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.

Pulse oximetry training landscape for healthcare workers in low- and middle-income countries: A scoping review.

Background: Pulse oximetry has been used in medical care for decades. Its use quickly became standard of care in high resource settings, with delayed widespread availability and use in lower resource settings. Pulse oximetry training initiatives have been ongoing for years, but a map of the literature describing such initiatives among health care workers in low- and middle-income countries (LMICs) has not previously been conducted. Additionally, the coronavirus disease 2019 (COVID-19) pandemic further highlighted the inequitable distribution of pulse oximetry use and training. We aimed to characterise the landscape of pulse oximetry training for health care workers in LMICs prior to the COVID-19 pandemic as described in the literature. Methods: We systematically searched six databases to identify studies reporting pulse oximetry training among health care workers, broadly defined, in LMICs prior to the COVID-19 pandemic. Two reviewers independently assessed titles and abstracts and relevant full texts for eligibility. Data were charted by one author and reviewed for accuracy by a second. We synthesised the results using a narrative synthesis. Results: A total of 7423 studies were identified and 182 screened in full. A total of 55 training initiatives in 42 countries met inclusion criteria, as described in 66 studies since some included studies reported on different aspects of the same training initiative. Five overarching reasons for conducting pulse oximetry training were identified: 1) anaesthesia and perioperative care, 2) respiratory support programme expansion, 3) perinatal assessment and monitoring, 4) assessment and monitoring of children and 5) assessment and monitoring of adults. Educational programmes varied in their purpose with respect to the types of patients being targeted, the health care workers being instructed, and the depth of pulse oximetry specific training. Conclusions: Pulse oximetry training initiatives have been ongoing for decades for a variety of purposes, utilising a multitude of approaches to equip health care workers with tools to improve patient care. It is important that these initiatives continue as pulse oximetry availability and knowledge gaps remain. Neither pulse oximetry provision nor training alone is enough to bolster patient care, but sustainable solutions for both must be considered to meet the needs of both health care workers and patients.

Inconsistencies in the Methodological Framework Throughout Published Studies in High-Impact Orthopaedic Journals: A Systematic Review.

BACKGROUND: Both the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) and Consolidated Standards of Reporting Trials (CONSORT) guidelines recommend that clinical trials follow a study framework that aligns with their objective to test the relative efficacy or safety (equality) or effectiveness (superiority, noninferiority, or equivalence) between interventions. We conducted a systematic review to assess the proportion of studies that demonstrated inconsistency between the framing of their research question, sample size calculation, and conclusion and those that should have framed their research question differently based on the compared interventions. METHODS: We included studies from 5 high-impact-factor orthopaedic journals published in 2017 and 2019 that compared at least 2 interventions using patient-reported outcome measures. RESULTS: We included 228 studies. The sample size calculation was reported in 60.5% (n = 138) of studies. Of these, 52.2% (n = 72) were inconsistent between the framing of their research question, sample size calculation, and conclusion. The majority (n = 137) of sample size calculations were for equality, but 43.8% of these studies concluded superiority, noninferiority, or equivalence. Studies that framed their research question as equality (n = 186) should have been framed as superiority (n = 129), equivalence (n = 52), or noninferiority (n = 3). Only 2 studies correctly framed their research question as equality. CONCLUSIONS: Studies published in high-impact journals were inconsistent between the framing of their research question, sample size calculation, and conclusion. Authors may be misinterpreting research findings and making clinical recommendations solely based on p values. Researchers are encouraged to state and justify their methodological framework and choice of margin(s) in a publicly published protocol as they have implications for sample size and the applicability of conclusions. CLINICAL RELEVANCE: The results of clinical research must be interpreted using confidence intervals, with careful consideration as to how the confidence intervals relate to clinically meaningful differences in outcomes between treatments. The more typical practice of relying on p values leaves the clinician at high risk of erroneous interpretation, recommendation, and/or action.

Anterior Cruciate Ligament Patellar Tendon Autograft Fixation at 0° Versus 30° Results in Improved Activity Scores and a Greater Proportion of Patients Achieving the Minimal Clinical Important Difference For Knee Injury and Osteoarthritis Outcome Score Pain: A Randomized Controlled Trial.

PURPOSE: The aim of the current study was to determine the effect of the knee flexion angle (KFA) during tibial anterior cruciate ligament (ACL) graft fixation on patient-reported outcomes, graft stability, extension loss, and reoperation after anatomic single-bundle ACL reconstruction. METHODS: All 169 included patients (mean age 28.5 years, 65% male) were treated with anatomic single-bundle ACL reconstruction using patellar tendon autograft and were randomized to tibial fixation of the ACL graft at either 0° (n = 85) or 30° (n = 84). The primary outcome was the Knee Injury and Osteoarthritis Outcome Score (KOOS) 2 years after surgery. Secondary outcomes were the Marx Activity Scale (MAS), the rate of reoperation, and physical examination findings at 1 year, including KT-1000 and side-to-side differences in knee extension. RESULTS: The follow-up rate was 82% (n = 139) for the primary outcome. Graft failure rate at 2 years was 1% (n = 2, 1 per group). ACL tibial graft fixation at 0° or 30° did not have a significant effect on KOOS scores at 2 years after ACLR. Patients whose graft was fixed at a knee flexion angle of 0° had greater scores on the MAS (mean 9.6 95% confidence interval [CI] 8.5 to 10.6, versus 8.0, 95% CI 6.9 to 9.1; P = .04), and a greater proportion achieved the minimal clinical important difference (MCID) for the KOOS pain subdomain (94% versus 81%; P = .04). There was no significant difference in knee extension loss, KT-1000 measurements, or reoperation between the 2 groups. CONCLUSION: In the setting of anatomic single-bundle ACLR using patellar tendon autograft and anteromedial portal femoral drilling, there was no difference in KOOS scores between patients fixed at 0° and 30°. Patient fixed in full extension did demonstrate higher activity scores at 2 years after surgery and a greater likelihood of achieving the MCID for KOOS pain. LEVEL OF EVIDENCE: II, prospective randomized trial.

Interpreting Patient-Reported Outcome Measures in Orthopaedic Surgery: A Systematic Review.

BACKGROUND: The Consolidated Standards of Reporting Trials (CONSORT) Statement recommends that studies report results beyond p values and include treatment effect(s) and measures of precision (e.g., confidence intervals [CIs]) to facilitate the interpretation of results. The objective of this systematic review was to assess the reporting and interpretation of patient-reported outcome measure (PROM) results in clinical studies from high-impact orthopaedic journals, to determine the proportion of studies that (1) only reported a p value; (2) reported a treatment effect, CI, or minimal clinically important difference (MCID); and (3) offered an interpretation of the results beyond interpreting a p value. METHODS: We included studies from 5 high-impact-factor orthopaedic journals published in 2017 and 2019 that compared at least 2 intervention groups using PROMs. RESULTS: A total of 228 studies were analyzed, including 126 randomized controlled trials, 35 prospective cohort studies, 61 retrospective cohort studies, 1 mixed cohort study, and 5 case-control studies. Seventy-six percent of studies (174) reported p values exclusively to express and interpret between-group differences, and only 22.4% (51) reported a treatment effect (mean difference, mean change, or odds ratio) with 95% CI. Of the 54 studies reporting a treatment effect, 31 interpreted the results using an important threshold (MCID, margin, or Cohen d), but only 3 interpreted the CIs. We found an absolute improvement of 35.5% (95% CI, 20.8% to 48.4%) in the reporting of the MCID between 2017 and 2019. CONCLUSIONS: The majority of interventional studies reporting PROMs do not report CIs around between-group differences in outcome and do not define a clinically meaningful difference. A p value cannot effectively communicate the readiness for implementation in a clinical setting and may be misleading. Thus, reporting requirements should be expanded to require authors to define and provide a rationale for between-group clinically important difference thresholds, and study findings should be communicated by comparing CIs with these thresholds.

The Impact of Resident Involvement on Surgical Outcomes following Anterior Cruciate Ligament Reconstruction.

Hands-on participation in the operating room (OR) is an integral component of surgical resident training. However, the implications of resident involvement in many orthopaedic procedures are not well defined. This study aims to assess the effect of resident involvement on short-term outcomes following anterior cruciate ligament reconstruction (ACLR). The National Surgical Quality Improvement Program (NSQIP) database was queried to identify all patients who underwent ACLR from 2005 to 2012. Demographic variables, resident participation, 30-day complications, and intraoperative time parameters were assessed for all cases. Resident and nonresident cases were matched using propensity scores. Outcomes were analyzed using univariate and multivariate regression analyses, as well as stratified by resident level of training. Univariate analysis of 1,222 resident and 1,188 nonresident cases demonstrated no difference in acute postoperative complication rates between groups. There was no significant difference in the incidence of overall complications based on resident level of training (p = 0.109). Operative time was significantly longer for cases in which a resident was involved (109.5 vs. 101.7 minutes; p < 0.001). Multivariate analysis identified no significant predictors of major postoperative complications, while patient history of chronic obstructive pulmonary disease was the only independent risk factor associated with minor complications. Resident involvement in ACLR was not associated with 30-day complications despite a slight increase in operative time. These findings provide reassurance that resident involvement in ACLR procedures is safe, although future investigations should focus on long-term postoperative outcomes.

Comparison of intra and post-operative complication rates among surgical approaches in Total Hip Arthroplasty: A systematic review and meta-analysis.

BACKGROUND: Various surgical approaches exist for Total Hip Arthroplasty (THA), but approach specific complication rates remain unknown. The purpose of this systematic review and meta-analysis was to compare rates of common complications between surgical approaches. METHODS: Four electronic databases (Medline, Embase, AMED, Ovid Healthstar) were searched from inception to June 2019. Three pairs of reviewers were involved in determining eligibility, rating internal and external validity, and data extraction. Pooled estimates were generated using a random-effects model and relative risk (RR) was calculated for dislocation, intraoperative and early postoperative fracture, early infection, deep vein thrombosis (DVT), wound complication, and failure of implant ingrowth between four approaches (posterior, anterior, direct lateral, and anterolateral). RESULTS: Sixty-nine studies (n = 283,036) were included with nineteen randomized control trials, fourteen prospective cohort, and thirty-six retrospective cohort studies (included studies ranged from 1987 to 2019). When compared to the posterior approach, the risk for dislocation was significantly lower in the anterior (RR 0.66, 95% CI 0.54-0.77, p < 0.01), anterolateral (RR 0.50, 95% CI 0.32-0.77, p = 0.03) and lateral (RR 0.74, 95% CI 0.58-0.96, p = 0.02). When compared to the posterior approach, we found higher risk of loosening in the anterolateral (RR 1.89, 95% CI 1.59-2.25, p < 0.01) and lateral (RR 1.21, 95% CI 1.02-1.44, p = 0.03). Overall, evidence was deemed very low and low-quality following GRADE assessment. CONCLUSION: Our findings reveal that the posterior approach was associated with a higher risk of dislocation (compared to the anterior, lateral, and anterolateral) but lower risk of loosening (compared to the lateral and anterolateral approach). However, the large number of cohorts and imprecision due to low sample size for most pooled comparisons was still insufficient to confidently conclude that one approach is superior to another. Each approach has its own strengths and weaknesses, and surgeons can use the approach they are most comfortable with.

Cannabis Use and Sport: A Systematic Review.

CONTEXT: Cannabis use has increased, in large part due to decriminalization. Despite this increase in usage, it remains unclear what proportion of athletes use cannabis and what effect it has on athletic performance and recovery. OBJECTIVE: To systematically review cannabis use among athletes, including epidemiology, effect on performance and recovery, and regulations for use in sport. DATA SOURCES: PubMed, MEDLINE, and EMBASE databases were queried from database inception through November 15, 2018. A hand search of policies, official documents, and media reports was performed for relevant information. STUDY SELECTION: All studies related to cannabis use in athletes, including impact on athletic performance or recovery, were included. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: Demographic and descriptive data of included studies relating to epidemiology of cannabis use in athletes were extracted and presented in weighted means or percentages where applicable. RESULTS: Overall, 37 studies were included, of which the majority were cross-sectional studies of elite and university athletes. Among 11 studies reporting use among athletes (n = 46,202), approximately 23.4% of respondents reported using cannabis in the past 12 months. Two studies found a negative impact on performance, while another 2 studies found no impact. There was no literature on the influence of cannabis on athletic recovery. Across athletic organizations and leagues, there is considerable variability in acceptable thresholds for urine tetrahydrocannabinol levels (>15 to 150 ng/mL) and penalties for athletes found to be above these accepted thresholds. CONCLUSION: Overall, these results suggest that approximately 1 in 4 athletes report using cannabis within the past year. Based on the available evidence, cannabis does not appear to positively affect performance, but the literature surrounding this is generally poor. Given the variability in regulation across different sport types and competition levels, as well as the growing number of states legalizing recreational cannabis use, there is a need to improve our understanding of the effects of cannabis use on the athlete and perhaps adopt a clearer and overarching policy for the use of cannabis by athletes in all sports and at all levels.

The Relationship Between the Critical Shoulder Angle and the Incidence of Chronic, Full-Thickness Rotator Cuff Tears and Outcomes After Rotator Cuff Repair: A Systematic Review.

PURPOSE: To summarize the available evidence and examine the relationship between the critical shoulder angle (CSA) and (1) the incidence of chronic full-thickness rotator cuff tears (RCTs) and (2) outcomes after rotator cuff repair (RCR). METHODS: A comprehensive search of MEDLINE, Embase, and CINAHL was completed. Comparative studies were included and the influence of the CSA on either the incidence of chronic, full-thickness RCTs, or outcomes following RCR was evaluated. Demographic variables and outcomes were collected. RESULTS: Seven comparative studies analyzed the influence of the CSA on the incidence of chronic, full-thickness RCTs (the control group constituted patients with a normal rotator cuff). High heterogeneity limited pooling of studies, but the majority concluded that a greater CSA significantly increased the likelihood of a chronic, full-thickness RCT. Conversely, 5 comparative studies analyzed the influence of CSA on outcomes following RCR, and although a greater CSA was associated with a greater re-tear rate, the majority reported that CSA did not significantly influence postoperative functional outcomes, including patient-reported outcome measures (PROMs), range of motion (ROM), and strength. CONCLUSIONS: Based on the available evidence, there appears to be a relationship between a greater CSA and the presence of a chronic, full-thickness RCT. Furthermore, a greater CSA may be associated with a greater re-tear rate following RCR; however, CSA does not appear to influence functional outcomes following RCR. Despite these observations, the available evidence is of poor quality, and the clinical utility and role of the CSA in the diagnosis and surgical management of a chronic, full-thickness RCT remains in question. LEVEL OF EVIDENCE: Level IV: Systematic review of Level II-IV studies.

Glenoid bone grafting in primary reverse total shoulder arthroplasty: a systematic review.

BACKGROUND: Reverse total shoulder arthroplasty (RSA) with glenoid bone grafting has become a common option for management of glenoid bone loss associated with glenohumeral osteoarthritis. The objectives of this review were to determine (1) the rate of graft union, (2) the revision and complication rates, and (3) functional outcomes following primary RSA with glenoid bone grafting. METHODS: A comprehensive search of the MEDLINE, Embase, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases was completed for studies reporting clinical outcomes following primary RSA with glenoid bone grafting. Pooled and frequency-weighted means were calculated where applicable. RESULTS: Overall, 11 studies and 393 patients were included in the study. The mean patient age was 73 ± 2.2 years, and the mean follow-up period was 34 ± 10 months. The overall graft union rate was 95%, but the rate was 97% among cases using autograft bone (8 studies, n = 254). When stratified by technique, concentric bone grafts had a 100% union rate (4 studies, n = 139). Conversely, eccentric grafts had an overall union rate of 92% (7 studies, n = 240), which improved to 94% when using autograft bone (4 studies, n = 115). At final follow-up, the revision rate was 2%, the complication rate was 18%, and there was consistent improvement in range of motion and functional outcome scores. CONCLUSION: Glenoid bone grafting during primary RSA results in excellent early-term clinical outcomes, low complication and revision rates, and high rates of graft union.

Perioperative Antibiotic Prophylaxis in Total Joint Arthroplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: The 2017 U.S. Centers for Disease Control and Prevention (CDC) guidelines for the prevention of surgical site infection (SSI) recommended against continuation of antibiotics postoperatively after total joint arthroplasty. This is disconcerting, as the revised guidelines are based on only 6 orthopaedic studies, of which 83% (5 of 6) were published from 1987 to 1991. The purpose of the current study was to conduct a systematic review and meta-analysis of the literature regarding the efficacy and duration of surgical antibiotic prophylaxis (SAP) in total joint arthroplasty. METHODS: PubMed, Ovid MEDLINE, and Ovid Embase were screened for "surgical antimicrobial prophylaxis orthopedic," in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, without a specified time frame with respect to publication date. A total of 693 studies were screened, and 32 studies were evaluated. Data were extracted regarding antibiotic type, number of doses, and duration. Prospective and retrospective studies examining perioperative antibiotics with subsequent SSI and periprosthetic joint infection (PJI) rates in total joint arthroplasty were included. RESULTS: Twenty-three randomized controlled trials (RCTs) and 2 prospective cohort, 3 retrospective cohort, and 4 case-control studies with a total of 51,627 patients were included in this review. The overall pooled effect for the comparison between a single preoperative dose of antibiotic and continued (preoperative plus postoperative) administration was 0.96 (95% confidence interval [CI], 0.73 to 1.26), suggesting no difference in effect. However, the 95% CI for the relative risk would include a reduction of approximately 27% in either group. The overall pooled effect from the comparison between SAP of ≤24 and >24 hours postoperatively demonstrated no difference in effect. All included studies were underpowered and heterogenous regarding type of antibiotic used and duration. CONCLUSIONS: Our review confirms the benefit of SAP utilization in total joint arthroplasty. The available evidence does not show added benefit of postoperative SAP or continuation beyond 24 hours. However, the overall GRADE (Grading of Recommendations Assessment, Development and Evaluation) of evidence of the available literature was low (high risk of bias, high risk of publication bias, and low precision). The findings of this study demonstrate the need for Level-I studies with adequate power to evaluate the safety of shortened SAP duration after total joint arthroplasty and its effect on SSI/PJI prior to widespread implementation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.