk of periprosthetic fracture compared with collared stems (HR 7.8 [95% CI 4.1 to 15]; p < 0. 001). CONCLUSION: If cementless femoral fixation is used for THA in patients 65 years or older, surgeons should consider using gradual taper/metadiaphyseal-filling and collared stem designs because they are associated with a lower risk of periprosthetic femur fracture. Future investigations should compare gradual taper/metadiaphyseal-filling and collared cementless designs with cemented fixation in this population. LEVEL OF EVIDENCE: Level III, therapeutic study.
Subject(s)
Arthroplasty, Replacement, Hip , Femoral Fractures , Hip Prosthesis , Periprosthetic Fractures , Prosthesis Design , Registries , Humans , Aged , Periprosthetic Fractures/surgery , Periprosthetic Fractures/etiology , Female , Male , Arthroplasty, Replacement, Hip/adverse effects , Arthroplasty, Replacement, Hip/instrumentation , Hip Prosthesis/adverse effects , Femoral Fractures/surgery , Femoral Fractures/etiology , Risk Factors , Aged, 80 and over , Reoperation/statistics & numerical data , United States/epidemiologyABSTRACT
PURPOSE: One of the most pertinent questions in total knee arthroplasty (TKA) is: what could be considered normal coronal alignment? This study aims to define normal, neutral, deviant and aberrant coronal alignment using large data from a computed tomography (CT)-scan database and previously published phenotypes. METHODS: Coronal alignment parameters from 11,191 knee osteoarthritis (OA) patients were measured based on three dimensional reconstructed CT data using a validated planning software. Based on these measurements, patients' coronal alignment was phenotyped according to the functional knee phenotype concept. These phenotypes represent an alignment variation of the overall hip knee ankle angle (HKA), femoral mechanical angle (FMA) and tibial mechanical angle (TMA). Each phenotype is defined by a specific mean and covers a range of ±1.5° from this mean. Coronal alignment is classified as normal, neutral, deviant and aberrant based on distribution frequency. Mean values and distribution among the phenotypes are presented and compared between two populations (OA patients in this study and non-OA patients from a previously published study). RESULTS: The arithmetic HKA (aHKA), combined normalised data of FMA and TMA, showed that 36.0% of knees were neutral within ±1 SD from the mean in both angles, 44.3% had either a TMA or a FMA within ±1-2 SD (normally aligned), 15.3% of the patients were deviant within ±2-3 SD and only 4.4% of them had an aberrant alignment (±3-4 SD in 3.4% and >4 SD in 1.0% of the patients respectively). However, combining the normalised data of HKA, FMA and TMA, 15.4% of patients were neutral in all three angles, 39.7% were at least normal, 27.7% had at least one deviant angle and 17.2% had at least one aberrant angle. For HKA, the males exhibited 1° varus and females were neutral. For FMA, the females exhibited 0.7° more valgus in mean than males and grew 1.8° per category (males grew 2.1° per category). For TMA, the males exhibited 1.3° more varus than females and both grew 2.3° and 2.4° (females) per category. Normal coronal alignment was 179.2° ± 2.8-5.6° (males) and 180.5 > ± 2.8-5.6° (females) for HKA, 93.1 > ± 2.1-4.2° (males) and 93.8 > ± 1.8-3.6° (females) for FMA and 86.7 > ± 2.3-4.6° (males) and 88 > ± 2.4-4.8° (females) for TMA. This means HKA 6.4 varus or 4.8° valgus (males) or 5.1° varus to 6.1° valgus was considered normal. For FMA HKA 1.1 varus or 7.3° valgus (males) or 0.2° valgus to 7.4° valgus was considered normal. For TMA HKA 7.9 varus or 1.3° valgus (males) or 6.8° varus to 2.8° valgus was considered normal. Aberrant coronal alignment started from 179.2° ± 8.4° (males) and 180.5 > ± 8.4° (females) for HKA, 93.1 > ± 6.3° (males) 93.8 > ± 5.4° (females) for FMA and 86.7 > ± 6.9° (males) and 88 > ± 7.2° (females) for TMA. This means HKA > 9.2° varus or 7.6° valgus (males) or 7.9° varus to 8.9° valgus was considered aberrant. CONCLUSION: Definitions of neutrality, normality, deviance as well as aberrance for coronal alignment in TKA were proposed in this study according to their distribution frequencies. This can be seen as an important first step towards a safe transition from the conventional one-size-fits-all to a more personalised coronal alignment target. There should be further definitions combining bony alignment, joint surfaces' morphology, soft tissue laxities and joint kinematics. LEVEL OF EVIDENCE: III.
Subject(s)
Arthroplasty, Replacement, Knee , Osteoarthritis, Knee , Male , Female , Humans , Arthroplasty, Replacement, Knee/methods , Knee Joint/diagnostic imaging , Knee Joint/surgery , Lower Extremity , Tibia/diagnostic imaging , Tibia/surgery , Femur/surgery , Osteoarthritis, Knee/diagnostic imaging , Osteoarthritis, Knee/surgery , Retrospective StudiesABSTRACT
BACKGROUND: Robotic-arm assistance continues to gain popularity in total hip arthroplasty (THA) for its potential to improve component placement accuracy and patient outcomes. Nonetheless, there is limited data on the impact of robotic-assisted THA (RA-THA) on hospital length of stay (LOS) and discharge location. This study thus aimed to compare LOS, discharge location, and readmission rate for propensity-matched cohorts of RA-THA versus manual THA (M-THA). METHODS: A retrospective review of a multi-hospital database was performed to identify patients who underwent THA between January 2016 and December 2021 from surgeons who performed both RA-THA and M-THA at 77 geographically diverse hospitals. The RA-THA and M-THA cohorts were 1-to-1 matched based on patient sex, age, and body mass index, resulting in 8,536 patients per cohort. Insurance type, LOS, same-day discharge, discharge disposition, and 90-day all-cause readmission rate were compared using Mann-Whitney U and Chi-square tests. RESULTS: Average LOS was significantly shorter for RA-THA patients (1.39 ± 0.85 days) than for M-THA patients (1.48 ± 0.91 days, P < .001). Compared to 5.6% of M-THA patients, 5.3% of RA-THA patients underwent same-day discharge (P = .38). There were statistically significant differences in discharge disposition between cohorts, with more RA-THA cases discharged home without home healthcare compared to M-THA (47.9 versus 45.5%, P = .001) and fewer RA-THA cases discharged to a skilled nursing facility compared to M-THA (5.6 versus 6.9%, P = .001). The 90-day all-cause readmission rate for RA-THA cases was 3.0%, compared to 3.4% for M-THA cases (P = .26). CONCLUSIONS: Compared to M-THA, RA-THA had a shorter average LOS, a similar percentage of patients with same-day discharge, fewer patients who had skilled nursing facility discharge, and a similar all-cause 90-day readmission rate. These results may be of interest to surgeons participating in bundled payment programs and engaging in cost savings.
Subject(s)
Arthroplasty, Replacement, Hip , Length of Stay , Patient Discharge , Patient Readmission , Propensity Score , Robotic Surgical Procedures , Humans , Arthroplasty, Replacement, Hip/statistics & numerical data , Length of Stay/statistics & numerical data , Male , Female , Retrospective Studies , Middle Aged , Robotic Surgical Procedures/statistics & numerical data , Patient Discharge/statistics & numerical data , Aged , Patient Readmission/statistics & numerical dataABSTRACT
BACKGROUND: Major research and recruitment efforts have focused on diversifying the orthopaedic surgery workforce, with a focus on gender diversity. This study aimed to characterize gender trends in the adult reconstruction fellowship match and the American Association of Hip and Knee Surgeons (AAHKS) membership over the past decade. We hypothesized that there would be increases in the percentage of women adult reconstruction fellows and AAHKS members. METHODS: For this retrospective, descriptive study, the full names of matched adult reconstruction fellows from 2012 to 2022 were collected. For the fellowship match, genders were predicted by the Genderize algorithm. From the AAHKS database, full names, self-identified genders, and clinical statuses were extracted from January 2016 to May 2023. Descriptive statistics were analyzed. Gender trends were evaluated with logistic regression analyses. P-values < 0.05 were considered significant. RESULTS: From 2012 to 2022, 1,762 residents were matched for adult reconstruction fellowships. Women represented between 2.5 and 9.0% of matched adult reconstruction fellows per year. The percentage of matched women applicants has remained stable (P = 0.4). From 2016 to 2023, the membership of AAHKS grew from 2,845 to 4,159 surgical members. The number of women adult reconstruction surgeons significantly increased from 2.5 to 3.8% (2016 to 2023, P < 0.001). At the resident level, women's membership increased from 4.0 to 12.0% (2016 to 2023, P < 0.001). CONCLUSION: Although more women orthopaedic surgeons are matching in adult reconstruction, the percentage of women adult reconstruction fellows has remained stable, with the highest level being in 2021. However, the increase in women's membership in AAHKS is encouraging, especially at the resident and international levels. More diverse work environments can enhance patient experiences and outcomes, in addition to provider well-being and productivity. Therefore, it is prudent and essential to continue building a more diverse adult reconstruction community.
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BACKGROUND: Total hip arthroplasty (THA), including primary and conversion procedures, is commonly used for many types of joint disease in patients aged below 65 years, though few studies have evaluated THA outcomes in young patients (≤ 40 years old). This study examined a large cohort of patients who underwent THA at a young (≤ 40 years old) age to identify predictors of reoperation and compare survivorship between primary and conversion THAs. METHODS: A retrospective study was conducted on 497 patients who underwent 612 primary and conversion THAs at 40 years old or younger between 1990 and 2020. Medical records were reviewed to collect patient/surgical data. A multivariable logistic regression model identified independent predictors of reoperation, and Kaplan-Meier analysis with log-rank tests was used to compare survival curves by THA type. RESULTS: The median age at surgery (interquartile range) was 31 years (25 to 36). The median follow-up time was 6.6 years (range, 3.8 to 10.5). Conversion THAs had an increased rate of both revisions (12.3 versus 5.6%, P = 0.02) and nonrevision reoperations (8.9 versus 3.2%, P = 0.03) compared to primary THAs. A ceramic-on-ceramic articulation (odds ratio: 5.17; P = 0.03) and a higher estimated blood loss (odds ratio: 1.0007; P = 0.03) were independent predictors of reoperation for primary and conversion THA, respectively. Conversion THAs had a lower 15-year survival (77.8 versus 90.8%, P = 0.009) compared to primary THAs. CONCLUSIONS: Patients ≤ 40 years old who underwent primary and conversion THAs demonstrated an impressive 15-year survival comparable to that of older populations (74 to 93%), while conversion procedures had a higher reoperation rate. Although primary THA may be more ideal, there are promising outcomes for patients who need THA at a younger age than typically implemented, especially for those who are very young (≤ 30 years old).
ABSTRACT
BACKGROUND: Academic accomplishments and demographics for presidents of hip and knee arthroplasty societies are poorly understood. This study compares the characteristics of presidents nominated to serve the Hip Society, Knee Society, and American Association of Hip and Knee Surgeons. METHODS: This was a cross-sectional study of arthroplasty presidents in the United States (1990 to 2022). Curriculum vitae and academic websites were analyzed for demographic, training, bibliometric, and National Institutes of Health (NIH) funding data. Comparisons were made between organizations and time periods (1990 to 2005 versus 2006 to 2022). RESULTS: There were 97 appointments of 78 unique arthroplasty presidents (80%). Most presidents were male (99%) and Caucasian (95%). There was 1 woman (1%) and 5 non-Caucasian presidents (2% Asian, 3% Hispanic). There were no differences in demographics between the 3 arthroplasty organizations and the 2 time periods (P > .05). Presidents were appointed at 55 ± 10 years old, which was on average 24 years after completion of residency training. Most presidents had arthroplasty fellowship training (68%), and the most common were the Hospital for Special Surgery (21%) and Massachusetts General Hospital (8%). The median h-index was 53 resulting from 191 peer-reviewed publications, which was similar between the 3 organizations (P > .05). There were 2 presidents who had NIH funding (2%), and there were no differences in NIH funding between the 3 organizations (P > .05). CONCLUSIONS: Arthroplasty society presidents have diverse training pedigrees, high levels of scholarly output, and similar demographics. There may be future opportunities to promote diversity and inclusion among the highest levels of leadership in total joint arthroplasty.
Subject(s)
Arthroplasty, Replacement, Hip , Arthroplasty, Replacement, Knee , Societies, Medical , Humans , United States , Female , Male , Arthroplasty, Replacement, Hip/statistics & numerical data , Cross-Sectional Studies , Middle Aged , LeadershipABSTRACT
BACKGROUND: Dissatisfaction after total knee arthroplasty (TKA) ranges from 15 to 30%. While patient selection may be partially responsible, morphological and reconstructive challenges may be determinants. Preoperative computed tomography (CT) scans for TKA planning allow us to evaluate the hip-knee-ankle axis and establish a baseline phenotypic distribution across anatomic parameters. The purpose of this cross-sectional analysis was to establish the distributions of 27 parameters in a pre-TKA cohort and perform threshold analysis to identify anatomic outliers. METHODS: There were 1,352 pre-TKA CTs that were processed. A 2-step deep learning pipeline of classification and segmentation models identified landmark images and then generated contour representations. We used an open-source computer vision library to compute measurements for 27 anatomic metrics along the hip-knee axis. Normative distribution plots were established, and thresholds for the 15th percentile at both extremes were calculated. Metrics falling outside the central 70th percentile were considered outlier indices. A threshold analysis of outlier indices against the proportion of the cohort was performed. RESULTS: Significant variation exists in pre-TKA anatomy across 27 normally distributed metrics. Threshold analysis revealed a sigmoid function with a critical point at 9 outlier indices, representing 31.2% of subjects as anatomic outliers. Metrics with the greatest variation related to deformity (tibiofemoral angle, medial proximal tibial angle, lateral distal femoral angle), bony size (tibial width, anteroposterior femoral size, femoral head size, medial femoral condyle size), intraoperative landmarks (posterior tibial slope, transepicondylar and posterior condylar axes), and neglected rotational considerations (acetabular and femoral version, femoral torsion). CONCLUSIONS: In the largest non-industry database of pre-TKA CTs using a fully automated 3-stage deep learning and computer vision-based pipeline, marked anatomic variation exists. In the pursuit of understanding the dissatisfaction rate after TKA, acknowledging that 31% of patients represent anatomic outliers may help us better achieve anatomically personalized TKA, with or without adjunctive technology.
Subject(s)
Arthroplasty, Replacement, Knee , Deep Learning , Knee Joint , Tomography, X-Ray Computed , Humans , Arthroplasty, Replacement, Knee/methods , Female , Male , Aged , Middle Aged , Cross-Sectional Studies , Knee Joint/diagnostic imaging , Knee Joint/surgery , Knee Joint/anatomy & histology , Hip Joint/diagnostic imaging , Hip Joint/surgery , Hip Joint/anatomy & histology , Ankle Joint/diagnostic imaging , Ankle Joint/surgery , Ankle Joint/anatomy & histology , Aged, 80 and overABSTRACT
BACKGROUND: Controversy remains over outcomes between total hip arthroplasty approaches. This study aimed to compare the time to achieve the minimal clinically important difference (MCID) for the Hip Disability and Osteoarthritis Outcome Score-Physical Function Short Form (HOOS-PS) and the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-Physical for patients who underwent anterior and posterior surgical approaches in primary total hip arthroplasty. METHODS: Patients from 2018 to 2021 with preoperative and postoperative HOOS-PS or PROMIS Global-Physical questionnaires were grouped by approach. Demographic and MCID achievement rates were compared, and survival curves with and without interval-censoring were used to assess the time to achieve the MCID by approach. Log-rank and weighted log-rank tests were used to compare groups, and Weibull regression analyses were performed to assess potential covariates. RESULTS: A total of 2,725 patients (1,054 anterior and 1,671 posterior) were analyzed. There were no significant differences in median MCID achievement times for either the HOOS-PS (anterior: 5.9 months, 95% confidence interval [CI]: 4.6 to 6.4; posterior: 4.4 months, 95% CI: 4.1 to 5.1, P = .65) or the PROMIS Global-Physical (anterior: 4.2 months, 95% CI: 3.5 to 5.3; posterior: 3.5 months, 95% CI: 3.4 to 3.8, P = .08) between approaches. Interval-censoring revealed earlier times of achieving the MCID for both the HOOS-PS (anterior: 1.509 to 1.511 months; posterior: 1.7 to 2.3 months, P = .87) and the PROMIS Global-Physical (anterior: 3.0 to 3.1 weeks; posterior: 2.7 to 3.3 weeks, P = .18) for both surgical approaches. CONCLUSIONS: The time to achieve the MCID did not differ by surgical approach. Most patients will achieve clinically meaningful improvements in physical function much earlier than previously believed. LEVEL OF EVIDENCE: Level III, Retrospective Comparative Study.
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BACKGROUND: Despite increasing adoption of the direct anterior (DA) approach in total hip arthroplasty (THA), uncertainty persists regarding its outcomes beyond the 1-year mark in comparison to other approaches. We used the reverse fragility index (RFI) to evaluate the robustness of reported findings in the literature. METHODS: We conducted a systematic review of randomized controlled trials (RCTs) comparing implant revision rates between DA and other approaches in THA, defined as all those different from DA. Our primary outcome was the RFI, which gauges the number of events needed for a nonsignificant result to become significant, in the revision rate between DA and other approaches. We also calculated the reverse fragility quotient by dividing the RFI by each study's sample size. Median values and interquartile ranges (IQRs) were displayed. RESULTS: A total of 10 RCTs with a total of 971 patients were included. The median RFI was 5 (IQR, 4 to 5), indicating the study's results would be statistically significant if the outcomes of 5 patients in 1 treatment arm were reversed. The median reverse fragility quotient was 0.049 (IQR, 0.04 to 0.057), indicating that a change of outcome in 4.9% of patients would render the revision rate significant. The median number of patients lost to follow-up was 4 (IQR, 0 to 7). Of the 10 RCTs, 6 had more patients lost to follow-up than their respective RFI values. CONCLUSIONS: Notable fragility was evidenced in most studies comparing DA to other approaches for THA. Surgeons should not solely rely on the P value to determine clinical significance and instead use multiple metrics. LEVEL OF EVIDENCE: II.
Subject(s)
Arthroplasty, Replacement, Hip , Hip Prosthesis , Randomized Controlled Trials as Topic , Reoperation , Arthroplasty, Replacement, Hip/methods , Humans , Reoperation/statistics & numerical data , Prosthesis Failure , Treatment OutcomeABSTRACT
BACKGROUND: African Americans have the highest prevalence of chronic Hepatitis C virus (HCV) infection. Racial disparities in outcome are observed after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). This study sought to identify if disparities in treatments and outcomes exist between Black and White patients who have HCV prior to elective THA and TKA. METHODS: Patient demographics, comorbidities, HCV characteristics, perioperative variables, in-hospital outcomes, and postoperative complications at 1-year follow-up were collected and compared between the 2 races. Patients who have preoperative positive viral load (PVL) and undetectable viral load were identified. Chi-square and Fisher's exact tests were used to compare categorical variables, while 2-tailed Student's Kruskal-Wallis t-tests were used for continuous variables. A P value of less than .05 was statistically significant. RESULTS: The liver function parameters, including aspartate aminotransferase and model for end-stage liver disease scores, were all higher preoperatively in Black patients undergoing THA (P = .01; P < .001) and TKA (P = .03; P = .003), respectively. Black patients were more likely to undergo THA (65.8% versus 35.6%; P = .002) and TKA (72.1% versus 37.3%; 0.009) without receiving prior treatment for HCV. Consequently, Black patients had higher rates of preoperative PVL compared to White patients in both THA (66% versus 38%, P = .006) and TKA (72% versus 37%, P < .001) groups. Black patients had a longer length of stay for both THA (3.7 versus 3.3; P = .008) and TKA (4.1 versus 3.0; P = .02). CONCLUSIONS: The HCV treatment prior to THA and TKA with undetectable viral load has been shown to be a key factor in mitigating postoperative complications, including joint infection. We noted that Black patients were more likely to undergo joint arthroplasty who did not receive treatment and with a PVL. While PVL rates decreased over time for both races, a significant gap persists for Black patients.
Subject(s)
Arthroplasty, Replacement, Hip , Arthroplasty, Replacement, Knee , Black or African American , Elective Surgical Procedures , Healthcare Disparities , White People , Humans , Male , Arthroplasty, Replacement, Knee/statistics & numerical data , Female , Arthroplasty, Replacement, Hip/statistics & numerical data , Middle Aged , Aged , White People/statistics & numerical data , Black or African American/statistics & numerical data , Healthcare Disparities/ethnology , Healthcare Disparities/statistics & numerical data , Treatment Outcome , Hepatitis C, Chronic/surgery , Hepatitis C, Chronic/ethnology , Postoperative Complications/ethnology , Postoperative Complications/epidemiology , Retrospective Studies , Viral LoadABSTRACT
BACKGROUND: Artificial intelligence in the field of orthopaedics has been a topic of increasing interest and opportunity in recent years. Its applications are widespread both for physicians and patients, including use in clinical decision-making, in the operating room, and in research. In this study, we aimed to assess the quality of ChatGPT answers when asked questions related to total knee arthroplasty. METHODS: ChatGPT prompts were created by turning 15 of the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines into questions. An online survey was created, which included screenshots of each prompt and answers to the 15 questions. Surgeons were asked to grade ChatGPT answers from 1 to 5 based on their characteristics: (1) relevance, (2) accuracy, (3) clarity, (4) completeness, (5) evidence-based, and (6) consistency. There were 11 Adult Joint Reconstruction fellowship-trained surgeons who completed the survey. Questions were subclassified based on the subject of the prompt: (1) risk factors, (2) implant/intraoperative, and (3) pain/functional outcomes. The average and standard deviation for all answers, as well as for each subgroup, were calculated. Inter-rater reliability (IRR) was also calculated. RESULTS: All answer characteristics were graded as being above average (ie, a score > 3). Relevance demonstrated the highest scores (4.43 ± 0.77) by surgeons surveyed, and consistency demonstrated the lowest scores (3.54 ± 1.10). ChatGPT prompts in the Risk Factors group demonstrated the best responses, while those in the Pain/Functional Outcome group demonstrated the lowest. The overall IRR was found to be 0.33 (poor reliability), with the highest IRR for relevance (0.43) and the lowest for evidence-based (0.28). CONCLUSIONS: ChatGPT can answer questions regarding well-established clinical guidelines in total knee arthroplasty with above-average accuracy but demonstrates variable reliability. This investigation is the first step in understanding large language model artificial intelligence like ChatGPT and how well they perform in the field of arthroplasty.
Subject(s)
Arthroplasty, Replacement, Knee , Humans , Surveys and Questionnaires , Artificial Intelligence , Reproducibility of Results , Orthopedics , Clinical Decision-Making , Orthopedic SurgeonsABSTRACT
BACKGROUND: Effective surgical wound management in total knee arthroplasty (TKA) is crucial for optimal healing and patient outcomes. Despite surgical advances, managing wounds to prevent complications remains challenging. This study aimed to identify and address evidence gaps in TKA wound management, including preoperative optimization, intraoperative options, and postoperative complication avoidance. Addressing these issues is vital for patient recovery and surgical success. METHODS: This study used the Delphi method with 20 experienced orthopedic surgeons from Europe and North America. Conducted from April to September 2023, the process involved three stages: an initial electronic survey, a virtual meeting, and a concluding electronic survey. The panel reviewed and reached a consensus on 26 statements about TKA wound management based on a comprehensive literature review. Additionally, the panel aimed to identify critical evidence gaps in wound management practices. RESULTS: The panel achieved consensus on various wound management practices but highlighted significant evidence gaps. Consensus was reached on wound closure methods, including mesh-adhesive dressings, skin glue, staples, barbed sutures, and negative pressure wound therapy. However, further evidence is needed to address the cost-effectiveness of these methods and develop best practices for patient outcomes. Identifying these gaps highlights the need for more research to improve TKA wound care. CONCLUSIONS: Identifying major evidence gaps underscores the need for targeted research in TKA wound management. Addressing these gaps is crucial for developing effective, efficient, and patient-friendly wound care strategies. Future research should focus on comparative effectiveness studies and developing guidelines for emerging technologies. Bridging these gaps could improve patient outcomes, reduce complications, and enhance TKA surgery success.
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BACKGROUND: This modified Delphi study aimed to develop a consensus on optimal wound closure and incision management strategies for total hip arthroplasty (THA). Given the critical nature of wound care and incision management in influencing patient outcomes, this study sought to synthesize evidence-based best practices for wound care in THA procedures. METHODS: An international panel of 20 orthopedic surgeons from Europe, Canada, and the United States evaluated a targeted literature review of 18 statements (14 specific to THA and 4 related to both THA and total knee arthroplasty). There were 3 rounds of anonymous voting per topic using a modified 5-point Likert scale with a predetermined consensus threshold of ≥ 75% agreement necessary for a statement to be accepted. RESULTS: After 3 rounds of voting, consensus was achieved for all 18 statements. Notable recommendations for THA wound management included (1) the use of barbed sutures over non-barbed sutures (shorter closing times and overall cost savings); (2) the use of subcuticular sutures over skin staples (lower risk of superficial infections and higher patient preferences, but longer closing times); (3) the use of mesh-adhesives over silver-impregnated dressings (lower rate of wound complications); (4) for at-risk patients, the use of negative pressure wound therapy over other dressings (lower wound complications and reoperations, as well as fewer dressing changes); and (5) the use of triclosan-coated sutures (lower risk of surgical site infection) over standard sutures. CONCLUSIONS: Through a structured modified Delphi approach, a panel of 20 orthopedic surgeons reached consensus on all 18 statements pertaining to wound closure and incision management in THA. This study provides a foundational framework for establishing evidence-based best practices, aiming to reduce variability in patient outcomes and to enhance the overall quality of care in THA procedures.
Subject(s)
Arthroplasty, Replacement, Hip , Delphi Technique , Humans , Consensus , Surgical Wound Infection/prevention & control , Surgical Wound Infection/etiology , Wound Healing , Wound Closure Techniques , Europe , Canada , Sutures , United StatesABSTRACT
BACKGROUND: The purpose of this modified Delphi study was to obtain consensus on wound closure and dressing management in total knee arthroplasty (TKA). METHODS: The Delphi panel included 20 orthopaedic surgeons from Europe and North America. There were 26 statements identified using a targeted literature review. Consensus was developed for the statements with up to three rounds of anonymous voting per topic. Panelists ranked their agreement with each statement on a five-point Likert scale. An a priori threshold of ≥ 75% was required for consensus. RESULTS: All 26 statements achieved consensus after three rounds of anonymous voting. Wound closure-related interventions that were recommended for use in TKA included: 1) closing in semi-flexion versus extension (superior range of motion); 2) using aspirin for venous thromboembolism prophylaxis over other agents (reduces wound complications); 3) barbed sutures over non-barbed sutures (lower wound complications, better cosmetic appearances, shorter closing times, and overall cost savings); 4) mesh-adhesives over other skin closure methods (lower wound complications, higher patient satisfaction scores, lower rates of readmission); 5) silver-impregnated dressings over standard dressings (lower wound complications, decreased infections, fewer dressing changes); 6) in high-risk patients, negative pressure wound therapy over other dressings (lower wound complications, decreased reoperations, fewer dressing changes); and 7) using triclosan-coated over non-antimicrobial-coated sutures (lower risks of surgical site infection). CONCLUSIONS: Using a modified Delphi approach, the panel achieved consensus on 26 statements pertaining to wound closure and dressing management in TKA. This study forms the basis for identifying critical evidence supported by clinical practice for wound management to help reduce variability, advance standardization, and ultimately improve outcomes during TKA. The results presented here can serve as the foundation for knowledge, education, and improved clinical outcomes for surgeons performing TKAs.
Subject(s)
Arthroplasty, Replacement, Knee , Humans , Arthroplasty, Replacement, Knee/adverse effects , Arthroplasty, Replacement, Knee/methods , Bandages , Delphi Technique , Reoperation , Surgical Wound Infection/prevention & control , Surgical Wound Infection/etiology , SuturesABSTRACT
INTRODUCTION: While total knee arthroplasty (TKA) is typically implemented in patients > 65 years old, young patients may need to undergo TKA for pain relief and functional improvement. Current data are limited by older cohorts and short-term survival rates. This study aimed to examine a large sample size of patients with degenerative and inflammatory conditions who underwent primary TKA at a young (≤ 40) age to identify predictors of reoperation, as well 15-year survivorship. MATERIALS AND METHODS: A retrospective study was performed on 77 patients (92 surgeries) who underwent primary TKA at ≤ 40 years old, between January 1990 and January 2020. Patient charts were reviewed and a multivariable logistic regression model identified independent predictors of reoperation. Kaplan-Meier analysis was employed to build survival curves and log-rank tests analyzed survival between groups. RESULTS: Of the 77 patients, the median age at the time of surgery was 35.7 years (IQR: 31.2-38.7) and median follow-up time was 6.88 years. Twenty-one (22.8%) primary TKAs underwent 24 reoperations, most commonly due to stiffness (n = 9, 32.1%) and infection (n = 13, 46.4%) more significantly in the OA group (p = 0.049). There were no independent predictors of reoperation in multivariable analysis, and 15-year revision-free survivorship after TKA did not differ by indication (77.3% for OA/PTOA vs. 96.7% for autoimmune, p = 0.09) or between ≤ 30 and 31-40 year age groups (94.7% vs. 83.6%, p = 0.55). CONCLUSIONS: In this cohort of patients ≤ 40 years old, revision-free survival was comparable to that reported in the literature for older TKA patients with osteoarthritis/autoimmune conditions (81-94% at 15-years). Though nearly a quarter of TKAs required reoperation and causes of secondary surgery differed between degenerative and inflammatory arthritis patients, there were no significant predictors of increased reoperation rate. Very young patients ≤ 30 years old did not have an increased risk of revision compared to those aged 31-40 years.
ABSTRACT
Over the last several decades, periprosthetic joint infection (PJI) has been increasing in incidence and is occurring in more complex patients. While there have been advances in both surgical and medical treatment strategies, there remain important gaps in our understanding. Here, we share our current approaches to the diagnosis and management of PJI, focusing on frequent clinical challenges and collaborative interdisciplinary care. The more detailed review including diagnosis, surgical considerations, and a detailed antimicrobial discussion is presented in the online version.
Subject(s)
Arthritis, Infectious , Prosthesis-Related Infections , Humans , Prosthesis-Related Infections/diagnosis , Prosthesis-Related Infections/drug therapy , Arthritis, Infectious/diagnosis , Arthritis, Infectious/drug therapyABSTRACT
Over the last several decades, periprosthetic joint infection has been increasing in incidence and is occurring in more complex patients. While there have been advances in both surgical and medical treatment strategies, there remain important gaps in our understanding. Here, we share our current approaches to the diagnosis and management of periprosthetic joint infection, focusing on frequent clinical challenges and collaborative interdisciplinary care.
Subject(s)
Arthritis, Infectious , Prosthesis-Related Infections , Humans , Prosthesis-Related Infections/diagnosis , Prosthesis-Related Infections/drug therapy , Prosthesis-Related Infections/epidemiology , Arthritis, Infectious/diagnosis , Arthritis, Infectious/drug therapy , Incidence , Reoperation/adverse effectsABSTRACT
OBJECTIVE: To determine whether surgical opioid prescriptions are associated with increased risk of opioid initiation by operative patients' spouses. SUMMARY OF BACKGROUND DATA: Adverse effects of surgical opioids on operative patients have been well described. Whether risks of surgical opioids extend to operative patients' family members is unknown. METHODS: This was a retrospective cohort study of opioid-naïve, married patients undergoing 1 of 11 common surgeries from January 1, 2011 to June 30, 2017. The adjusted association between surgical opioid prescriptions and opioid initiation by the operative patient's spouse in the 6-months after surgery was assessed. Secondary analyses assessed how this association varied with postoperative time. RESULTS: There were 318,022 patients (mean ± standard deviation age 48.8 ±9.3 years; 49.5% women). Among the 50,833 (16.0%) patients that did not fill a surgical opioid prescription, 2152 (4.2%) had spouses who filled an opioid prescription within 6-months of their surgery. In comparison, among the 267,189 (84.0%) patients who filled a surgical opioid prescription, 15,026 (5.6%) had spouses who filled opioid prescriptions within 6-months of their surgery [unadjusted P < 0.001; adjusted odds ratio (aOR) 1.37, 95% confidence interval (CI) 1.31-1.43, P < 0.001]. Associated risks were only mildly elevated in postoperative month 1 (aOR 1.11, 95% CI 1.00-1.23, P = 0.04) before increasing to a peak in postoperative month 3 (aOR 1.57,95% CI 1.391.76, P < 0.001). CONCLUSIONS: Surgical opioid prescriptions were associated with increased risk of opioid initiation by spouses of operative patients, suggesting that risks associated with surgical opioids may extend beyond the surgical patient. These findings may highlight the importance of preoperative counseling on safe opioid use, storage, and disposal for both patients and their partners.
Subject(s)
Analgesics, Opioid , Spouses , Humans , Female , Adult , Middle Aged , Male , Analgesics, Opioid/therapeutic use , Pain, Postoperative/drug therapy , Pain, Postoperative/etiology , Retrospective Studies , Drug PrescriptionsABSTRACT
PURPOSE: We conducted semi-structured qualitative interviews with surgeons to assess their goals for incorporating a patient-reported outcome measure (PROM)-based shared decision report into discussions around surgical and non-surgical treatment options for osteoarthritis of the knee and hip. METHODS: Surgeons actively enrolling patients into a study incorporating a standardized PROM-based shared decision report were invited to participate in a semi-structured interview lasting 30 min. Open-ended questions explored how the surgeon used report content, features that were helpful, confusing, or could be improved, and how use of the report fit into the surgeon's workflow. We used a conventional content analysis approach. RESULTS: Of the 16 eligible surgeons, 11 agreed to participate with 9 completing the interview and 2 withdrawing due to work demands. We identified 8 themes related to PROM-based report use: Acceptability, Patient Characteristics, Communication Goals, Useful Content, Not Useful Content, Challenges, Training Needs, and Recommended Improvements. Additional sub-themes emerged for Communication Goals (7) and Challenges (8). All surgeons shared positive feedback about using the report as part of clinical care. Whereas surgeons described the use of the report to achieve different goals, the most common uses related to setting expectations for post-surgical outcomes (89%) and educating patients (100%). CONCLUSION: Surgeons tailor their use of a PROM-based report with individual patients to achieve a range of aims. This study suggests multiple opportunities to further our understanding of the ways PROMs can be used in clinical practice. The way PROM information is visually displayed and multi-component reports are assembled can facilitate diverse aims.