Why Do Patients Choose Skilled Nursing Facilities After Total Hip and Knee Arthroplasty?

BACKGROUND: Current research indicates that total joint arthroplasty patients who are discharged to skilled nursing facilities (SNFs) have higher complication rates as compared to home. Many factors like age, sex, race, Medicare status, and past medical history have been shown to influence discharge destination. The present study sought to gather patient-indicated reasons for SNF discharge and identify potentially modifiable factors influencing the decision. METHODS: Primary total joint arthroplasty patients were asked to complete surveys at their presurgical and 2-week postsurgical follow-up appointments. The surveys included home access and social support questions as well as patient-reported outcome measures: Patient-Reported Outcomes Measurement and Information System, Risk Assessment and Prediction Tool, Knee injury and Osteoarthritis Outcome Score for Joint Replacement, or Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement. RESULTS: Of 765 patients who met inclusion criteria, 3.9% were discharged to an SNF and these were more frequently post-THA, women, older, Black, and persons living alone. Regression analyses indicated that lower Risk Assessment and Prediction Tool score, higher age, no caregiver presence, and Black race were significantly associated with SNF discharge. Patients discharged to an SNF most commonly reported social concerns rather than medical or home access concerns as the main factor for SNF discharge. CONCLUSIONS: While age and sex are nonmodifiable factors, the availability of a caregiver and social support represents an important modifiable factor in regard to discharge destination. Dedicated attention during the preoperative planning period may help augment social support and avoid unnecessary discharges to SNFs.

Safe transport of spica casted infants: Reducing the risk of traumatic injury in side impact collisions.

BACKGROUND: There is limited data on transporting small children in hip spica casts used to treat pediatric femur fractures. Specific challenges include the fixed position of the body in the casted position and the increased size of the child due to cast thickness. Additionally, children less than 2 years old are recommended to be rear facing during transportation. This traveling position requires seats that are specifically designed to accommodate the small size of the child as well as accommodate the rear facing position. While seats able to accommodate casted children are available, it is unclear if they provide adequate protection in side impact collisions for rear facing spica casted infants. Therefore, the aim of this study was to evaluate traumatic injury metrics in a side impact collision model where a spica casted infant crash dummy was restrained in currently available car seats. METHODS: Two seats designed for spica casted children (R82 Quokka, Merritt Wallenberg) and two traditional car seats (Britax Emblem, Graco Sequel) able to accommodate a casted one-year-old crash test dummy were identified. Side impact collision testing was performed with the dummy positioned in the rear facing position and injury metrics recorded. RESULTS: Testing identified contact between the dummy's head and the door panel for a specialty spica car seat without protective side-wings for the head. All other seats contained side wings and prevented door-head contact. CONCLUSIONS: Casted children should be transported in a seat able to accommodate the cast and safely restrain them. Our results demonstrate the importance of side wing protection in any seat used to transport these children as side bolsters may help decrease the potential for head contact with the door and lower the risk of severe head injury.

Analysis of restraint use in pregnant versus non-pregnant populations involved in motor vehicle collisions.

BACKGROUND: Traumatic injuries obtained by pregnant females in motor vehicle collisions present unique treatment challenges for trauma and orthopaedic surgeons. Understanding safety choices in this population can help physicians and public safety advocates in delivering effective and targeted safety messages. METHODS: A publicly available, de-identified national data set that documents crash information (NASS-CDS) was examined to identify cohorts of pregnant and non-pregnant vehicle occupants and regression analysis employed to identify factors associated with belt non-use. RESULTS: Pregnant women were found to have significantly lower rates of belt use compared to non-pregnant females (70.0% vs. 90.3%, Rao-Scott Sample Weighted Chi-Square p = 0.0265). Logistic regression identified younger age and sitting in the back seat as associated with lower rates of belt use. CONCLUSION: Pregnant women wear belts at significantly lower frequencies than non-pregnant women and youth and second row seating increase noncompliance rates. This work suggests the need for targeted intervention strategies to improve belt compliance.

Frontal Crash Injury Metrics Are Below Mandated Limits for a Spica Casted Child Dummy in Currently Available Restraints.

BACKGROUND: There is a paucity of data defining safe transport protocols for children treated with hip spica casting. Although restraint devices for casted children are available, all federally mandated testing uses a noncasted anthropomorphic test device (ATD or crash dummy). The purpose of this study was to evaluate current restraint options in simulated frontal crash testing using a casted pediatric ATD to determine injury risk to the head, cervical spine, chest, and pelvis. METHODS: Using a 3-year-old ATD, dynamic crash sled tests simulating frontal crash were performed in accordance with government safety standards. The ATD was casted in a double-leg spica and the following restraint devices were tested: a seat designed for spica casted children, a restraint vest-harness, a traditional booster seat, and 2 traditional forward-facing car seats. RESULTS: Although the presence of the cast increased many of the injury metrics measured, all seats passed current federal guidelines for the head and chest. No single seat performed best in all metrics. The greatest magnitude of neck loading and second-highest head injury criterion values were observed for the booster seat. The vest-harness produced the highest head injury criterion and the chest compression exceeded proposed federal limits. CONCLUSIONS: The results suggest safe transport in commercially available seats is possible with the child properly restrained in a correctly fitting seat. However, parents should not assume a child restraint system is appropriate for use just based on fit as, for example, seats with harnesses outperformed an easy to fit booster seat. CLINICAL RELEVANCE: Each child and the position of the child's cast are unique and discharge planning involves consideration of safe transportation. Although this study suggests several seats used to transport spica casted children pass the federal head and chest injury prevention requirements, it is important to recognize that some children may still require emergency vehicle transport.

Improvement in Depression and Physical Health Following Total Joint Arthroplasty.

BACKGROUND: Depression is a common co-morbid condition seen in arthroplasty patients. Pain and depression have been understood to influence one another, which may explain why this patient group experiences higher rates of depression than the general population. Arthroplasty can relieve pain and improve function, which may thereby initiate an improvement in the patient's depressive symptoms. METHODS: This retrospective study examined physical and mental domain outcomes of Short Form-36 health-related quality of life questionnaire among 146 patients who underwent primary hip or knee arthroplasty for osteoarthritis at a single institution during 2001-2004. These patients were classified into "depressed/anxious" and "non-depressed" groups based on their pre-operative mental component summary (MCS), with MCS < 42 defining depression. MCS and the subscales from the 36-Item Short-Form Health Survey form expected to be influenced by arthroplasty, Physical Function, Pain, and Role Physical were examined at 3 months and 1 year post-operative. RESULTS: At 1 year, 66.7% of the "depressed/anxious" group reported MCS > 42, suggesting improvement of their depressive symptoms. Both groups reported similar improvements in their 36-Item Short-Form Health Survey subscale scores for Pain and Physical Function. However, the depressed group's scores were lower than the non-depressed group's at all time points. CONCLUSION: Arthroplasty significantly improved Physical Function and Pain in depressed patients, while their depressive symptoms improved. This improvement may be in response to the resolution of physical symptoms and represents an additional benefit to this elective surgery. Further studies, in larger populations, are needed to establish patient characteristics associated with non-resolution of depressive symptoms and the role of mental health interventions to optimize outcomes for hip and knee arthroplasty patients.

Pull-out and shear failure strengths of arthroscopic meniscal repair systems.

Meniscal repair is common and recommended in young patients. Suture techniques and fixation devices were developed for stronger, more facile repairs. Three devices (T-Fix, Meniscal Staple, Meniscus Arrow) were biomechanically compared to horizontal PDS suture. Peripheral tears were created in porcine menisci and repaired using the manufacturer's technique. An Instron was used to distract the menisci at 50 mm/min in axial-pullout and longitudinal shear loads. Load to failure curves and peak failure loads were noted. Load to failure in axially loaded pull-out mode was: Staple, 4.195+/-3.70 N; Arrow, 39.755+/-11.37 N; T-Fix, 45.892+/-13.99 N; Suture, 107.65+/-22.37 N. Analysis of variance with post hoc testing revealed Staple failure at lower load than all devices and Suture failure at higher loads than all devices; Arrow and T-Fix were similar. The data varied significantly from that obtained in shear. Shear loads to failure were: Staple, 8.39+/-8.62 N; Arrow, 27.67+/-14.33 N; T-Fix, 57.47+/-17.05 N; Suture, 64.15+/-17.05 N. Analysis of variance, power analysis, and pair-wise multiple comparisons revealed significant differences between: Suture and Staple, Suture and Arrow, and T-Fix and Staple. No differences were noted between Suture and T-Fix, T-Fix and Arrow, or Arrow and Staple. In pullout, Suture and T-Fix maintained better apposition at low loads. As load increased, the menisci separated until device failure. Arrows allowed low load separation but held tissue until failure. Staples failed at low load. For shear, the menisci attempted to reorient parallel to the force. The devices failed in a pull-slide pattern. Suture failed by pull-through. Meniscal repair devices are easy to use and may provide resistance to shear and pull out. The resistance to pullout loads was very different than the resistance to longitudinal shear loads.