Caring for Diverse and High-Risk Patients: Surgeon, Health System, and Patient Integration.

Access and outcome disparities exist in hip and knee arthroplasty care. These disparities are associated with race, ethnicity, and social determinants of health such as income, housing, transportation, education, language, and health literacy. Additionally, medical comorbidities affecting postoperative outcomes are more prevalent in underresourced communities, which are more commonly communities of color. Navigating racial and ethnic differences in treating our patients undergoing hip and knee arthroplasty is necessary to reduce inequitable care. It is important to recognize our implicit biases and lessen their influence on our healthcare decision-making. Social determinants of health need to be addressed on a large scale as the current inequitable system disproportionally impacts communities of color. Patients with lower health literacy have a higher risk of postoperative complications and poor outcomes after hip and knee replacement. Low health literacy can be addressed by improving communication, reducing barriers to care, and supporting patients in their efforts to improve their own health. High-risk patients require more financial, physical, and mental resources to care for them, and hospitals, surgeons, and health insurance companies are often disincentivized to do so. By advocating for alternative payment models that adjust for the increased risk and take into account the increased perioperative work needed to care for these patients, surgeons can help reduce inequities in access to care. We have a responsibility to our patients to recognize and address social determinants of health, improve the diversity of our workforce, and advocate for improved access to care to decrease inequity and outcomes disparities in our field.

Cardiovascular Disease in Total Knee Arthroplasty: An Analysis of Hospital Outcomes, Complications, and Mortality.

Background: Cardiovascular comorbidities have been identified as a significant risk factor for adverse outcomes following surgery. The purpose of this study was to investigate its prevalence and impact on postoperative outcomes, hospital metrics, and mortality in patients undergoing total knee arthroplasty (TKA). Our hypothesis was that patients with cardiovascular comorbidities would have worse outcomes, greater postoperative complication rates, and increased mortality compared to patients without cardiovascular disease. Methods: In this retrospective study, data from the National Inpatient Sample database from 2011 to 2020 were queried for patients who underwent TKA with preexisting cardiac comorbidities, including congestive heart failure (CHF), coronary artery disease (CAD), valvular dysfunction, and arrhythmia. Multivariate logistic regression analyses compared hospital metrics (length of stay, costs, and adverse discharge disposition), postoperative complications, and mortality rates while adjusting for demographic and clinical variables. All statistical analyses were performed using R studio 4.2.2 and Stata MP 17 and 18 with Python package. Results: A total of 385,585 patients were identified. Those with preexisting CHF, CAD, valvular dysfunction, or arrhythmias were found to be older and at higher risk of adverse outcomes, including prolonged length of stay, increased hospital charges, and increased mortality (p < 0.001). Additionally, all preexisting cardiac diagnoses led to an increased risk of postoperative myocardial infarction, acute kidney injury (AKI), and need for transfusion (p < 0.001). The presence of valvular dysfunction, arrhythmia, or CHF was associated with an increased risk of thromboembolic events (p < 0.001). The presence of CAD and valvular dysfunction was associated with an increased risk of urologic infection (p < 0.001). Conclusions: This study demonstrated that CHF, CAD, valvular dysfunction, and arrhythmia are prevalent among TKA patients and associated with worse hospital metrics, higher risk of perioperative complications, and increased mortality. As our use of TKA rises, a lower threshold for preoperative cardiology referral in older individuals and early preoperative counseling/intervention in those with known cardiac disease may be necessary to reduce adverse outcomes.

Adult Reconstruction Fellowship: What is Important to the Applicants?

Background: Orthopaedic surgery trainees who aim to specialize in total joint arthroplasty commonly complete an additional year of fellowship training. Limited information regarding individual programs is readily available to potential applicants. The purpose of this study is to determine what information applicants value when considering an adult reconstruction fellowship program. Methods: An anonymous survey was distributed to all 470 junior members of AAHKS. The 12-question survey gathered demographic information as well as average weighted scores (1-10) of various components regarding fellowship education, recruitment, and experiences. Subgroup analysis was performed on survey responses based on the following 3 different categories: Gender, year of training, and geographical location. Results: A total of 135 respondents completed the survey (135 of 470, 28.7% response rate). Sixty-two (45.9%) participants held the position of postgraduate year 5, 43 (31.9%) participants held the position of postgraduate year 4. Exposure to operative techniques in revision surgery (9.62), exposure to operative techniques in primary surgery (9.51), and ability to obtain desired job opportunity after fellowship (8.89) were the 3 most considered components. Higher level trainees valued information regarding average number of hours worked relative to junior trainees (P = .046). Geographic differences were noted in the following 3 variables: the number of cases performed (P = .010), whether fellows had a dedicated clinic and/or operating room (P = .002), and the average number of hours worked (P = .020). Conclusions: Amongst the 3 domains studied, applicants most valued educational components, such as exposure to various techniques surrounding total joint arthroplasty. There is a need for a centralized, comprehensive database that contains information applicants value most and this database should be customizable toward training level and location.