Post-Traumatic Stress Disorder Is Associated With Increased Emergency Department Services and Similar Rates of Opioid Prescriptions Following Primary Total Hip Arthroplasty: A Propensity Matched Analysis.

BACKGROUND: There is a paucity of literature regarding patients who have post-traumatic stress disorder (PTSD) following primary total hip arthroplasty (THA). The purpose of this study was to compare the rates of postoperative complications, prescriptions, health care utilization, and revision arthroplasty of patients who had PTSD undergoing primary THA against a propensity matched control group of patients who did not have PTSD (NPTSD). METHODS: The TriNetX database was queried to identify PTSD patients undergoing primary THA. Patients were then propensity matched in a 1:1 ratio based on twelve preoperative characteristics to a cohort of NPTSD patients. Postoperative prescriptions and rates of health care utilization were analyzed within 5 days, 14 days, and 1 month postoperatively. Complications were analyzed within one month. Revision arthroplasty rates were analyzed within 1 year and 2 years. RESULTS: A total of 198,560 patients undergoing primary THA were identified. Ultimately, 1,310 PTSD patients were successfully propensity matched to a cohort of 1,310 NPTSD patients. Patients who have PTSD presented to the emergency department at significantly higher rates than NPTSD patients within 14 days and 1 month postoperatively. Within 1 month postoperatively, cohorts were prescribed opioid analgesics at similar rates (P = .709). Patients who had PTSD received more prescriptions per patient compared to NPTSD patients. Patients who had PTSD were also found to have a higher number of total complications per person within 1 month (P = .022). Within 2 years postoperatively, rates of revision hip arthroplasty were comparable between cohorts (P = .912). CONCLUSIONS: Patients who have PTSD experience similar rates of revision hip arthroplasty and opioid prescribing compared to NPTSD patients following primary THA; however, within 1 month postoperatively, emergency department visits were greater in PTSD patients. These findings can help delineate early postoperative education and expectations for patients who have PTSD in contrast to other psychiatric diagnoses.

Effects of a Continuous Adductor Canal Block After Total Knee Arthroplasty.

This retrospective cohort study analyzed the short-term outcomes of patients undergoing total knee arthroplasty receiving periarticular anesthetic injections (PAIs) with and without continuous adductor canal blocks (CACBs) regarding early postoperative narcotic use, pain scores, and range of motion with otherwise similar postoperative regimens. Two hundred ninety-four patients were included: 120 received PAIs with CACBs, and 174 received PAIs only. Matched analysis was performed for type of anesthesia. There were substantial decreases in early inpatient narcotic use with the addition of CACBs to PAIs with general and spinal anesthesia without an adverse effect on pain, knee range of motion, or length of stay. [Orthopedics. 2023;46(3):185-191.].

Corrigendum to 'Outcomes of Revision Hip Arthroplasty Using the Supine Anterior- Based Muscle Sparing Approach' [Arthroplasty Today 14 (2022) 199-203].

[This corrects the article DOI: 10.1016/j.artd.2022.02.016.].

Outcomes of Revision Hip Arthroplasty Using the Supine Anterior-Based Muscle Sparing Approach.

Background: In the United States, the number of revision total hip arthroplasty (THA) cases is projected to grow from 50,000 in 2014 to 85,000 by 2030. The anterior-based muscle sparing approach (ABMS) has been described as a viable approach for primary THA, but little has been written in the revision setting. This study compares the supine ABMS approach to alternative approaches in revision THA. Material and methods: A retrospective review was performed on 149 revision THAs from 2016 to 2019. The ABMS, modified Müller Hardinge (MMH), and posterolateral (PL) approaches were studied. Age, reason for arthroplasty, length of operation, length of stay, blood loss, and complications were extracted. Clinical outcomes were measured by the Hip Disability and Osteoarthritis Outcome Score, Modified Harris Hip Score, University of California Los Angeles activity score, and Veterans RAND 12 Mental/Physical scores. Results: Approaches included 52 ABMS (33.8%), 58 MHH (37.7%), and 39 PL (25.3%). Complexity of cases and patient demographics were equivalent for each cohort. Extensile approaches were used in 12 of the 52 ABMS, 26 of the 58 MMH, and 13 of the 39 PL revisions, including acetabular cages, open reduction internal fixation for periprosthetic fracture, extended trochanteric osteotomy, hardware removal, and/or pelvic discontinuity. There were no differences for blood loss, length of stay, complications, and outcome scores between approaches. Conclusion: We found no difference in complications or clinical outcome scores between the ABMS, MMH, and PL approaches for revision THA. The supine ABMS approach provides adequate extensile exposure of the femur and acetabulum for complex revisions and is a reliable approach for revision THA.

Outcomes of the Supine Anterior-based Muscle-sparing Approach for Primary and Revision Hip Arthroplasty.

INTRODUCTION: Risks and outcomes of total hip arthroplasty (THA) are believed to vary relative to the surgical approach. This study compares the supine anterior-based muscle-sparing (ABMS) approach with its modern-day counterparts. METHODS: A retrospective review was done on 550 patients undergoing primary or revision THA from 2016 to 2018. Surgical modalities included direct anterior (DAA), ABMS, posterolateral, and Müller modified Hardinge approaches. Surgical data were collected, and clinical outcomes were measured by the Hip Disability and Osteoarthritis Outcome Score, Modified Harris Hip Score, UCLA, and VR-12 Mental/Physical scores preoperatively and compared clinical outcomes among approaches. RESULTS: A total of 550 patients were included (447 primaries, 103 revisions). The average age was 64 years (231 men, 319 women). Approaches included 79 DAA (14%), 212 ABMS (39%), 180 modified Müller-Hardinge (33%), and 79 posterolateral (14%). The incidence of lateral femoral cutaneous nerve injury was more common with the DAA (P = 0.008), but no other clinically significant differences were noted among the groups. CONCLUSION: The results of this study showed no clinically notable differences between the supine ABMS and other approaches. The supine ABMS approach is an acceptable approach in modern day THA when used by an experienced surgeon well-versed in the approach.

An Orthopaedic Virtual Clinical Clerkship for Visiting Medical Students: Early Successes and Future Implications.

OBJECTIVE: The visiting orthopaedic clerkship is viewed by both students and program directors as an important part of the orthopaedic surgery residency application process, despite being criticized as costly and inefficient. Restrictions due to the COVID-19 pandemic prevented students from participating in in-person clerkships at institutions other than at their home programs, necessitating a virtual replacement for the in-person orthopaedics clerkship experience. It remains unclear how the virtual clerkships will affect the application process this year, and moving forward. We describe and review our institution's initial experience with a virtual orthopaedic clerkship. We hypothesize that students would view the virtual clerkship as valuable, and that students would see a role for such clerkships going forward. DESIGN: A virtual orthopaedic surgery clerkship was created and students were invited to enroll. Thirty-one 4th-year medical students participated. Each clerkship included 8 two-hour sessions. Each session was moderated by a faculty member, and participants included only medical students. Students presented virtual cases, which provided the basis for the discussion and education. At the conclusion of each clerkship, students were given an anonymous survey assessing various aspects of the clerkship. RESULTS: Twenty-seven students responded to the survey. Overall, 15 students rated the experience as outstanding, 11 excellent, and 1 good. Twenty-two students saw a role for virtual clerkships moving forward, and five students did not see a role moving forward. Student reported strengths of the clerkship included direct faculty interaction, structured curriculum, and student-centered discussions. Lack of hands-on experience was cited as the biggest weakness. CONCLUSIONS: Students valued the opportunity for a virtual clerkship, and most could envision a role for such virtual clerkships moving forward. We suggest that virtual clerkships may be a cost-effective and useful tool in helping both students and programs navigate the residency selection process.

Outcomes of Total Knee Arthroplasty with a Prior Contralateral Above-Knee Amputation: A Report of 10 Cases.

BACKGROUND: Total knee arthroplasty (TKA) in the setting of a prior contralateral above-knee amputation (AKA) represents a rare scenario with limited reported outcomes. As such, it is difficult for surgeons to effectively counsel these patients relative to risks and expected outcomes after TKA. We report outcomes for a series of 10 such patients. METHODS: We retrospectively reviewed all patients at our institution from 2005 to 2018 who underwent a primary TKA and prior contralateral AKA and had a minimum 12-month follow-up. Data regarding complications, ambulatory status, reported pain, patient demographics, length of follow-up, and comorbidities were obtained. RESULTS: Ten patients met criteria. Follow-up ranged from 1 to 8 years. Six reported no pain or improved pain with weight-bearing. Ambulatory status worsened for 5 patients, remained unchanged for 3, and improved for 2. Five patients had significant postoperative complications: infection requiring repeat surgery (3), quadriceps tendon rupture (1), and revision for implant failure and instability (1). Patients in this cohort had a median of 3 medical comorbidities known to affect postoperative outcomes and complication rates. CONCLUSIONS: While a contralateral AKA is not an absolute contraindication to TKA, these results should influence patient counseling. Most of our cohort benefited from improved pain, but only 2 of 10 had improved ambulation and half had significant complications. Medical comorbidities may have contributed to these complications. Surgeons contemplating TKA in this situation might consider modified postoperative recovery protocols and aggressive preoperative optimization of medical comorbidities to lower the risk of complication in this high-risk population.

Individual Patient-reported Activity Levels Before and After Joint Arthroplasty Are Neither Accurate nor Reproducible.

BACKGROUND: Patients often are asked to report walking distances before joint arthroplasty and when discussing their results after surgery, but little evidence demonstrates whether patient responses accurately represent their activity. QUESTIONS/PURPOSES: Are patients accurate in reporting distance walked, when compared with distance measured by an accelerometer, within a 50% margin of error? METHODS: Patients undergoing THA or TKA were recruited over a 16-month period. One hundred twenty-one patients were screened and 66 patients (55%) were enrolled. There were no differences in mean age (p = 0.68), proportion of hips versus knees (p = 0.95), or sex (p = 0.16) between screened and enrolled patients. Each patient wore a FitBit Zip accelerometer for 1 week and was blinded to its measurements. The patients reported their perceived walking distance in miles daily. Data were collected preoperatively and 6 to 8 weeks postoperatively. Responses were normalized against the accelerometer distances and Wilcoxon one-tailed signed-rank testing was performed to compare the mean patient error with a 50% margin of error, our primary endpoint. RESULTS: We found that patients' self-reported walking distances were not accurate. The mean error of reporting was > 50% both preoperatively (p = 0.002) and postoperatively (p < 0.001). The mean magnitude of error was 69% (SD 58%) preoperatively and 93% (SD 86%) postoperatively and increased with time (p = 0.001). CONCLUSIONS: Patients' estimates of daily walking distances differed substantially from those patients' walking distances as recorded by an accelerometer, the accuracy of which has been validated in treadmill tests. Providers should exercise caution when interpreting patient-reported activity levels. LEVEL OF EVIDENCE: Level III, diagnostic study.

Comparative Effectiveness of Biomarkers to Target Cancer Treatment: Modeling Implications for Survival and Costs.

BACKGROUND: Biomarkers used at the time of diagnosis to tailor treatment decisions may diffuse into clinical practice before data become available on whether biomarker testing reduces cancer mortality. In the interim, quantitative estimates of the mortality impact of testing are needed to assess the value of these diagnostic biomarkers. These estimates are typically generated by customized models that are resource intensive to build and apply. METHODS: We developed a user-friendly system of models for Cancer Translation of Comparative Effectiveness Research (CANTRANce) to model the mortality impact of cancer interventions. The Diagnostic Biomarker module of this system projects the mortality impact of testing for a diagnostic biomarker, given data on how testing affects treatment recommendations. Costs and quality-of-life outcomes may also be modeled. We applied the Diagnostic Biomarker module to 2 case studies to demonstrate its capabilities. RESULTS: The user interface (http://www.fhcrc.org/cantrance) allows comparative effectiveness researchers to use the Diagnostic Biomarker module of CANTRANce. Our case studies indicate that the model produces estimates on par with those generated by customized models and is a strong tool for quickly generating novel projections. LIMITATIONS: The simple structure that makes CANTRANce user-friendly also constrains the complexity with which cancer progression can be modeled. The quality of the results rests on the quality of the input data, which may pertain to small or dissimilar populations or suffer from informative censoring. CONCLUSIONS: The Diagnostic Biomarker module of CANTRANce is a novel public resource that can provide timely insights into the expected mortality impact of testing for diagnostic biomarkers. The model projections should be useful for understanding the long-term potential of emerging diagnostic biomarkers.