A Strategic Approach to Introducing New Technology Into Orthopaedic Practices.

Orthopaedic surgeons have a strong legacy for the early of adoption of new technologies that promise to advance patient care. Such technologies are being developed at an extraordinary pace, leveraging advances in orthobiologics and cartilage restoration, surgical navigation, robotic surgery, 3-D printing, and manufacturing of customized implants and sensors. The functionality provided by this revolution is impressive, promising substantial benefits for patients. However, the value of these technologies resides not in their "newness" but in the ability to improve outcomes for patients and reduce overall costs of care. Deciding whether a new technology brings value to an orthopaedic practice can be difficult, especially in an environment of rising health care costs, abundant choice, competition, consumer pressures, variable quality in supporting data, and a shifting regulatory landscape. In this article, we explore the drivers for orthopaedic companies, institutions, and care providers to develop, evaluate, and incorporate new technology. We outline the technology innovation cycle and the major demographic and psychosocial characteristics of adopter groups. We introduce factors considered in evaluating new technologies, such as patient safety, product efficacy, regulatory issues, and their value. Finally, we summarize the ethical concerns associated with new technology, alongside education and training, network security, financial remuneration and informed consent. This article aims to empower orthopaedic surgeons with a balanced and critical approach to ensure the adoption of new technologies in a safe, effective, and ethical manner.

Preoperative Treatment of Hepatitis C Is Associated With Lower Prosthetic Joint Infection Rates in US Veterans.

BACKGROUND: Hepatitis C virus (HCV) is associated with poorer outcomes in total joint arthroplasty (TJA). Recently, oral direct-acting antivirals (DAAs) have become available for HCV curative treatment. The goal of this study is to determine if HCV may be a modifiable risk factor in TJA by comparing postoperative complications among patients with and without preoperative treatment for HCV. METHODS: US Department of Veterans Affairs dataset of all consecutive primary TJAs performed between 2014 and 2018, when DAAs were available, was retrospectively reviewed. HCV-infected patients were identified using International Classification of Diseases, Ninth and Tenth Revision codes and laboratory values. HCV-infected patients treated prior to TJA with DAA were included in the "treated" group. HCV-infected patients untreated preoperatively were assigned to the "untreated" group. Medical and surgical complications up to 1 year postoperatively were identified using International Classification of Diseases, Ninth and Tenth Revision inpatient and outpatient codes. RESULTS: In total, 42,268 patients underwent TJA at Veterans Affairs Hospitals between 2014 and 2018. About 6.0% (n = 2557) of TJA patients had HCV, 17.3% of whom received HCV treatment preoperatively. When evaluating inpatient and outpatient codes, implant infection rates were statistically lower at 90 days and 1 year postoperatively among HCV-treated patients than among those untreated. Odds ratios (ORs) favor lower infection rates in HCV-treated patients (90-day OR: 3.30, P = .045; 1-year OR: 2.16, P = .07). CONCLUSION: Preoperative HCV treatment was associated with lower periprosthetic infection rates among US veterans undergoing TJA. Further investigation is necessary for definitive conclusions.

Total joint replacement: A multiple risk factor analysis of physical activity level 1-2 years postoperatively.

Background and purpose - The effect of total joint arthroplasty (TJA) on physical activity is not fully understood. We investigated the change in physical activity after TJA and patient factors associated with change. Patients and methods - Using a total joint replacement registry, primary total hip arthroplasty (THA) patients (n = 5,678) and knee arthroplasty (TKA) patients (n = 11,084) between January 1, 2010 and December 31, 2012 were identified. Median age at THA was 68 and median age at TKA was 67. Change in self-reported physical activity (minutes per week) from before TJA (within 1 year of surgery) to after TJA (1-2 years) was the outcome of interest. Patient demographics and comorbidities were evaluated as risk factors. Multiple linear regression was used. Results - Median physical activity before surgery was 50 min/week (IQR: 0-140) for THA patients and 58 (IQR: 3-143) for TKA patients. Median physical activity after surgery was 150 min/week (IQR: 60-280) for both THA patients and TKA patients. Following TJA, 50% of patients met CDC/WHO physical activity guideline criteria. Higher body mass index was associated with lower change in physical activity (THA: -7.1 min/week; TKA: -5.9 min/week). Females had lower change than males (THA: -11 min/week; TKA: -9.1 min/week). In TKA patients, renal failure was associated with lower change (-17 min/week), as were neurological disorders (-30 min/week). Interpretation - Self-reported minutes of physical activity increased from before to after TJA, but 50% of TJA patients did not meet recommended physical activity guideline criteria. Higher body mass index, female sex, and specific comorbidities were found to be associated with low change in physical activity. Patient education on the benefits of physical activity should concentrate on these subgroups of patients.

Bariatric surgery prior to total joint arthroplasty may not provide dramatic improvements in post-arthroplasty surgical outcomes.

This study compared the total joint arthroplasty (TJA) surgical outcomes of patients who had bariatric surgery prior to TJA to TJA patients who were candidates but did not have bariatric surgery. Patients were retrospectively grouped into: Group 1 (n = 69), those with bariatric surgery >2 years prior to TJA, Group 2 (n = 102), those with surgery within 2 years of TJA, and Group 3 (n = 11,032), those without bariatric surgery. In Group 1, 2.9% (95% CI 0.0-6.9%) had complications within 1 year compared to 5.9% (95% CI 1.3%-10.4%) in Group 2, and 4.1% (95% CI 3.8%-4.5%) in Group 3. Ninety-day readmission (7.2%, 95% CI 1.1%-13.4%) and revision density (3.4/100 years of observation) was highest in Group 1. Bariatric surgery prior to TJA may not provide dramatic improvements in post-operative TJA surgical outcomes.

Kaiser Permanente implant registries benefit patient safety, quality improvement, cost-effectiveness.

BACKGROUND: In response to the increased volume, risk, and cost of medical devices, in 2001 Kaiser Permanente (KP) developed implant registries to enhance patient safety and quality, and to evaluate cost-effectiveness. METHODS: Using an integrated electronic health record system, administrative databases, and other institutional databases, orthopedic, cardiology, and vascular implant registries were developed in 2001, 2006, and 2011, respectively. These registries monitor patients, implants, clinical practices, and surgical outcomes for KP's 9 million members. Critical to registry success is surgeon leadership and engagement; each geographical region has a surgeon champion who provides feedback on registry initiatives and disseminates registry findings. RESULTS: The registries enhance patient safety by providing a variety of clinical decision tools such as risk calculators, quality reports, risk-adjusted medical center reports, summaries of surgeon data, and infection control reports to registry stakeholders. The registries are used to immediately identify patients with recalled devices, evaluate new and established device technology, and identify outlier implants. The registries contribute to cost-effectiveness initiatives through collaboration with sourcing and contracting groups and confirming adherence to device formulary guidelines. Research studies based on registry data have directly influenced clinical best practices. CONCLUSIONS: Registries are important tools to evaluate longitudinal device performance and safety, study the clinical indications for and outcomes of device implantation, respond promptly to recalls and advisories, and contribute to the overall high quality of care of our patients.

Evaluation of the accuracy and use of x-ray markers in digital templating for total hip arthroplasty.

Despite benefits of digital templating, digital image acquisition techniques often make image magnification unknown and variable. We assessed the accuracy of digital x-ray scaling devices based on position. Radiographs of 106 total hip arthroplasty (THA) patients were studied to determine the accuracy of 2 digital x-ray markers at 1 of 4 positions by comparing true to expected x-ray magnification. The Pearson r coefficient was calculated as an indicator of measurement correlation between investigators. Greater accuracy was obtained for markers placed at the greater trochanter without skin overlap than for markers placed with soft tissue or bone overlap on x-ray. Flexible positioning markers provided greater accuracy than adhesive markers. Based on our data, we suggest positioning at the greater trochanter without skin overlap on x-ray and suggest flexible positioning over adhesive marker use.