Revision Total Joint Arthroplasty Places a Disproportionate Burden on Surgeons: A Comparison Using the National Aeronautics and Space Administration Task Load Index (NASA TLX).

BACKGROUND: Perceived surgeon workload of performing primary and revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) is challenging to quantify. The National Aeronautics and Space Administration Task Load Index (NASA TLX) survey was developed to quantify experiences following aviation and has been applied to healthcare fields. Our purposes were to 1) quantify the workload endured by surgeons who are performing primary and revision TKA and THA and 2) compare these values to their Center for Medicare & Medicaid Services (CMS) reimbursement. METHODS: A prospective cohort of 5 fellowship-trained adult reconstruction surgeons completed NASA TLX surveys following primary and revision TKA/THA cases. A total of 122 surveys consisting of 70 TKA (48 primaries and 22 revisions) and 55 THA surveys (38 primaries and 17 revisions) were completed. Patient demographics and surgical variables were recorded. Final NASA TLX workloads were compared to 2021 CMS work relative value units. RESULTS: Compared to primary TKA, revision TKA had 176% increased intraoperative workload (P < .001), 233% increased mental burden (P < .001), and 150% increased physical burden (P < .001). Compared to primary THA, revision THA had 106% increased intraoperative workload (P < .001), 96% increased mental burden (P < .001), and 91% increased physical burden (P < .001). Operative time was higher in revision versus primary TKA (118 versus 84.5 minutes, P = .05) and THA (150 versus 115 minutes, P = .001). Based upon 2021 CMS data, revision TKA and THA would need to be compensated by an additional 36% and 12.3%, respectively, to parallel intraoperative efforts. CONCLUSIONS: Revision hip and knee arthroplasty places a major mental and physical workload upon surgeons and is disproportionately compensated by CMS.

Effects of a Prescription Drug Monitoring Program on Opioid Prescriptions Following Total Joint Arthroplasty in the State of California.

In an attempt to reduce opioid prescriptions, the state of California mandated physician participation in the Controlled Substance Utilization Review and Evaluation System (CURES). The goal of this study is to assess whether this intervention led to a change in prescribing habits after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). The 90-day postoperative narcotic use was retrospectively reviewed for 13,382 patients undergoing primary THA and TKA. Patients were divided into pre-CURES and post-CURES cohorts based on date of surgery. Narcotic use was measured in morphine milligram equivalents (MME). There was a 21.3% decrease in postoperative MME post-CURES for patients undergoing THA (756.5±759.5 MME vs 962.00±864.4 MME, P<.0001) and a 19.9% decrease in postoperative MME post-CURES for patients undergoing TKA (1274.3±2707.1 MME vs 1590.6±1725.3 MME, P<.0001). Patients post-CURES required an additional prescription at 2 weeks more frequently compared with patients pre-CURES after THA (27.5% vs 20.5%, P<.001) and TKA (54.2% vs 44.2%, P<.001). Patients undergoing THA had 40.5% and 40.6% less narcotic prescribed compared with patients undergoing TKA pre-CURES and post-CURES (P<.001), respectively. Government guidelines led to a substantial decrease in postoperative MME prescribed after TKA and THA. Patients undergoing THA had a substantially smaller amount of narcotic prescribed than patients undergoing TKA. [Orthopedics. 2023;46(2):70-75.].

The most-cited sources on the orthopaedic in-training examination: question yield, reading efficiency, and time lag from publication.

BACKGROUND: Each Orthopaedic In-Training Examination (OITE) question references one or more journal articles or textbook sections as the evidence-based origin of its "preferred response." Previous studies identified the number of references to the top sources but not the number of questions covered by these top sources. The current study analyzes the question yield, time lag from publication, and sequential benefit-in terms of OITE questions covered-of the most referenced sources in order to provide residents and educators strategies for developing an efficient reading program. METHODS: We analyzed all OITE references from 2002 to 2009 and identified 1. The most referenced journals, text- books, authors, and journal articles; 2. The question yield of the top journals; 3. The time lag from article publication to OITE reference; and 4. The additional question benefit of the top sources when added sequentially. We repeated the analysis considering only journal articles published within 5 years of each respective OITE. RESULTS: The most referenced journals were the The Journal of Bone and Joint Surgery, American Edition (JBJS-Am), Clinical Orthopaedics and Related Research (CORR), and the The Journal of the American Academy of Orthopaedic Surgeons (JAAOS). JBJS-Am accounted for 14% of all references and was referenced on 24% of questions; CORR and JAAOS each contributed 6% of references and were referenced on 11% of questions. The average time from article publication to OITE reference was 8.1 years (median: 6 years, mode: 2 years). The top 29 authors were referenced on 15% of OITE questions. The two most-referenced articles were each referenced 7 times in 8 years. Regarding question yield, 18% of published JAAOS articles were referenced on an OITE, as opposed to 7% of JBJS-Am articles and 2% of CORR articles. Considering articles published within 5 years of an OITE, the number of questions referencing JBJS-Am decreased from 24% to 10%. The sequential benefit of adding JAAOS and CORR during the 5 years was an additional 8% of total questions. CONCLUSIONS: When developing a reading curriculum, educators and residents should be aware of the question yield, reading efficiency, and time lag to publication of the most common OITE reference sources.

Incidence of atypical nontraumatic diaphyseal fractures of the femur.

Bisphosphonates reduce the rate of osteoporotic fractures in clinical trials and community practice. "Atypical" nontraumatic fractures of the diaphyseal (subtrochanteric or shaft) part of the femur have been observed in patients taking bisphosphonates. We calculated the incidence of these fractures within a defined population and examined the incidence rates according to duration of bisphosphonate use. We identified all femur fractures from January 1, 2007 until December 31, 2011 in 1,835,116 patients older than 45 years who were enrolled in the Healthy Bones Program at Kaiser Southern California, an integrated health care provider. Potential atypical fractures were identified by diagnostic or procedure codes and adjudicated by examination of radiographs. Bisphosphonate exposure was derived from internal pharmacy records. The results showed that 142 patients had atypical fractures; of these, 128 had bisphosphonate exposure. There was no significant correlation between duration of use (5.5 ± 3.4 years) and age (69.3 ± 8.6 years) or bone density (T-score -2.1 ± 1.0). There were 188,814 patients who had used bisphosphonates. The age-adjusted incidence rates for an atypical fracture were 1.78/100,000/year (95% confidence interval [CI], 1.5-2.0) with exposure from 0.1 to 1.9 years, and increased to 113.1/100,000/year (95% CI, 69.3-156.8) with exposure from 8 to 9.9 years. We conclude that the incidence of atypical fractures of the femur increases with longer duration of bisphosphonate use. The rate is much lower than the expected rate of devastating hip fractures in elderly osteoporotic patients. Patients at risk for osteoporotic fractures should not be discouraged from initiating bisphosphonates, because clinical trials have documented that these medicines can substantially reduce the incidence of typical hip fractures. The increased risk of atypical fractures should be taken into consideration when continuing bisphosphonates beyond 5 years.