Not All Patients Need Supervised Physical Therapy After Primary Total Knee Arthroplasty: A Systematic Review and Meta-Analysis.

Although postoperative physical therapy (PT) has long been considered essential to successful total knee arthroplasty (TKA) recovery, recent literature has suggested that unsupervised home exercise regimens may offer similar benefits to formal supervised sessions. We aimed to compare objectively measured physical function and subjective patient-reported outcomes (PROs) between primary TKA patients who received formal supervised physical therapy sessions and those who received unsupervised home exercise regimens after discharge. Six electronic databases were queried to identify randomized controlled trials comparing supervised physical therapy to unsupervised home exercise regimens in primary TKA patients after discharge. Outcomes of interest included change from baseline in objective measures (knee flexion range of motion (ROM), lower extremity strength, and aerobic capacity) and PROs (physical function and quality of life scores). These outcomes were subdivided into short-term (<6 months from surgery; closest data point to three months is used if multiple measurements were made in this time period) and long-term (≥6 months from surgery; closest data point to 12 months is used if multiple measurements were made in this time period) assessments. A total of 1,884 cases performed in 11 studies were included in this review. There were no significant differences between cohorts with regard to short-term knee flexion ROM (p = 0.7), lower extremity strength (p = 0.6), or patient-reported quality of life (p = 0.5), as well as long-term knee flexion ROM (p = 0.7), patient-reported quality of life (p = 0.2), or patient-reported physical outcome scores (p = 0.3). A small difference in short-term patient-reported physical outcomes was observed in favor of the supervised cohort (standardized mean difference (SMD): 0.3 (95% confidence interval (CI): 0.01, 0.6); I2 = 82%; p = 0.04). Formal supervised physical therapy regimens do not confer clinically significant benefits over unsupervised home exercise regimens following primary TKA. The routine use of supervised physical therapy after discharge may not be warranted. Further study is needed to determine the subset of patients that may benefit from supervised care.

Unsupervised Home Exercises Versus Formal Physical Therapy After Primary Total Hip Arthroplasty: A Systematic Review.

Historically, postoperative exercise and physical therapy (PT) have been viewed as crucial to a successful outcome following primary total hip arthroplasty (THA). This systematic review and meta-analysis aimed to assess differences in both short- and long-term objective and self-reported measures between primary THA patients with formal supervised physical therapy versus unsupervised home exercises after discharge. A search was conducted of six electronic databases from inception to December 14, 2020, for randomized controlled trials (RCTs) comparing changes from baseline in lower extremity strength (LES), aerobic capacity, and self-reported physical function and quality of life (QoL) between supervised and unsupervised physical therapy/exercise regimens following primary THA. Outcomes were separated into short-term (<6 months from surgery, closest to 3 months) and long-term (≥6 months from surgery, closest to 12 months) measures. Meta-analyses were performed when possible and reported in standardized mean differences (SMDs) with 95% confidence intervals (CI). Seven studies (N=398) were included for review. No significant differences were observed with regard to lower extremity strength (p=0.85), aerobic capacity (p=0.98), or short-term quality of life scores (p=0.18). Although patients in supervised physical therapy demonstrated improved short-term self-reported outcomes compared to those performing unsupervised exercises, this was represented by a small effect size (SMD 0.23 [95% CI, 0.02-0.44]; p=0.04). No differences were observed between groups regarding long-term lower extremity strength (p=0.24), physical outcome scores (p=0.37), or quality of life (p=0.14). The routine use of supervised physical therapy may not provide any clinically significant benefit over unsupervised exercises following primary THA. These results suggest that providers should reconsider the routine use of supervised physical therapy after discharge.

Laboratory-Reported Normal Value Ranges Should Not Be Used to Diagnose Periprosthetic Joint Infection.

INTRODUCTION: Clinical laboratories offer several multipurpose tests, such as the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), which are not intended to diagnose any specific disease but are used by clinicians in multiple fields. The results and laboratory interpretation (normal/abnormal) of these multipurpose tests are based on laboratory-reported normal thresholds, which vary across clinical laboratories. In 2018, the International Consensus Meeting on Musculoskeletal Infection (2018 ICM) provided a gold-standard definition to diagnose periprosthetic joint infection (PJI) which included many multipurpose laboratory tests, along with thresholds optimized to diagnose PJI. The discrepancy between laboratory-reported normal thresholds and 2018 ICM-recommended PJI-optimized test thresholds has never been studied. The purpose of this study was to assess the existing variation in laboratory-reported normal thresholds for tests commonly used to diagnose PJI and evaluate the potential diagnostic impact of using laboratory-reported normal thresholds instead of 2018 ICM-recommended PJI-optimized thresholds. METHODS: Clinical laboratories (N=85) were surveyed to determine the laboratory-reported units of measure and normal thresholds for common multipurpose tests to diagnose PJI, including the ESR, CRP, D-dimer, synovial fluid white blood cells (SF-WBC), and polymorphonuclear cell percent (SF-PMN%). The variability of units of measure and normal thresholds for each test was then assessed among the 85 included clinical laboratories. A representative dataset from patients awaiting a revision arthroplasty was used to determine the clinical significance of the existing discrepancy between laboratory-reported normal test interpretations and 2018 ICM-recommended PJI-optimized test interpretations. RESULTS: Two units of measure for the CRP and six units of measure for the D-dimer were observed, with only 59% of laboratories reporting the CRP in terms of mg/L and only 16% reporting the D-dimer in ng/ml, as needed to utilize the 2018 ICM definition of PJI. Across clinical laboratories surveyed, the mean laboratory-reported normal thresholds for the ESR (20 mm/h), CRP (7.69 mg/L), D-dimer (500 ng/mL), SF-WBC (5 cells/uL), and SF-PMN% (25%) were substantially lower than the 2018 ICM-recommended PJI-optimized thresholds of 30 mm/h, 10 mg/L, 860 ng/mL, 3,000 cells/uL, and 70%, respectively. Interpretation of test results from a representative PJI dataset using each laboratory's normal test thresholds yielded mean false-positive rates of 14% (ESR), 18% (CRP), 42% (D-dimer), 93% (SF-WBC), and 36% (SF-PMN%) versus the ICM-recommended PJI-optimized thresholds. CONCLUSION: When reporting the results for multipurpose laboratory tests, such as the ESR, CRP, D-dimer, SF-WBC, and SF-PMN%, clinical laboratories utilize laboratory-reported units of measure and normal thresholds that are not intended to diagnose PJI, and therefore may not match the 2018 ICM recommendations. Our findings reveal that laboratory-reported normal thresholds for these multipurpose tests are well below the 2018 ICM recommendations to diagnose PJI. Clinical reliance on laboratory-reported results and interpretations, instead of strict use of the 2018 ICM-recommended units and PJI-optimized thresholds, may lead to false-positive interpretation of multipurpose laboratory tests.

Does Body Mass Index Influence the Outcomes and Survivorship of Modern Cementless Total Knee Arthroplasty?

BACKGROUND: Higher body mass index (BMI) has been associated with higher rates of aseptic loosening following cemented total knee arthroplasty (TKA). However, there is a paucity of evidence on the effect of BMI on the durability of modern cementless TKA. We aimed to assess the association between BMI and clinical outcomes following cementless TKA and to determine if there was a BMI threshold beyond which the risk of revision significantly increased. METHODS: We identified 1,408 cementless TKAs of a modern design from an institutional registry. Patients were classified into BMI categories: normal (n = 136), overweight (n = 476), obese class I (n = 423), II (n = 258), and III (n = 115). The Knee Injury and Osteoarthritis Outcome Score for Joint Replacement and 12-item Short Form Health Survey scores were collected preoperatively and 2 years postoperatively. Survivorship was recorded at minimum 2 years (range, 24 to 88 months). BMI was analyzed as a continuous and categorical variable. RESULTS: The improvement in patient-reported outcomes was similar across the groups. Thirty four knees (2.4%) were revised and 14 (1.0%) were for aseptic failure. Mean time-to-revision was 1.2 ± 1.3 years and did not differ across BMI categories (P = .455). Survivorship free from all-cause and aseptic revision was 97.1% and 99.0% at mean 4 years, respectively. Using Cox regression to control for demographics and bilateral procedures, BMI had no association with all-cause revision (P = .612) or aseptic revision (P = .186). Receiver operating characteristic curve analysis found no relationship between BMI and revision risk (c-statistic = 0.51). CONCLUSION: BMI did not influence functional outcomes and survivorship of modern cementless TKA, possibly due to improved biological fixation at the bone-implant interface. Longer follow-up is necessary to confirm these findings.

Access to Total Knee Arthroplasty Among Patients With Low Incomes Has Not Increased Under Global Budget Revenue.

In 2014, Maryland implemented an experimental reimbursement model, Global Budget Revenue (GBR). This model provided hospitals with a capitated annual budget each fiscal year to use toward all services, regardless of payer. Goals of GBR include reductions in cost, improvements in care quality, and increased access for patients to high-volume procedures, such as total knee arthroplasty (TKA). We assessed demographics and outcomes among patients with low incomes and patients of racial minority groups in Maryland who underwent TKA before and after GBR implementation. Patients undergoing TKAs from 2011 to 2016 were queried from the Maryland State Inpatient Database, resulting in 71,066 patients. There were 13,722 patients with low incomes and 19,846 patients of racial minority groups. The chi-square test was used for sex, income, insurance, Charlson Comorbidity Index, and morbid obesity, with the Student's t test being reserved for age before and after GBR. The proportion of patients with low incomes decreased the year before GBR but increased with GBR and maintained (P<.001). The proportion of patients of racial minority groups increased the year before GBR implementation, decreased slightly, and then maintained (P<.001). Mean cost decreased for both cohorts of patients (both P<.001). Discharges to home increased for both cohorts (P<.001), while length of stay decreased (both P<.001). Global Budget Revenue decreased cost while improving outcomes for TKA patients post-GBR. Patients with low incomes have not increased their use of TKA, contrary to patients of racial minority groups. This suggests that barriers remain. Further follow-up of GBR performance in subsequent years will increase understanding of the sustainability of this trend and the degree to which any increase in access is dependent on the implementation of the Affordable Care Act. [Orthopedics. 2022;45(1):e11-e16.].

Humeral Shaft Fractures: Surgical versus Nonsurgical Management in Workers' Compensation.

BACKGROUND: The optimal surgical indications for humeral shaft fractures in the working population remain uncertain. This study investigates the impact of surgical fixation on return to duty, union, and complications in workers' compensation patients with humeral shaft fractures. METHODS: All workers' compensation patients with humeral shaft fractures managed at a single institution between 2007 and 2017 were identified. Manual chart and radiographic review was performed to identify etiology of injury, type of work, time until return to duty, length of physical therapy, complications, and time to fracture union. RESULTS: There were 39 humeral shaft fractures in workers' compensation patients managed at our institution (25 surgical; 64.1%). There was no difference in the return to light (106.1 versus 60.4 days; P=0.20) or full (140.1 vs. 139.9 days; P=0.99) duty for surgical versus nonsurgical treatment, respectively. There was no difference in the length of physical therapy (132.6 versus 106.3 days; P=0.15) or time to maximum medical improvement (174.3 vs. 198.8 days; P=0.25) for surgical versus nonsurgical treatment, respectively. Three patients returned to the operating room in the surgical group. Nonunion was observed in two surgical cases (8.0%) and one case (7.1%) of nonsurgical management. CONCLUSION: This study did not identify an advantage for faster return to work after surgical management of humeral shaft fractures in workers' compensation patients. Though one of the perceived advantages of surgical fixation is a quicker return to physical activity, there may be other variables in this patient population that influence the timing of return to work.

Trends in Leadership at Orthopedic Surgery Adult Reconstruction Fellowships.

BACKGROUND: Fellowship directors (FDs) in adult reconstruction have a profound impact on current and future trainees within orthopedics. Our group sought to evaluate the shared characteristics among current adult reconstruction FDs to provide a framework for those aspiring to achieve this position and identify possible areas of improvement. METHODS: Fellowship programs were identified using the American Association of Hip and Knee Surgeons Directory. Data for each FD were gathered via electronic mail, telephone, curriculum vitae, and online searches. Demographic information collected included age, gender, ethnicity, residency/fellowship training, residency/fellowship graduation year, year hired by current institution, time since training completion until FD appointment, length in FD role, and Scopus H-index. RESULTS: Information was gathered for 94 FDs. Of these, 100% were males; 80.6% were Caucasian, 12.90% were Asian American, 5.38% were Hispanic, and 1.08% were African American. The average age (52.6 years old), H-index (16.54), year of residency (2000) and fellowship (2001) graduation, and time since training until FD appointment (9.55 years) were analyzed. The top training programs to produce future FDs were Mayo Clinic (residency) and Harvard University (fellowship). CONCLUSION: Adult reconstruction FDs are frequently distinguished by their level of research productivity and experience, but certainly more demographic diversity is needed within this cohort. Specific training programs may inherently have a vital role in the development of individuals for future leadership positions. These developments could be a result of unique features inherent to the training programs or because of a subset of applicants who pursue specific programs with aspirations of subsequent leadership opportunities.

Reverse Shoulder Arthroplasty is Superior to Hemiarthroplasty for Cuff Tear Arthropathy with Preserved Motion.

BACKGROUND: It is unclear whether hemiarthroplasty (HA) or reverse shoulder arthroplasty (RS) are superior for patients with cuff tear arthropathy (CTA) and preserved preoperative motion (elevation >90˚). METHODS: This was a retrospective, single institution study. Patients who underwent RSA or HA for CTA were included if they had preserved preoperative motion with a minimum of 2 years of follow-up, or until complication/revision. Shoulder ROM and functional outcomes scores were obtained. RESULTS: Twenty-six HAs and 21 RSAs were evaluated at mean of 38.6 months (HA) and 36.3 months (RSA). Patients in the RSA group were significantly older at surgery (73.9 versus 65.1 years; P=0.003). Postoperatively, the mean change in active elevation was -15° for HA versus 26° for RSA, with RSA having significantly greater active elevation (153° versus 123°; P=0.01). There were no significant differences in final internal or external rotation between groups. Superior outcomes were seen for RSA versus HA for ASES score (84 vs. 66, P=0.003), Simple Shoulder Test (8.8 vs. 7.3, P=0.3), Single Assessment Numeric Evaluation (85 vs. 70, P=0.017), and 100mm VAS pain (7 vs. 33, P<0.001). CONCLUSION: In patients with CTA and preserved preoperative forward elevation, RSA provided greater pain relief, superior functional outcomes, and better ROM compared with HA.

Prognostic indicators for early mortality after tracheostomy in the intensive care unit.

BACKGROUND: Tracheostomy is indicated for patients requiring prolonged mechanical ventilation. The aim of this study is to identify prognostic indicators for early mortality after tracheostomy to potentially avoid futility in the intensive care unit. METHODS: Patients who underwent tracheostomy and died within 30 d of admission (futile group) were compared with patients who underwent tracheostomy and survived more than 30 d after admission (nonfutile group). Categorical data were analyzed using chi-square and Fisher's exact tests. Continuous variables were analyzed using T-tests and Mann-Whitney U tests. Prognostic factors were evaluated with univariable and multivariable logistic regression analyses. RESULTS: Overall, 88.3% of patients underwent nonfutile tracheostomy, while 11.7% underwent futile tracheostomy. Serum albumin level (1.5 g/dL versus 1.9 g/dL, P = 0.040) and mechanical ventilation duration before procedure (10 versus 12 d, P = 0.029) were significantly less in the futile group. Hypoalbuminemia (<2 g/dL) and preoperative mechanical ventilation ≤10 d were also predictive of futile tracheostomy in multivariable analysis. CONCLUSIONS: Hypoalbuminemia may serve as a prognostic indicator and risk factor for early mortality after tracheostomy. In patients with hypoalbuminemia, treatment of underlying disease processes and trending serum albumin level recovery in response to treatment may provide some insight to clinicians with regard to timing of tracheostomy. Better prognostic tools are still needed for critically ill patients to avoid futility in the intensive care unit. In this cohort, 88.3% of patients undergoing tracheostomy survived past 30 d.