Validation of a Discharge Risk Calculator for Rural Patients Following Total Joint Arthroplasty.

INTRODUCTION: As the volume of total joint arthroplasty (TJA) in the US continues to grow, new challenges surrounding appropriate discharge surface. Arthroplasty literature has demonstrated discharge disposition to post-acute care facilities carries major risks regarding the need for revision surgery, patient co-morbidities, and financial burden. To quantify, categorize, and mitigaterisks, a decision tool that uses preoperative patient variables has previously been published and validated using an urban patient population. The aim of our investigation was to validate the same predictive model using patients in a rural setting undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA). METHODS: All TKA and THA procedures that were performed between January 2012 and September 2022 at our institution were collected. A total of 9,477 cases (39.6% TKA, 60.4% THA) were included for the validation analysis. There were nine preoperative variables that were extracted in an automated fashion from the electronic medical record. Included patients were then run through the predictive model, generating a risk score representing that patient's differential risk of discharge to a skilled nursing facility (SNF) versus home. Overall accuracy, sensitivity and specificity were calculated after obtaining risk scores. RESULTS: Score cutoff equally maximizing sensitivity and specificity was 0.23, and the proportion of correct classifications by the predictive tool in this study population was found to be 0.723, with an area under the curve (AUC) of 0.788-both higher than previously published accuracy levels. With the threshold of 0.23, sensitivity and specificity were found to be 0.720 and 0.723, respectively. CONCLUSION: The risk calculator showed very good accuracy, sensitivity, and specificity in predicting discharge location for rural patients undergoing TKA and THA, with accuracy even higher than in urban populations. The model provides an easy-to-use interface, with automation representing a viable tool in helping with shared decision-making regarding postoperative discharge plans.

Ethical Considerations in Total Joint Arthroplasty.

Hip and knee arthroplasty surgeries have excellent outcomes and notably improve quality of life. However, ethical issues permeate the practice of adult reconstruction, and as economics and technology evolve, these issues have become increasingly important. This article will review the currently published literature on ethical issues including industry influences, implants and instrumentations, surgical innovation, new technology adoptions, and healthcare policy-relevant issues, including patient cost sharing and bundled care programs. In addition, the direct marketing of implants from the manufacturer to the general public may falsely raise patient expectations concerning the long-term clinical outcome and performance of newer devices in the absence of long-term studies. This article will also focus on relevant contemporary ethical issues that do not necessarily have preexisting published literature or guidelines but, nonetheless, are crucial for adult reconstruction surgeons to address. These issues include access to care and challenges with orthopaedic resident and fellow education. Surgeons must understand the ethical issues that can arise in their clinical practice and how those issues affect patients. Clinicians are tasked with making the best-reasoned judgment possible to optimize their patients' outcomes. Still, the ability to standardize treatment while optimizing individual outcomes for unique patients remains a challenge.

Patient "No-Show" Increases the Risk of 90-Day Complications Following Primary Total Knee Arthroplasty: A Retrospective Cohort Study of 6,776 Patients.

BACKGROUND: Patients who "no-show" (NS) clinical appointments are at a high risk of adverse health outcomes. The objective of this study was to evaluate and characterize the relationship between NS visits prior to primary total knee arthroplasty (TKA) and 90-day complications after TKA. METHODS: We retrospectively reviewed 6,776 consecutive patients undergoing primary TKA. Study groups were separated based on whether patients who NS versus always attended their appointment. A NS was defined as an intended appointment that was not canceled or rescheduled ≤2 hours before the appointment in which the patient did not show. Data collected included total number of follow-up appointments prior to surgery, patient demographics, comorbidities, and 90-day postoperative complications. RESULTS: Patients who have ≥3 NS appointments had 1.5 times increased odds of a surgical site infection (odds ratio (OR) 1.54, P = .002) compared to always attended patients. Patients who were ≤65 years old (OR: 1.41, P < .001), smokers (OR: 2.01, P < .001), and had a Charlson comorbidity index ≥3 (OR: 4.48, P < .001) were more likely to miss clinical appointments. CONCLUSION: Patients who have ≥3 NS appointments prior to TKA had an increased risk for surgical site infection. Sociodemographic factors were associated with higher odds of missing a scheduled clinical appointment. These data suggest that orthopaedic surgeons should consider NS data as an important clinical decision-making tool to assess risk for postoperative complications to minimize complications following TKA.

Physician Perspectives on Telemedicine at an Integrated Health System During the COVID-19 Pandemic.

Introduction: The use of telemedicine (TM) for patient care greatly increased during the COVID pandemic. This study presents data from a single health system regarding physician's perspectives on TM, which could ultimately determine how it is used in the future. Methods: A questionnaire was distributed to physicians throughout the health system. Physicians were divided based on the standard level of patient interaction in each specialty, as well as practice locations and years in practice. Physician perspectives were categorized by their opinions on different aspects of telehealth visits. Results: Of 1,794 physicians, 379 (20.7%) responded to the survey. Psychiatrists used TM significantly more than other groups and project the most future use. Surgeons were least likely to incorporate TM in the future. Ability to perform a physical examination via TM differed significantly by specialty and practice environment, but not by years in practice. Frequency of being able to complete a treatment plan via TM differed significantly by specialty, but not by years in practice or practice environment. Overall, 76.3% of physicians reported feeling "satisfied" with performing TM visits. Satisfaction with TM varied significantly by specialty and practice environment, but not by years in practice. There were no significant differences regarding physician expectations on reimbursement or billing for TM visits based on specialty, age, or practice environment. Conclusions: Discrepancies exist among physicians with respect to their satisfaction and expected future use of TM. Consensus may be difficult to reach regarding reimbursement for these visits, and further work is needed to clarify the optimal practice setting for TM.

The accuracy of component positioning during revision total hip arthroplasty using 3D optical computer-assisted navigation.

INTRODUCTION: Despite the excellent outcomes associated with primary total hip arthroplasty (THA), implant failure and revision continue to burden the healthcare system. The use of computer-assisted navigation (CAN) offers the potential for more accurate placement of hip components during surgery. While intraoperative CAN systems have been shown to improve outcomes in primary THA, their use in the context of revision total hip arthroplasty (rTHA) has not been elucidated. We sought to investigate the validity of using CAN during rTHA. METHODS: A retrospective analysis was performed at an academic medical institution identifying all patients who underwent rTHA using CAN from 2016-2019. Patients were 1:1 matched with patients undergoing rTHA without CAN (control) based on demographic data. Cup anteversion, inclination, change in leg length discrepancy (ΔLLD) and change in femoral offset between pre- and post-operative plain weight-bearing radiographic images were measured and compared between both groups. A safety target zone of 15-25° for anteversion and 30-50° for inclination was used as a reference for precision analysis of cup position. RESULTS: Eighty-four patients were included: 42 CAN cases and 42 control cases. CAN cases displayed a lower ΔLLD (5.74 ± 7.0 mm vs 9.13 ± 7.9 mm, p = 0.04) and greater anteversion (23.4 ± 8.53° vs 19.76 ± 8.36°, p = 0.0468). There was no statistical difference between the proportion of CAN or control cases that fell within the target safe zone (40% vs 20.9%, p = 0.06). Femoral offset was similar in CAN and control cases (7.63 ± 5.84 mm vs 7.14 ± 4.8 mm, p = 0.68). CONCLUSION: Our findings suggest that the use of CAN may improve accuracy in cup placement compared to conventional methodology, but our numbers are underpowered to show a statistical difference. However, with a ΔLLD of ~ 3.4 mm, CAN may be useful in facilitating the successful restoration of pre-operative leg length following rTHA. Therefore, CAN may be a helpful tool for orthopedic surgeons to assist in cup placement and LLD during complex revision cases.

Bone loss in aseptic revision total knee arthroplasty: management and outcomes.

BACKGROUND: Although several techniques and implants have been developed to address bone loss in revision total knee arthroplasty (rTKA), management of these defects remains challenging. This review article discusses the indications and management options of bone loss following total knee arthroplasty based on preoperative workup and intraoperative findings. MAIN TEXT: Various imaging modalities are available that can be augmented with intraoperative examination to provide a clear classification of a bony defect. For this reason, the Anderson Orthopaedic Research Institute (AORI) classification is frequently used to guide treatment. The AORI provides a reliable system by which surgeons can classify lesions based on their size and involvement of surrounding structures. AORI type I defects are managed with cement with or without screws as well as impaction bone grafting. For AORI type IIA lesions, wedge or block augmentation is available. For large defects encompassing AORI type IIB and type III defects, bulk allografts, cones, sleeves, and megaprostheses can be used in conjunction with intramedullary stems. CONCLUSIONS: Treatment of bone loss in rTKA continues to evolve as different techniques and approaches have been validated through short- and mid-term follow-up. Extensive preoperative planning with imaging, accurate intraoperative evaluation of the bone loss, and comprehensive understanding of all the implant options available for the bone loss are paramount to success.

Lumbar Spine Fusion and Symptoms of Leg Length Discrepancy After Hip Arthroplasty.

BACKGROUND: Hip length discrepancy (HLD) is common after total hip arthroplasty (THA); however, the effect of spinal fusion on perceived leg length discrepancy (LLD) symptoms after THA has not been examined. This study tested the hypothesis that LLD symptoms are increased in patients who underwent lumbar spinal fusion and THA, compared with patients with THA only. METHODS: This retrospective cohort study included 67 patients who underwent lumbar spinal fusion and THA, along with 78 matched control patients who underwent THA only. Hip and spine measurements were taken on postoperative, standing anterior-posterior pelvic, lateral lumbar, and anterior-posterior lumbar spinal radiographs. Perceived LLD symptoms were assessed via telephone survey. RESULTS: Between the spinal fusion and control groups, there was no significant difference in HLD (M = 7.10 mm, SE = 0.70 and M = 5.60 mm, SE = 0.49) (P = .403). The spinal fusion patients reported more frequently noticing a difference in the length of their legs than the control group (P = .046) and reported limping "all the time" compared with the control group (P = .001). Among all patients with an HLD ≤10 mm, those in the spinal fusion group reported limping at a higher frequency than patients in the control group (P = .008). Patients in the spinal fusion group were also more likely to report worsened back pain after THA (P = .011) than the control group. CONCLUSION: Frequencies of a perceived LLD, limping, and worsened back pain after THA were increased in patients with THA and a spinal fusion compared with patients who had THA only, even in a population with HLD traditionally considered to be subclinical. The results indicate that in patients with prior spinal fusion, precautions should be taken to avoid even minor LLD in the setting of THA.

Utility of Upright Weight-bearing Imaging in Total Hip Arthroplasty.

Planning for total hip arthroplasty (THA) has traditionally been performed using static supine anteroposterior radiographs of the pelvis. Recent advances in imaging technology and the understanding of human spinopelvic kinematics have made weight-bearing radiography an important adjunct to supine imaging. Hip surgeons can use weight-bearing imaging to optimize THA component position to prevent hip instability and early component wear. The goal of this narrative review is to delineate the fundamentals of spinopelvic kinematics, the benefits of surgical planning using weight-bearing radiography, and the underpinnings of upright full-body stereoradiography as a useful adjunct to traditional supine radiographs.

Coronal and Sagittal Balancing of Total Knee Arthroplasty Old Principles and New Technologies.

The number of total knee arthroplasties performed in the United States is growing, and a leading cause of failure is postoperative knee instability from suboptimal coronal or sagittal balancing. This article reviews native knee anatomy as well as several guiding principles of total knee arthroplasty such as limb axis, femoral referencing, and implant constraint. Next, techniques that can be used by the surgeon to achieve ideal sagittal balance and coronal balance are discussed in detail. Finally, due to the growing use of computer and robotic technologies in knee replacement, the impact of advanced technologies on total knee arthroplasty balancing and alignment is reviewed. An in-depth understanding of these topics will enable surgeons to optimize the outcome of their total knee arthroplasty patients.

Resident Physician Duty-hour Requirements: What Does the Public Think?

INTRODUCTION: To date, no study has reported on the public's opinion of orthopaedic resident duty-hour requirements (DHR). METHODS: A survey was administered to people in orthopaedic waiting rooms and at three senior centers. Responses were analyzed to evaluate seven domains: knowledge of duty hours; opinions about duty hours; attitudes regarding shift work; patient safety concerns; and the effects of DHRs on continuity of care, on resident training, and on resident professionalism. RESULTS: Respondents felt that fatigue was unsafe and duty hours were beneficial in preventing resident physician fatigue. They supported the idea of residents working in shifts but did not support shifts for attending physicians. However, respondents wanted the same resident to provide continuity of care, even if that violated DHRs. They were supportive of increasing the length of residency to complete training. DHRs were not believed to affect professionalism. Half of the respondents believed that patient opinion should influence policy on this topic. DISCUSSION: Orthopaedic patients and those likely to require orthopaedic care have inconsistent opinions regarding DHRs, making it potentially difficult to incorporate their preferences into policy.

Moral Dilemmas in Pediatric Orthopedics.

All orthopedic surgeons face moral dilemmas on a regular basis; however, little has been written about the moral dilemmas that are encountered when providing orthopedic care to pediatric patients and their families. This article aims to provide surgeons with a better understanding of how bioethics and professionalism apply to the care of their pediatric patients. First, several foundational concepts of both bioethics and professionalism are summarized, and definitions are offered for 16 important terms within the disciplines. Next, some of the unique aspects of pediatric orthopedics as a subspecialty are reviewed before engaging in a discussion of 5 common moral dilemmas within the field. Those dilemmas include the following: (1) obtaining informed consent and assent for either surgery or research from pediatric patients and their families; (2) performing cosmetic surgery on pediatric patients; (3) caring for pediatric patients with cognitive or physical impairments; (4) caring for injured pediatric athletes; and (5) meeting the demand for pediatric orthopedic care in the United States. Pertinent considerations are reviewed for each of these 5 moral dilemmas, thereby better preparing surgeons for principled moral decision making in their own practices. Each of these dilemmas is inherently complex with few straightforward answers; however, orthopedic surgeons have an obligation to take the lead and better define these kinds of difficult issues within their field. The lives of pediatric patients and their families will be immeasurably improved as a result.

Risk of hepatitis C virus exposure in orthopedic surgery: is universal screening needed?

The aging baby boomer generation will soon start using tremendous orthopedic surgical resources. This group has also been identified as a group at high risk for having undiagnosed hepatitis C virus (HCV) infection. We conducted a study to assess the prevalence of HCV among orthopedic surgery patients at our institution-using their demographic data to determine whether they represent a unique cohort at high risk for having undiagnosed HCV. We estimated that we operated on as many as 233 patients with undiagnosed HCV in 2011. A cost-effective, universal preoperative HCV screening program may reduce the risk for occupational exposure in orthopedic surgery and significantly benefit public health by bringing undiagnosed patients to treatment. A robust screening program requires several ethical considerations. By offering routine screening to patients, orthopedic surgeons have an opportunity to maintain intraoperative safety and improve the health of the public.

Moral reasoning strategies of orthopaedic surgery residents.

BACKGROUND: Little is known about the moral reasoning utilized by orthopaedic surgery residents when resolving moral dilemmas. METHODS: Sixty-three residents in an accredited program took the Defining Issues Test-2, an online examination designed to measure and analyze moral reasoning. Scores approximate how often residents utilize three schemas in their moral reasoning: personal interest, maintaining social norms, and postconventional. Scores were analyzed for differences among years of training, previous literature, and established norms. RESULTS: Approximately 9.5% of residents utilized personal interest heavily in their moral reasoning, 27% utilized maintaining norms, and 63.5% utilized postconventional reasoning. There were no significant differences between years of training. The fourth-year (R4) class recorded the highest utilization of principled reasoning, while the fifth-year (R5) class recorded the lowest. The range of principled reasoning scores narrowed from the first year (R1) to R5. The principled reasoning scores of residents were significantly lower than previously reported scores of professional degree-holders and medical students, and empirically lower than previously reported scores of orthopaedic attendings and medical students. CONCLUSIONS: Residents utilized principled reasoning less frequently than expected for physicians. It remains unclear as to what factors contributed to high utilization of principled reasoning in the R4 class but low utilization in the R5 class. Our cross-sectional data suggest that each year of training homogenizes toward a class-specific utilization of principled reasoning. It remains unclear why residents utilized principled reasoning less than orthopaedic attendings, medical students, and other professional degree-holders.

Updates in the management of orthopedic soft-tissue injuries associated with lower extremity trauma.

Management of traumatic soft-tissue injuries remains a challenging and ever evolving field within orthopedic surgery. The basic principle of addressing life before limb in the initial assessment of critically injured patients has not changed. Although arteriography remains the gold standard for vascular injury screening, computed tomography angiography is being used more often to determine limb viability, and its sensitivity and specificity for detecting vascular lesions are reported to be excellent. Thorough debridement and irrigation with early institution of antibiotics are crucial in preventing infection; debridement should be performed urgently once life-threatening conditions have been addressed. Increasing use of vacuum-assisted closure therapy has created a trend down the reconstructive ladder, with improvements in resulting wound closure. Although the orthoplastics approach and new microsurgical techniques have made limb salvage possible in even the most severely injured extremities, it is important to clearly identify the zone of injury and to inform patients and their families of the outcomes of limb salvage versus amputation. Results from the LEAP (Lower Extremity Assessment Project) trials and similar studies should guide orthopedic surgeons in the management of these complex injuries. Nevertheless, it is important to individualize management plans according to patient factors.