Current Practice Patterns of Fellowship-Trained Arthroplasty Surgeons: Has the Influence of Fellowship Training Been Undervalued?

BACKGROUND: As the clinical and financial environments of total joint arthroplasty (TJA) have evolved over the last several decades so has the role of the surgeon in providing this care to patients. Our objective was to examine current practices and influential factors among fellowship-trained arthroplasty surgeons. METHODS: An electronic survey was sent to all surgeons who had completed one of the three high-volume adult reconstruction fellowships from the years 2007-2016. The survey consisted of 34 questions regarding current practice characteristics, case volumes for primary and revision total hip arthroplasty (THA) and total knee arthroplasty (TKA), use of advanced technologies, choice of surgical approach and implant design, factors influencing their choices, and their involvement in implant selection and contract negotiations. RESULTS: Questionnaires were sent to 53 surgeons; 52 were completed. Sixty percent of respondents performed at least 100 TKAs and 84% performed at least 50 THAs annually. Ninety-four percent use a single company's implant for more than 90% of primary TKA and THA. Fellowship or residency experience was the most significant influence on TKA and THA implant selection for 62% and 45% of surgeons, respectively, while contracts of their current institution were the primary influence for 17% and 12%, respectively. Fifty-five percent of surgeons used some advanced technology of which 16% said this influenced their implant choice. Eighty-six percent perform the majority of cases at centers performing at least 200 TJAs per year, and 39% participate in implant contract negotiations. CONCLUSION: Despite changes in the economic environment of TJA, this study demonstrates that experience with a specific implant during training, particularly fellowship, is the most influential factor for implant selection among fellowship-trained arthroplasty surgeons.

Predictors of bone mineral density improvement in patients undergoing parathyroidectomy for primary hyperparathyroidism.

INTRODUCTION: Primary hyperparathyroidism (PHPT) results in increased bone turnover, resulting in bone mineral density (BMD) reduction and a predisposition towards fractures. Parathyroidectomy (PTX) is the only definitive cure. OBJECTIVE: The primary goals of this study were to investigate the impact of PTX on BMD in patients with PHPT and to identify factors associated with post-operative BMD improvement using a multivariate model. METHODS: Between 1999 and 2010, a total of 757 patients underwent PTX for treatment of PHPT; 123 patients had both a pre- and a post-operative dual-energy X-ray absorptiometry (DEXA) scan. A prospective database was queried to obtain information about patient demographics, medications, comorbidities, and pre- and post-operative laboratory values. A Cox regression model was used to stratify patients and to identify factors that independently predict BMD response following PTX in this patient population. RESULTS: Overall, mean percent change in BMD was +12.31 % at the spine, +8.9 % at the femoral neck (FN), and +8.5 % at the hip, with a mean follow-up of 2.3 ± 1.5 years. A total of 101 (82.1 %) patients had BMD improvement at their worst pre-operative site. In patients who improved, 69.9 % (n = 86) had >5 % increase. Factors associated with BMD improvement at the worst pre-operative site were as follows: male gender (hazard ratio [HR] 2.29; 95 % confidence interval [CI] 1.54-4.21); pre-operative BMD with T-score less than -2.0 (HR 1.89; 95 % CI 1.11-2.39); age <55 years (HR 1.74; 95 % CI 1.14-2.25); BMD DEXA scan at >2.5 years post-operatively (HR 1.71; 95 % CI 1.09-2.17); history of previous fracture (HR 1.24; 95 % CI 1.05-1.92); and private insurance (HR 1.18; 95 % CI 1.06-2.1). The use of bisphosphonates, estrogens, vitamin D supplementation, or tobacco; obesity; history of previous PTX, serum calcium or parathyroid hormone levels were not independently associated with post-operative BMD improvement. CONCLUSION: Osteoporosis is one of the established National Institutes of Health criteria for PTX in asymptomatic patients with PHPT, but BMD improvement is not consistently seen during the post-operative period. Gender, age, more severe pre-operative bone disease, and insurance status were all predictors for greater BMD improvement following PTX. Further studies with a rigorous post-operative BMD regimen are needed in order to validate these results.

Implant Failure Rates and Cost Analysis of Contoured Locking Versus Conventional Plate Fixation of Distal Fibula Fractures.

The authors analyzed 330 consecutive Weber B distal fibula fractures that occurred during a 3-year period and were treated with either a contoured locking plate or a conventional one-third tubular plate to compare the cost and failure rates of the 2 constructs. The primary outcomes were failure of the distal fibular implant and loss of reduction. Secondary outcomes were surgical wound infection requiring surgical debridement and/or removal of the fibular implant, and removal of the fibular plate for persistent implant-related symptoms. No failure of the fibular plates or distal fibular fixation occurred in either group. A total of 5 patients required surgical revision of syndesmotic fixation within 4 weeks of the index surgery. Of these patients, 1 was in the contoured locking plate group and 4 were in the one-third tubular plate group (P=.610). The rate of deep infection requiring surgical debridement and/or implant removal was 6.2% in the contoured locking plate group and 1.4% in the one-third tubular plate group (P=.017). The rate of lateral implant removal for either infection or symptomatic implant was 9.3% in the contoured locking plate group and 2.3% in the one-third tubular plate group (P=.005). A typical contoured locking plate construct costs $800 more than a comparable one-third tubular plate construct. Based on a calculated estimate of 60,000 locking plates used annually in the United States, this difference translates to a potential avoided annual cost of $50 million nationally. This study demonstrates that it is possible to treat Weber B distal fibula fractures with one-third tubular plates at a substantially lower cost than that of contoured locking plates without increasing complications. [Orthopedics. 2017; 40(6):e1024-e1029.].

Case Series Using a Novel Implant and Accelerated Rehabilitation for Patients Undergoing an Isolated Talonavicular Arthrodesis.

UNLABELLED: Talonavicular (TN) arthrodeses for TN arthritis have a high rate of nonunions for an essential hindfoot joint. In this case series, 12 patients underwent an isolated TN arthrodesis using a novel implant (IO FiX) by a single surgeon with a minimum 1-year follow-up (30.1 ± 14.7 months; mean ± SD). All patients (62 ± 12 years) underwent an aggressive rehabilitation protocol given the strength and compression of the implant. There were no nonunions, nor were there any patients lost to follow-up. Time to radiographic union was 9.6 ± 1.4 weeks. The Visual Analog Scale pain level decreased from 7.3 ± 0.9 preoperatively to 2.1 ± 0.7 postoperatively (P < .001). The Short-Form-12 physical component improved from 27.9 ± 4.2 preoperatively to 42.2 ± 3.5 postoperatively (P < 0.001), while the Short-Form-12 mental component did not change from 50.8 ± 6.9 preoperatively to 54.4 ± 3.8 postoperatively (P > .05). Use of the novel fixation device for TN arthrodesis by a single surgeon with an accelerated rehabilitation protocol significantly decreased patients' pain and improved their physical functional outcomes (P < .001). The IO FiX implant can potentially improve TN arthrodesis fusion rates and surgical outcomes. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case series.

Delayed Open Reduction Internal Fixation of Missed, Low-Energy Lisfranc Injuries.

BACKGROUND: The aim of this study was to determine the outcome of delayed presentation (at least 6 weeks from the time of injury) of low-energy Lisfranc injuries limited to the first and second tarsometatarsal joints treated with open reduction internal fixation. METHODS: 8 patients with an average age at surgery of 39.8 years were retrospectively reviewed with a mean time to surgery from injury of 15.1 (range of 6.3 to 31.1) weeks. We used radiographic measurements, physical examination, SF-12 scores, Foot and Ankle Ability Measure (FAAM) scores, VAS scores and return to work or sports as outcome measures. Patients were treated with an open reduction and internal fixation as opposed to a formal arthrodesis with a variety of internal fixation. All 8 patients were available for follow-up and outcome reporting at an average of 3.1 years (minimum 2.0) postoperatively. RESULTS: The mean VAS improved from 8.5 to 2.8 postoperatively. The mean postoperative physical and mental SF-12 scores were 46.8 and 57.1, respectively. The mean postoperative overall and sports FAAM scores were 75.4 and 65.9, respectively. There were no radiographic signs of a late diastasis at the Lisfranc joint. All patients including 2 workers compensation cases returned to work and all were able to return to their prior sporting activity. CONCLUSION: A delayed open reduction internal fixation of patients with missed, low-energy Lisfranc injury was performed and resulted in decreased pain. In this series, a fair to good functional outcome was observed, and the ability to return to work or previous sport was possible for all patients studied. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Dorsal plating of low-energy Lisfranc injuries: a case report.

Surgically repairing acute Lisfranc injuries remains a difficult task, and the injury remains a challenging one for the treating surgeon. Although there are many proponents of acute arthrodesis for Lisfranc injuries, there remain a proportion of patients with low-energy trauma who may be best treated with open reduction internal fixation and joint salvaging procedures. Here, the authors present a case report and technique to anatomically fix Lisfranc injuries while preventing any concomitant articular damage in the process. They have found this to be a reliable and safe procedure in this demanding patient population. LEVELS: Level IV-Case Report.