Contextual Determinants of Time to Surgery for Patients With Hip Fracture.

Importance: Surgery within 24 hours after a hip fracture improves patient morbidity and mortality, which has led some hospitals to launch quality improvement programs (eg, targeted resource management, documented protocols) to address delays. However, these programs have had mixed results in terms of decreased time to surgery (TTS), identifying an opportunity to improve the effectiveness of interventions. Objective: To identify the contextual determinants (site-specific barriers and facilitators) of TTS for patients with hip fracture across diverse hospitals. Design, Setting, and Participants: This qualitative mixed-methods study used an exploratory sequential design that comprised 2 phases. In phase 1, qualitative semistructured interviews were conducted with stakeholders involved in hip fracture care (orthopedic surgeons or residents, emergency medicine physicians, hospitalists, anesthesiologists, nurses, and clinical or support staff) at 4 hospitals with differing financial, operational, and educational structures. Interviews were completed between May and July 2021. In phase 2, a quantitative survey assessing contextual determinants of TTS within 24 hours for adult patients with hip fracture was completed by orthopedic surgeon leaders representing 23 diverse hospitals across the US between May and July 2022. Data analysis was performed in August 2022. Main Outcomes and Measures: Thematic analysis of the interviews identified themes of contextual determinants of TTS within 24 hours for patients with hip fracture. The emergent contextual determinants were then measured across multiple hospitals, and frequency and distribution were used to assess associations between determinants and various hospital characteristics (eg, setting, number of beds). Results: A total of 34 stakeholders were interviewed in phase 1, and 23 surveys were completed in phase 2. More than half of respondents in both phases were men (19 [56%] and 18 [78%], respectively). The following 4 themes of contextual determinants of TTS within 24 hours were identified: availability, care coordination, improvement climate, and incentive structure. Within these themes, the most commonly identified determinants across the various hospitals involved operating room availability, a formal comanagement system between orthopedics and medicine or geriatrics, the presence of a physician champion focused on timely surgery, and a program that facilitates improvement work. Conclusions and Relevance: In this study, contextual determinants of TTS within 24 hours for patients with hip fracture varied across hospital sites and could not be generalized across various hospital contexts because no 2 sites had identical profiles. As such, these findings suggest that guidance on strategies for improving TTS should be based on the contextual determinants unique to each hospital.

Accuracy of digital templating in total hip arthroplasty.

Digital radiography is becoming the standard of care for many hospitals and clinics worldwide. The introduction of this new standard has led to the development of arthroplasty templating software. We sought to compare our results using the standard acetate method with the new software method. Our digital preoperative plan was accurate to within 1 size in 78% of the acetabular components and 90% of the femoral components. The manually templated plan was accurate to within 1 size in 67% of the acetabular components and 82% of the femoral components. There did not appear to be any correlation between body mass index and inaccuracies in the preoperative template. Digital templating is an accurate tool to preoperatively plan total hip arthroplasty. The accuracy demonstrated in this study should be achieved easily with any digital templating software. The benefit comes from the ability to scale the templates to the actual x-ray magnification. We expect that this improved accuracy over traditional acetate templating will enhance our ability to restore normal hip biomechanics.

Stability of revision acetabular components using the rim-fit technique.

Use of the rim-fit technique in revision acetabular surgery was reviewed for 20 hips in 18 patients. Defects at revision surgery included isolated medial segmental and global cavitary deficiencies with largely intact peripheral rim. A cementless acetabular component is placed to achieve a press-fit against the bony acetabular rim after morselized allograft and/or autograft was placed behind the cup. The average follow-up period was 68.3 months (5.7 years) (range, 27-112 months). Cup migration was assessed using digital radiography. Average vertical migration was 1.02 mm superiorly, and average horizontal migration was 0.8 mm medially. The abduction angle changed on average by 0.25 degrees. Use of the rim-fit technique for treatment of cavitary acetabular defects is associated with component stability and minimal component migration.

Use of ceramics in total hip replacement.

Ceramics have been used as a bearing surface in total hip arthroplasty (THA) for more than 30 years. Properties of this material which make it particularly attractive for this application include its hardness, high compression strength, and excellent wettability. The low incidence of biologically significant particle generation and clinically significant osteolysis with the use of ceramics in THA reflects these properties. However, low fracture toughness and linear elastic behavior demonstrated by ceramic make it prone to breakage under stress. Improvements in the processing of ceramic as well as advances in engineering of head-neck articulations and liner design have led to an overall decrease in the incidence of ceramic fracture and dislocation. This article reviews the science behind the use of ceramics in THA, the clinical results of ceramics in THA, including complications unique to this bearing surface, and future directions for the application of ceramics in THA.

Advances in the management of medial elbow pain in baseball pitchers.

Overhead-throwing athletes, particularly baseball pitchers, subject their elbows to tremendous amounts of valgus stress during the throwing motion. As a result of this stress, baseball pitchers are at considerable risk for injury. The proper functioning and stability of the elbow depends upon the bony articulations and soft tissue structures. The stresses placed across the elbow joint with repetitive throwing can lead to injury. Although the majority of injuries encountered are overuse injuries, acute injuries can also occur. Proper and timely diagnosis and treatment of these throwers is critical, to allow for the athlete's successful return to competition.