Total Hip Arthroplasty Versus Education and Exercise: A Propensity-Matched Analysis of 266 Patients Who Have Hip Osteoarthritis.

BACKGROUND: Total hip arthroplasty (THA) for osteoarthritis (OA) is a major health system cost. Education and exercise (Edu+Ex) programs may reduce the number of THAs needed, but supporting data is limited. This study aimed to estimate the treatment effect of THA versus Edu+Ex on pain, function, and quality of life outcomes 3- and 12-months after treatment initiation for hip OA. METHODS: Patients who had hip OA who underwent THA or an Edu+Ex program were included in this propensity-matched study. In 778 patients (Edu+Ex n = 303; THA n = 475), propensity scores were based on pre-treatment characteristics, and patients were matched on a 1:1 ratio. Between-group treatment effects (pain, function, and quality of life) were estimated as the mean difference in change from pre-treatment to 3- and 12-month follow-up using linear mixed models. RESULTS: The matched sample consisted of 266 patients (Edu+Ex n = 133; THA n = 133) that were balanced on all pre-treatment characteristics except opioid use. At 12-month follow-up, THA resulted in significantly greater improvements in pain (mean difference [MD] 35.4; 95% CI [confidence interval] 31.4 to 39.4), function (MD 30.5; 95% CI 26.3 to 34.7), and quality of life (MD 33.6; 95% CI 28.8 to 38.4). Between 17 and 30% of patients receiving Edu+Ex experienced a surgical threshold for clinically meaningful improvement in outcomes, compared to 84 and 90% of THA patients. CONCLUSIONS: A THA provides greater improvements in pain, function, and quality of life. A significant proportion of Edu+Ex patients had clinically meaningful improvements, suggesting Edu+Ex may result in THA deferral in some patients, but confirmatory trials are needed.

The impact of diabetes status on pain and physical function following total joint arthroplasty for hip and knee osteoarthritis: variation by sex and body mass index.

Few studies have examined diabetes impact on total joint arthroplasty (TJA) outcomes, with variable findings. We investigated the association between diabetes and post-TJA physical function and pain, examining whether diabetes impact differs by sex and BMI. Patient sample completed questionnaires within 3 months prior to hip or knee TJA for osteoarthritis (OA) and 1-year post-surgery. Surgical 'non-response' was defined as < 30% improvement in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and physical function at 1-year. Two adjusted logistic regression models were estimated: (1) excluding, (2) including an interaction between diabetes, sex and BMI. The sample (626 hip, 754 knee) was 54.9% female, had mean BMI of 30.1, 13.0% reported diabetes. In adjusted models excluding an interaction, diabetes was not associated with non-response. However, a significant 3-way interaction (physical function: p = 0.003; pain: p = 0.006) between diabetes, sex, and BMI was found and was associated with non-response: non-response probability increased with increasing BMI in men with diabetes, but decreased with increasing BMI in women in diabetes. Findings suggest uncertainty in diabetes impact may be due to differential impacts by sex and BMI. A simple consideration of diabetes as present vs. absent may not be sufficient, with implications for the large TJA population.

The impact of diabetes on physical and mental health status and patient satisfaction after total hip and knee arthroplasty.

OBJECTIVE: To assess the impact of diabetes on physical and mental health status, as well as patient satisfaction, one-year following knee and hip total joint arthroplasty (TJA) for osteoarthritis (OA). METHODS: Participants were 626 hip and 754 knee TJA patients. Pre-surgery data were collected on socio-demographics and health status. The 12-item Short Form Health Survey (SF-12) was collected pre- and one year post-surgery, and physical (PCS) and mental component (MCS) summary scores computed. One-year patient satisfaction was also recorded. Four regression models tested the effect of diabetes on: 1) PCS change score; 2) MCS change score; 3) achieving minimal clinically important improvement (MCII) on PCS; and 4) patient satisfaction ('Somewhat or Very Satisfied' vs. 'Somewhat or Very Dissatisfied'). An interaction between surgical joint and diabetes was tested in each model. RESULTS: Self-reported diabetes prevalence was 13.0% (95% CI: 11.2%-14.7%) and was more common in knee 16.1% (95% CI: 13.4%-18.7%) than hip 9.3% (95% CI: 7.0%-11.5%) patients. In adjusted analyses, change scores were 2.3 units less on the PCS for those with diabetes compared to those without (p = 0.005). Patients with diabetes were about half as likely to achieve MCII as patients without diabetes (p = 0.004). Diabetes was not significantly associated with satisfaction or changes in MCS scores. Diabetes effects did not differ by surgical joint. CONCLUSIONS: Findings support that diabetes has a negative impact on improvements in physical health after TJA. Considering the growing prevalence of OA and diabetes in the population, our findings support the importance of perioperative screening and management of diabetes in patients undergoing TJA.

Total Knee Arthroplasty Versus Education and Exercise for Knee Osteoarthritis: A Propensity-Matched Analysis.

OBJECTIVE: We estimate the treatment effect of total knee arthroplasty (TKA) versus an education and exercise (Edu+Ex) program on pain, function, and quality of life outcomes 3 and 12 months after treatment initiation for knee osteoarthritis (OA). METHODS: Patients with knee OA who had undergone TKA were matched on a 1:1 ratio with participants in an Edu+Ex program based on a propensity score fitted to a range of pretreatment covariates. After matching, between-group differences in improvement (the treatment effect) in Knee Injury and Osteoarthritis Outcome Score 12-item version (0, worst to 100, best) pain, function, and quality of life from baseline to 3 and 12 months were estimated using linear mixed models, adjusting for unbalanced covariates, if any, after matching. RESULTS: The matched sample consisted of 522 patients (Edu+Ex, n = 261; TKA, n = 261) who were balanced on all pretreatment characteristics. At 12-month follow-up, TKA resulted in significantly greater improvements in pain (mean difference [MD] 22.8; 95% confidence interval [95% CI] 19.7-25.8), function (MD 21.2; 95% CI 17.7-24.4), and quality of life (MD 18.3; 15.0-21.6). Even so, at least one-third of patients receiving Edu+Ex had a clinically meaningful improvement in outcomes at 12 months compared with 75% of patients with TKA. CONCLUSION: TKA is associated with greater improvements in pain, function, and quality of life, but these findings also suggest that Edu+Ex may be a viable alternative to TKA in a meaningful proportion of patients, which may reduce overall TKA need. Confirmatory trials are needed.

Imaging in an academic orthopedic shoulder service: a report on incidental lung pathology findings.

INTRODUCTION: Computed tomography (CT) is often utilized for both diagnostic and pre-operative planning purposes in shoulder arthroplasty. Our study reports on the incidence of pulmonary findings in our pre-operative shoulder arthroplasty population over 14 years at our institution. METHODS: We conducted a retrospective review of all "shoulder CT" exams ordered by two orthopedic upper extremity surgeons between the years of 2008 and 2021. These exams were then further analyzed to include only those ordered for the purpose of pre-operative "shoulder arthroplasty" planning. All incidental findings were documented and those with pulmonary findings were then further analyzed. A detailed chart review was then performed on these patients to determine the impact on their planned shoulder arthroplasty. RESULTS: A total of 363 shoulder pre-operative CTs were ordered by our two upper extremity orthopedic surgeons at our institution between the years of 2008 and 2021. Primary lung cancer in the form of adenocarcinoma (n = 3) had an incidence of 0.8% of all CT scans and 1.4% of all pulmonary incidental findings. Fifteen patients (4% of all CT scans and 7% of all pulmonary incidental findings) had no concern for malignancy and were appropriately evaluated with further imaging based on their initial shoulder CT. CONCLUSION: While shoulder arthroplasty and pre-operative planning with CT imaging continue to become more common, so too is the incidence of reported pulmonary findings. From a patient care standpoint, it is important that these findings are accurately identified, appropriately triaged, and communicated clearly to our patients.

Time trends and patterns in opioid prescription use following orthopaedic surgery in Ontario, Canada, from 2004/2005 to 2017/2018: a population-based study.

OBJECTIVES: Increased use of opioids and their associated harms have raised concerns around prescription opioid use for pain management following surgery. We examined trends and patterns of opioid prescribing following elective orthopaedic surgery. DESIGN: Population-based study. SETTING: Ontario, Canada. PARTICIPANTS: Ontario residents aged 66+ years who had elective orthopaedic surgery from April 2004 to March 2018. PRIMARY AND SECONDARY OUTCOME MEASURES: Postoperative opioid use (short term: within 90 days of surgery, prolonged: within 180 days and chronic: within 1 year), specific opioids prescribed, average duration (days) and amount (morphine milligram equivalents) of the initial prescription by year of surgery. RESULTS: We included 464 460 elective orthopaedic surgeries in 2004/2005-2017/2018: 80% of patients used opioids within 1 year of surgery-25.1% were chronic users. There was an 8% increase in opioid use within 1 year of surgery, from 75.1% in 2004/2005 to 80.9% in 2017/2018: a 29% increase in short-term use and a decline in prolonged (9%) and chronic (22%) use. After 2014/2015, prescribed opioid amounts initially declined sharply, while the duration of the initial prescription increased substantially. Across categories of use, there was a steady decline in coprescription of benzodiazepines and opioids. CONCLUSIONS: Most patients filled opioid prescriptions after surgery, and many continued filling prescriptions after 3 months. During a period of general increase in awareness of opioid harms and dissemination of guidelines/policies aimed at opioid prescribing for chronic pain, we found changes in prescribing practices following elective orthopaedic surgery. Findings illustrate the potential impact of guidelines/policies on shaping prescription patterns in the surgical population, even in the absence of specific guidelines for surgical prescribing.

Hospital spending and length of stay attributable to perioperative adverse events for inpatient hip, knee, and spine surgery: a retrospective cohort study.

BACKGROUND: The incremental hospital cost and length of stay (LOS) associated with adverse events (AEs) has not been well characterized for planned and unplanned inpatient spine, hip, and knee surgeries. METHODS: Retrospective cohort study of hip, knee, and spine surgeries at an academic hospital in 2011-2012. Adverse events were prospectively collected for 3,063 inpatient cases using the Orthopaedic Surgical AdVerse Event Severity (OrthoSAVES) reporting tool. Case costs were retrospectively obtained and inflated to equivalent 2021 CAD values. Propensity score methodology was used to assess the cost and LOS attributable to AEs, controlling for a variety of patient and procedure factors. RESULTS: The sample was 55% female and average age was 64; 79% of admissions were planned. 30% of cases had one or more AEs (82% had low-severity AEs at worst). The incremental cost and LOS attributable to AEs were $8,500 (95% confidence interval [CI]: 5100-11,800) and 4.7 days (95% CI: 3.4-5.9) per admission. This corresponded to a cumulative $7.8 M (14% of total cohort cost) and 4,290 bed-days (19% of cohort bed-days) attributable to AEs. Incremental estimates varied substantially by (1) admission type (planned: $4,700/2.4 days; unplanned: $20,700/11.5 days), (2) AE severity (low: $4,000/3.1 days; high: $29,500/11.9 days), and (3) anatomical region (spine: $19,800/9 days; hip: $4,900/3.8 days; knee: $1,900/1.5 days). Despite only 21% of admissions being unplanned, adverse events in these admissions cumulatively accounted for 59% of costs and 62% of bed-days attributable to AEs. CONCLUSIONS: This study comprehensively demonstrates the considerable cost and LOS attributable to AEs in orthopaedic and spine admissions. In particular, the incremental cost and LOS attributable to AEs per admission were almost five times as high among unplanned admissions compared to planned admissions. Mitigation strategies focused on unplanned surgeries may result in significant quality improvement and cost savings in the healthcare system.

The GLA:D® Canada program for knee and hip osteoarthritis: A comprehensive profile of program participants from 2017 to 2022.

BACKGROUND: The Good Life with osteoArthritis in Denmark (GLA:D®) program was implemented in Canada in 2017 with the aim of making treatment guideline-recommended care available to the 4 million Canadians with knee and hip osteoarthritis (OA). This report describes the GLA:D® Canada program, registry and data collection procedures, and summarizes the sociodemographic and clinical profile of participants with knee and hip OA to inform the scientific research community of the availability of these data for future investigations and collaborations. METHODS: The GLA:D® program consists of three standardized components: a training course for health care providers, a group-based patient education and exercise therapy program, and a participant data registry. Patients seeking care for knee or hip OA symptoms and enrolling in GLA:D® are given the option to provide data to the GLA:D® Canada registry. Participants agreeing to provide data complete a pre-program survey and are followed up after 3-, and 12-months. Data collected on the pre-program and follow-up surveys include sociodemographic factors, clinical characteristics, health status measures, and objective physical function tests. These variables were selected to capture information across relevant health constructs and for future research investigations. RESULTS: At 2022 year-end, a total of 15,193 (11,228 knee; 3,965 hip) participants were included in the GLA:D® Canada registry with 7,527 (knee; 67.0%) and 2,798 (hip; 70.6%) providing pre-program data. Participants were 66 years of age on average, predominately female, and overweight or obese. Typically, participants had knee or hip problems for multiple years prior to initiating GLA:D®, multiple symptomatic knee and hip joints, and at least one medical comorbidity. Before starting the program, the average pain intensity was 5 out of 10, with approximately 2 out of 3 participants using pain medication and 1 in 3 participants reporting a desire to have joint surgery. Likewise, 9 out 10 participants report having previously been given a diagnosis of OA, with 9 out 10 also reporting having had a radiograph, of which approximately 87% reported the radiograph showed signs of OA. CONCLUSION: We have described the GLA:D® Canada program, registry and data collection procedures, and provided a detailed summary to date of the profiles of participants with knee and hip OA. These individual participant data have the potential to be linked with local health administrative data registries and comparatively assessed with other international GLA:D® registries. Researchers are invited to make use of these rich datasets and participate in collaborative endeavours to tackle questions of Canadian and global importance for a large and growing clinical population of individuals with hip and knee OA.

Osteoarthritis Data Integration Portal (OsteoDIP): A web-based gene and non-coding RNA expression database.

Objective: OsteoDIP aims to collect and provide, in a simple searchable format, curated high throughput RNA expression data related to osteoarthritis. Design: Datasets are collected annually by searching "osteoarthritis gene expression profile" in PubMed. Only publications containing patient data and a list of differentially expressed genes are considered. From 2020, the search has expanded to include non-coding RNAs. Moreover, a search in GEO for "osteoarthritis" datasets has been performed using 'Homo sapiens' and 'Expression profiling by array' filters. Annotations for genes linked to osteoarthritis have been downloaded from external databases. Results: Out of 1204 curated papers, 63 have been included in OsteoDIP, while GEO curation led to the collection of 28 datasets. Literature data provides a snapshot of osteoarthritis research derived from 1924 human samples, while GEO datasets provide expression for additional 1012 patients. Similar to osteoarthritis literature, OsteoDIP data has been created mostly from studies focused on knee, and the tissue most frequently investigated is cartilage. GEO data sets were fully integrated with associated clinical data. We showcase examples and use cases applicable for translational research in osteoarthritis. Conclusions: OsteoDIP is publicly available at http://ophid.utoronto.ca/OsteoDIP. The website is easy to navigate and all the data is available for download. Data consolidation allows researchers to perform comparisons across studies and to combine data from different datasets. Our examples show how OsteoDIP can integrate with and improve osteoarthritis researchers' pipelines.

Association of presurgical circulating MicroRNAs with 1-year postsurgical pain reduction in spine facet osteoarthritis patients with lumbar spinal stenosis.

Purpose: Up to 30% of spine facet osteoarthritis patients with lumbar spinal stenosis (SF-OA â€‹+ â€‹LSS) have little to no improvement in their pain after surgery. Lack of meaningful improvement in pain following surgery provides a unique opportunity to identify specific predictive biomarker signatures that might be associated with the outcomes of surgical treatment. The objective of the present study was to determine whether a microRNA (miRNA) biomarker signature could be identified in presurgical blood plasma that corresponded with levels of SF-OA â€‹+ â€‹LSS patient post-surgical pain intensity one year later. Methods: RNA was extracted from baseline plasma of SF-OA â€‹+ â€‹LSS patients and prepared for miRNA sequencing. Statistical approaches were performed to identify differentially expressed miRNAs associated with reduced 1-year postsurgical pain (n â€‹= â€‹56). Using an integrated computational approach, we further created predicted gene and pathway networks for each identified miRNA. Results: We identified a panel of 4 circulating candidate miRNAs (hsa-miR-155-5p, hsa-let-7e-5p, hsa-miR-125a-5p, hsa-miR-99b-5p) with higher levels at presurgical baseline that were associated with greater changes in % NPRS20Δ, reflecting reduced pain intensity levels at one year. Genes encoding hsa-let-7e-5p, hsa-miR-125a-5p, and hsa-miR-99b-5p are part of an evolutionarily conserved miRNA cluster. Using integrated computational analyses, we showed that mammalian target of rapamycin, transforming growth factor-ß1 receptor, Wnt signaling, epithelial-mesenchymal transition regulators, and cholecystokinin signaling were enriched pathways of predicted gene targets. Conclusions: Taken together, our findings suggest that 4 presurgical baseline circulating miRNAs correlate with 1-year postsurgical SF-OA â€‹+ â€‹LSS patient pain intensity and represent possible candidate biomarker signature of surgical pain response.

Healthcare Utilization and Costs for Musculoskeletal Disorders in Ontario, Canada.

OBJECTIVE: To examine the magnitude and costs of ambulatory primary care, specialist physician care, and hospital service use for musculoskeletal disorders (MSDs) in Canada's largest province, Ontario. METHODS: Administrative health databases were analyzed for fiscal year 2013-2014 for adults aged ≥ 18 years, including data on physician services, emergency department (ED) visits, and hospitalizations. International Classification of Diseases diagnostic codes were used to identify MSD services. A validated algorithm was used to estimate direct medical costs. Person-visit rates and numbers of persons and visits were tabulated by care setting, age, sex, and physician specialty. Data were examined for all MSDs combined, as well as for specific diagnostic groupings. RESULTS: Overall, 3.1 million adult Ontarians (28.5%) made over 8 million outpatient physician visits associated with MSDs. These included 5.6 million primary care visits. MSDs accounted for 560,000 (12.3%) of all adult ED visits. Total costs for MSD-related care were $1.6 billion, with 12.6% of costs attributed to primary care, 9.2% to specialist care, 8.6% to ED care, 8.5% to day surgery, and 61.2% associated with inpatient hospitalizations. Costs due to arthritis accounted for 40% of total MSD care costs ($639 million). MSD-related imaging costs were $169 million, yielding a total cost estimate of $1.8 billion for MSDs overall. CONCLUSION: MSDs place a significant and costly burden on the healthcare system. Health system planning needs to consider the large and escalating demand for care to reduce both the individual and population burden.

Evaluation of Trends in Knee Arthroscopy from 2004 to 2019 in Ontario, Canada.

Trends in Knee Arthroscopy in Ontario, CanadaThis study included 408,040 patients who underwent arthroscopy procedures in Ontario, Canada between 2004 and 2019. The number of procedures declined 8.9% from 24,070 in 2004/2005 to 21,930 in 2018/2019. Among patients with osteoarthritis, rates of progression to knee arthroplasty were 3.8%, 9.6% and 16.0% at 1, 2, and 5 years, respectively, compared with rates among patients with degenerative meniscal disorders, which were 1.6%, 4.1%, and 7.3%, at 1, 2 and 5 years, respectively.

Injection of Bone Marrow Aspirate for Glenohumeral Joint Osteoarthritis: A Pilot Randomized Control Trial.

PURPOSE: To compare the efficacy of a single, intra-articular, nonconcentrated bone marrow aspirate (BMA) injection in comparison to cortisone for the treatment of glenohumeral joint osteoarthritis (GHJ OA). METHODS: Inclusion criteria were patients between the ages of 18 and 75 with a diagnosis of GHJ OA on radiograph. Patients were randomized to receive an ultrasound-guided, intra-articular cortisone injection or BMA injection (without concentration). The primary outcome measure was the Western Ontario Osteoarthritis of the Shoulder (WOOS) index at 12 months. Secondary outcome measures were the QuickDASH, EuroQOL 5-dimensions 5-level questionnaire (EQ-5D-5L) and visual analogue scale. RESULTS: The study included 25 shoulders of 22 patients who completed baseline and 12 months' patient-reported outcome measures (12 shoulders received cortisone, 13 shoulders received BMA) after the study was terminated early by changes in Health Canada regulations. Baseline characteristics demonstrated a significant difference in the ages of the 2 groups, with the BMA group being older (61.6 vs 53.8 mean years, P = 0.021). For the BMA group, a significant improvement was seen in the WOOS index (P = 0.002), the QuickDASH (P < 0.001), and the EQ-5D-5L pain dimension (P = 0.004) between baseline and 12 months. No significant difference was seen for any outcome in the cortisone group between baseline and 12 months. No significant difference was demonstrated between changes in the WOOS scores from baseline to 12 months when compared between groups (P = 0.07). However, a significant difference in changes in scores was seen in the QuickDASH (P = 0.006) and the EQ-5D-5L pain scores (P = 0.003) and the EQ-5D-5L health scores (P = 0.032) in favor of BMA. CONCLUSIONS: The results of this study demonstrate that patients with GHJ OA treated with BMA have superior changes in the QuickDASH and EQ-5D-5L pain and health scores but not in the WOOS outcomes measures at 12 months post injection when compared to patients treated with cortisone. However, because of the limited number of patients as a result of the early termination of the study, larger randomized studies are required to confirm these findings. LEVEL OF EVIDENCE: Level II, randomized controlled trial.

The GoodHope Ehlers Danlos Syndrome Clinic: development and implementation of the first interdisciplinary program for multi-system issues in connective tissue disorders at the Toronto General Hospital.

Ehlers-Danlos Syndrome (EDS) are a heterogeneous group of genetic connective tissue disorders, and typically manifests as weak joints that subluxate/dislocate, stretchy and/or fragile skin, organ/systems dysfunction, and significant widespread pain. Historically, this syndrome has been poorly understood and often overlooked. As a result, people living with EDS had difficulty obtaining an accurate diagnosis and appropriate treatment, leading to untold personal suffering as well as ineffective health care utilization. The GoodHope EDS clinic addresses systemic gaps in the diagnosis and treatment of EDS. This paper describes a leap forward-from lack of awareness, diagnosis, and treatment-to expert care that is tailored to meet the specific needs of patients with EDS. The GoodHope EDS clinic consists of experts from various medical specialties who work together to provide comprehensive care that addresses the multi-systemic nature of the syndrome. In addition, EDS-specific self-management programs have been developed that draw on exercise science, rehabilitation, and health psychology to improve physical and psychosocial wellbeing and overall quality of life. Embedded into the program are research initiatives to shed light on the clinical presentation, underlying mechanisms of pathophysiology, and syndrome management. We also lead regular educational activities for community health care providers to increase awareness and competence in the interprofessional management of EDS beyond our doors and throughout the province and country.

The Use of Telehealth for Orthopedic Consultations and Assessments: A Systematic Review.

As a result of the coronavirus disease 2019 (COVID-19) pandemic, tele-health for orthopedic care is expanding rapidly. The authors sought to identify the evidence describing the effectiveness, barriers, and clinical applications of telehealth for orthopedic assessments and consultations. MEDLINE, PubMed, EMBASE, and the Cochrane Library were searched from inception to March 2020. Forty-seven studies were included, with the most common conditions evaluated being trauma related and the primary modality being videoconferencing. Available literature supports the use of telehealth for orthopedic consultations and assessments because it yields moderate-to-high patient and provider satisfaction, accurate examinations, cost-effectiveness, and reduced wait times. Most commonly reported concerns were professional liability, network security, and technical issues. Given the COVID-19 pandemic, rapid implementation and uptake of virtual assessment for patient care has occurred. The current evidence suggests that telehealth is capable of providing prompt access to quality, cost-efficient orthopedic consultations and assessments. [Orthopedics. 2021;44(4):198--206.].

Implementation of the Good Life with osteoArthritis in Denmark (GLA:D) Program across Canada for the Management of Hip and Knee Osteoarthritis.

Good Life with osteoArthritis in Denmark (GLA:D®) is a program for the management of patients with hip and knee osteoarthritis (OA). Adapted for the Canadian population, the GLA:DTM Canada program implements evidence-based strategies to support the prevention, early diagnosis and effective management of hip and knee OA. GLA:D assists local communities in implementing OA strategies across the spectrum of disease severity. An integral part of this program is a national quality and outcomes registry, which includes data concerning participant characteristics and both patient-reported and functional outcomes. This registry helps healthcare providers and healthcare decision makers ensure that individuals with OA receive effective, high-quality care through the GLA:D Canada program.

Emergency Department Presentation After Total Hip and Knee Arthroplasty: A Systematic Review.

BACKGROUND: Recent changes to payment models for elective total joint arthroplasty (TJA) have led to increased interest in postdischarge health care utilization. Although readmission has historically been of primary interest, emergency department (ED) presentation is increasingly a point of focus. The purpose of this review was to summarize the available literature pertaining to ED visits after total hip arthroplasty and total knee arthroplasty. METHODS: PubMed, MEDLINE, and Embase were searched. Clinical studies reporting rate, reasons, and/or risk factors associated with ED presentation after TJA were included. Pooled return to ED rates were calculated using weighted means. RESULTS: Twenty-seven studies (n = 1,484,043) were included. After TJA, the mean 30-day and 90-day rates of ED presentation were 8.1% and 10.3%, respectively. Rates were slightly higher in total knee arthroplasty vs total hip arthroplasty patients at 30 days (11.5% vs 6.5%) and 90 days (10.8% vs 9.7%). The most common reasons for ED presentation after TJA were pain (4.6%-35%), medical concerns (5.6%-24.5%), and swelling (1.4%-17.5%). Studies analyzing the timing of ED visits found that most occurred within the first 2 weeks postdischarge. Black race and Medicaid/Medicare insurance coverage were identified as risk factors associated with ED visits. CONCLUSION: ED visits present a high burden for the health care system, as upward of 1 in 10 patients will return to the ED within 90 days of TJA. Future efforts should be made to develop cost-effective and patient-centered interventions that reduce preventable ED visits after TJA. As well, these rates should be taken into consideration when allocating resources for the care of TJA patients.

The lower trapezius transfer: a systematic review of biomechanical data, techniques, and clinical outcomes.

BACKGROUND: Lower trapezius (LT) transfers were originally described to restore external rotation (ER) in the management of brachial plexus palsy; however, there is recent interest in the role of this transfer to restore shoulder function, specifically ER, in patients with a massive irreparable rotator cuff tear (RCT). The purpose of this systematic review is to summarize the current literature pertaining to LT transfers, including biomechanics, techniques, and clinical outcomes for patients with brachial plexus palsy and massive RCTs. METHODS: MEDLINE, EMBASE, and PubMed were searched for biomechanical and clinical studies, as well as technique articles. Four biomechanical studies reported on moment arms, range of motion (ROM), and force vectors. Seven clinical studies reported postoperative ROM and functional outcomes, and weighted mean improvements in ROM were calculated. RESULTS: Overall, 18 studies were included, and then subdivided into 3 themes: biomechanical, technique, and clinical. Biomechanical studies comparing LT and latissimus dorsi (LD) transfers observed an overall larger moment arm in abduction and ER in adduction for the LT transfer, with similar results in forward elevation. Clinical studies noted significant improvement in shoulder function following the LT transfer, including ROM and functional outcome scores. There were several described techniques for performing the LT transfer, including arthroscopically assisted and open approaches, and the use of both allograft and autograft augmentation. CONCLUSION: This study suggests that the LT transfer is generally safe, and the clinical and biomechanical data to date support the use of the LT transfer for restoration of function in these challenging patient populations.

Healthcare utilization and costs for spinal conditions in Ontario, Canada - opportunities for funding high-value care: a retrospective cohort study.

BACKGROUND CONTEXT: An important step in improving spinal care is understanding how current health-care resources and associated cost are being utilized and distributed across a health-care system. PURPOSE: Our objective was to examine the magnitude and distribution of direct health care costs for spinal conditions across physician type and hospital setting. DESIGN/SETTING: Cross-sectional analysis of administrative health data for the fiscal year 2013-2014 from the province of Ontario, Canada. PATIENT SAMPLE: Adult population aged 18+ years (N=10,841,302). OUTCOME MEASURES: Person visit rates and total number of people and visits by specific care settings were calculated for all spinal conditions as well as stratified by nontrauma and trauma-related conditions. Variation in rates by age and sex was examined. The proportion of patients seeing physicians of different specialties was calculated for each condition grouping. Direct medical costs were estimated and their percentage distribution by care setting calculated for nontrauma and trauma-related conditions. Additionally, costs for spinal imaging overall and stratified by type of scan were determined. METHODS: Administrative health databases were analyzed, including data on physician services, emergency department visits, and hospitalizations. ICD-9 and -10 diagnostic codes were used to identify nontraumatic (degenerative or inflammatory) and traumatic spinal disorders. A validated algorithm was used to estimate direct medical costs. RESULTS: Overall, 822,000 adult Ontarians (7.6%) made 1.6 million outpatient physician visits for spinal conditions; the majority (1.1 million) of these visits were for nontrauma conditions. Approximately, 86% of outpatient visits were in primary care. Emergency Department (ED) visits for nontrauma spinal conditions (130,000 out of 156,000 ED visits) accounted for 2.8% of all ED visits in the province. Total costs for spine-related care were $264 million (CDN) with 64% of costs due to nontrauma conditions. For these nontrauma conditions, ED visits cost $28 million for 130,000 visits ($215 per visit). For $32 million spent in primary care, 890,000 visits were made ($36 per visit). Spine imaging costs were $66.5 million, yielding a combined total of $330 million in health care spending for spinal conditions. CONCLUSIONS: Spinal conditions place a large and costly burden on the health-care system. The disproportionate annual cost associated with ED visits represents a potential opportunity to redirect costs to fund more clinically and cost-effective models of care for nontraumatic spinal conditions.