Impact of a Remote Patient Monitoring Platform on Outcomes Following a Total Hip or Knee Arthroplasty.

Background: The coronavirus pandemic highlighted the need for remote patient monitoring to deliver and provide access to patient care and education. A mobile-based app providing interactive tools for patient education and monitoring was piloted at Thunder Bay Regional Health Sciences Centre (TBRHSC) in November 2020. We aimed to examine the platform's impact on postoperative length of stay, hospital readmissions, and emergency department (ED) visits 60 days postsurgery in total hip and knee arthroplasty patients in Northwestern Ontario. Methods: Data were assessed from patients undergoing primary total hip or knee arthroplasties at TBRHSC from March 1, 2020, to February 28, 2022. Patients were divided into 2 cohorts based on enrollment with the mobile-based app (SeamlessMD). Statistical differences in outcomes were determined using Mann-Whitney or χ2 tests. An odds ratio was calculated for ED visits. Results: Patients enrolled in the mobile-based app had statistically lower length of stay (U = 7779.0, P < .001) and fewer ED visits (χ2 (1,212) = 5.570, P = .018) than patients not enrolled in the program. Patients not enrolled had 2.31 times greater odds of visiting the ED postsurgery (odds ratio = 0.432, 95% confidence interval = 0.213-0.877, P = .022). There were no statistical differences found in readmission rates. Conclusions: The implementation of the mobile-based app at TBRHSC showed its potential value as a tool to reduce costs in the healthcare system and improve patient outcomes. Consequentially, more formal studies are required to elucidate the magnitude of this effect.

Comparison of a validated decision-support tool to a standard of care triage system for knee osteoarthritis assessment: a proof-of-concept study.

BACKGROUND: Patients with knee osteoarthritis (OA) in northwestern Ontario are referred by their primary care provider (PCP) to a centralized assessment clinic for evaluation by an advanced practice physiotherapist (APP) to determine if they will require surgical management. However, many patients are found to not require surgical management, resulting in delays for patients who do. A decision-support tool was developed to address this issue and to guide treatment options by determining the need for surgical or nonsurgical approaches. METHODS: We used a proof-of-concept method to assess the use of the decision-support tool in northwestern Ontario. Data from 100 consecutive patients assessed for knee OA management were collected from the Thunder Bay centralized assessment clinic. Two levels of agreement analyses (calculated using Cohen κ statistic) were performed, between the APP assessment decision (surgical or non-surgical) and the decision-support tool recommendation, and between the surgeon's decision (surgical or non-surgical) and the decision-support tool recommendation. RESULTS: We found a near-perfect agreement (κ = 0.870, n = 65) between the APP decision and the decision-support tool recommendation, when controlled for patient preference. There was a substantial level of agreement (κ = 0.618, n = 72) between the decision-support tool recommendation and the surgeon's decision. CONCLUSION: The decision-support tool recommendation showed considerable agreement with the decisions of the APP and surgeon indicating that it could be a valuable tool to guide PCPs caring for patients with knee OA. The applicability of a decision-support tool in northwestern Ontario displayed promising results, but further research is needed to examine the feasibility in a primary care setting.

Efficacy of surgical skin preparation solutions in hip arthroplasty: a prospective randomized trial.

BACKGROUND: The use of an effective antimicrobial preoperative skin preparation solution is essential in preventing infections after surgery, but the findings in the literature regarding efficacy are not necessarily applicable to surgery involving the hip. The purpose of the present study was twofold: 1) to examine the native bacteria on the skin at the hip and 2) to determine the efficacy of 2 surgical skin preparation solutions at eliminating bacteria from the hip site in patients undergoing total hip arthroplasty. METHODS: We conducted a prospective randomized controlled trial in consecutive adult patients who underwent primary total hip arthroplasty at a single institution from October 2014 to December 2015. Each patient was randomly allocated to be treated with 1 of 2 commonly used surgical skin preparation solutions: ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol) or DuraPrep (0.7% iodophor and 74% isopropyl alcohol). Aerobic and anaerobic samples were obtained for culture before skin preparation, immediately after skin preparation and after skin closure. RESULTS: Full data were obtained for 105 patients: 54 in the ChloraPrep group and 51 in the DuraPrep group. Staphylococcus epidermidis, Corynebacterium and Micrococcus luteus were the organisms most commonly isolated from the hip before skin preparation. Positive bacterial culture results were obtained in 50 patients (93%) in the ChloraPrep group and 48 patients (94%) in the DuraPrep group. Immediately after skin preparation, the overall proportion of positive culture results was significantly lower in the DuraPrep group than the ChloraPrep group (14% v. 35%, adjusted relative risk 0.40, 95% confidence interval 0.18-0.85). After wound closure, there was no significant difference in the rate of positive culture results between the 2 groups. CONCLUSION: DuraPrep was more effective than ChloraPrep at eliminating skin flora at the hip initially on application, but the 2 solutions were equally effective at the time of closure. Further study with larger samples is required to identify any influence of skin preparation solution on the incidence of prosthetic joint infection.

The results of early primary open reduction and internal fixation for treatment of OTA 43.C-type tibial pilon fractures: a cohort study.

OBJECTIVES: The optimal treatment for pilon fractures remains controversial. We have used early single-stage open reduction and internal fixation (ORIF) to treat these injuries and the purpose of this study was to determine the safety and efficacy of this strategy. DESIGN: Cohort study. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Ninety-five patients with Orthopaedic Trauma Association type 43.C pilon fractures. INTERVENTION: Primary ORIF. MAIN OUTCOME MEASUREMENT: Primary: Wound dehiscence or deep infection requiring surgery; secondary: quality of fracture reduction, functional outcomes (SF-36 and Foot and Ankle Outcome Score). RESULTS: Primary ORIF was performed within 24 hours in 70% of cases and within 48 hours in 88%. Reduction was judged to be anatomic in 90% cases. Six patients developed a deep wound infection or dehiscence that required surgical débridement, four after open fractures (four of 21 [19%]) and two after closed fractures (two of 74 [2.7%]). Complications were associated with local scarring, chronic alcohol abuse, schizophrenia, diabetes, and peripheral neuropathy. CONCLUSIONS: Provided surgery is performed expeditiously by experienced orthopaedic trauma surgeons, most tibial pilon fractures can be stabilized by primary ORIF within a safe and effective operative window with relatively low rates of wound complications, a high quality of reduction, and functional outcomes that compare favorably with the published results for all other reported surgical treatments of these severe injuries.

New concepts in revision total knee arthroplasty.

Revision knee arthroplasty should be regarded as a discipline separate from primary surgery. A disciplined approach to diagnosis is mandatory in which the following categories for failure are useful: (a) sepsis, (b) extensor mechanism rupture, (c) stiffness, (d) instability, (e) periprosthetic fracture, (f) aseptic loosening and osteolysis, (g) patellar complications and malrotation, (h) component breakage, and (i) no diagnosis. In the event of no coherent explanation for pain and disability, the possibilities of chronic regional pain syndrome, hip or spine pathology, and inability of current technology to meet patient expectations should be considered and revision surgery should be avoided. Revision arthroplasty cannot be performed as if it were a primary procedure and indeed will be eight (or more) different surgeries depending on the cause of failure. Though perhaps counterintuitive, there is a logical rationale and empirical evidence to support complete revision in virtually every case. In general, revision implant systems are required. The early dependence on the "joint line" is inadequate, failing as it does to recognize that the level of the articulation is a three-dimensional concept and not simply a "line." The key to revision surgery technique is that the flexion gap is determined by femoral component size and the extension gap by proximal distal component position. Accordingly, a general technical pathway of three steps can be recommended: 1) tibial platform; 2) stabilization of the knee in flexion with (a) femoral component rotation and (b) size selected with evaluation of (c) patellar height as an indication of "joint line" in flexion only; and 3) stabilization of the knee in extension, an automatic step. Stem extensions improve fixation and, if they engage the diaphysis, may be used as a guide for positioning. Porous metals designed as augments for bone defects may prove more important as "modular fixation interfaces." It is postulated that with the exception of septic and extensor mechanism complications, first revision knee arthroplasty may exceed the durability of primary knee arthroplasty.

Fracture of the femoral head.

Fracture of the femoral head is a severe, relatively uncommon injury; typically, it occurs following traumatic posterior dislocation of the hip joint. The Pipkin classification is the most commonly used classification system. Diagnosis is aided by a complete history, physical examination, and imaging, including computed tomography. Treatment consists of urgent closed reduction of the dislocated hip followed by nonsurgical or surgical management of any associated fractures. Controversies include the preferred surgical approach (anterior versus posterior) and whether to perform femoral head fragment excision or internal fixation. Complications associated with fracture of the femoral head and subsequent treatment include osteonecrosis, posttraumatic osteoarthritis, and heterotopic ossification. Fracture of the femoral head has been associated with a relatively poor functional outcome.

Outcomes following plate fixation of fractures of both bones of the forearm in adults.

BACKGROUND: Internal fixation of diaphyseal forearm fractures has been associated with high union rates and satisfactory forearm motion. The purpose of this study was to investigate patient-based functional outcomes and to objectively measure strength following plate fixation of fractures of both bones of the forearm. METHODS: Range of motion, quantitative strength measurements, and validated outcome measures-i.e., DASH (Disabilities of the Arm, Shoulder and Hand) and SF-36 (Short Form-36) scores-were assessed in a cohort of thirty patients (nineteen men and eleven women with a mean age of 43.9 years) treated with plate fixation for fractures of both bones of the forearm. The mean duration of follow-up was 5.4 years, and standardized radiographs of the forearm were evaluated. Univariate and multivariate analyses were performed to identify determinants of the DASH and SF-36 Physical and Mental Component Summary (PCS and MCS) scores. RESULTS: Compared with the uninjured arms, the injured arms had reduced strength of forearm pronation (70% of that of the normal arm, p < 0.0001), forearm supination (68%, p < 0.0001), wrist flexion (84%, p = 0.0011), wrist extension (63%, p < 0.0001), and grip (75%, p < 0.0001). In addition, the injured arms had a significantly reduced active range of forearm supination (90% of that of the uninjured arm, p = 0.0001), forearm pronation (91%, p = 0.0028), and wrist flexion (82%, p < 0.0001). The mean DASH score (18.6 points; range, 0 to 61 points) was significantly higher than the normative value in the United States (p = 0.02). Limitations in strength correlated with worse DASH and SF-36 PCS scores. Pain and a work-related injury were independent determinants of the DASH score. CONCLUSIONS: Stabilization with internal plate fixation following fracture of both bones of the forearm restores nearly normal anatomy and motion. However, a moderate reduction in the strength of the forearm, the wrist, and grip should be expected following this injury. Perceived disability as measured with the DASH and SF-36 questionnaires is determined by pain more than by objective physical impairment.

The use of postoperative bone scintigraphy to predict graft retention.

BACKGROUND: Osteonecrosis of the femoral head commonly occurs in patients aged under 50 years. Because of a high rate of complications associated with joint replacement surgery in this population, surgical techniques, such as vascularized fibular grafting, have been devised in an attempt to salvage the femoral head. The purpose of this study was to investigate the use of bone scintigraphy to predict graft retention after vascularized fibular grafting for osteonecrosis of the hip. METHODS: We evaluated single photon emission computed tomography images from 104 subjects whose hips were treated with vascularized fibular grafts between 1994 and 2000. We compared the signal intensity of the graft with the intensity of the ipsilateral proximal femoral diaphysis and assigned a score of 1 if less than diaphysis, 2 if equal to diaphysis and 3 if greater than diaphysis. We defined graft failure as conversion to or on the waiting list for total hip arthroplasty. RESULTS: Thirty percent of hips failed treatment (n = 31, mean graft survival 34.9 mo), while 70% of grafts were retained (n = 73, mean follow-up 56.6 mo). Bone scan scores were significantly lower in the failed group (mean 7.1, range 6-12), compared with the retained group (mean 8.5, range 6-18; p = 0.03). Logistic regression demonstrated that a bone scan score > 6 was associated with graft retention (p = 0.028), with an odds ratio of 3.08 (range 1.13-8.40). CONCLUSION: These results suggest that having a well-perfused graft in the early postoperative period improves the chances of graft retention in the future.

Wound complications after total knee arthroplasty.

Some wound complications can be prevented with attention to patient, surgical, and postoperative factors; others develop despite all efforts. Some practices that affect wound healing, such as the use of drains and methods of thromboprophylaxis are contentious. Superficial wound problems must always be discriminated from deep infection, which is not the focus of this article. Wound complications require prompt attention. As there is little morbidity from early irrigation and debridement of problem total knee arthroplasties (Weiss AP, Krackow KA. Persistent wound drainage after primary total knee arthroplasty. J Arthroplasty. 1993;8(3):285-9), early intervention is generally preferred.

Carotid-jugular arteriovenous fistula: case report of an iatrogenic complication following internal jugular vein catheterization.

Central venous catheterization is frequently performed for perioperative management and long-term intravenous access. Although the complications of central venous catheter insertion have been widely reported, there are few reports of carotid-jugular arteriovenous fistula formation. We describe a case of a carotid-jugular arteriovenous fistula following the insertion of a double-lumen catheter for hemodialysis access. We provide recommendations for the prevention and early detection of this iatrogenic complication.