Publications by authors named "Nicholas R Pagani"

30 Publications

  • Page 1 of 1

Current Status Regarding the Safety of Inpatient Versus Outpatient Total Shoulder Arthroplasty: A Systematic Review.

HSS J 2022 Aug 5;18(3):428-438. Epub 2021 Jul 5.

Department of Orthopaedic Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA.

Background: Surgeons have begun to transition total shoulder arthroplasty (TSA) to the outpatient setting in order to contain costs and reallocate resources.

Purpose: The purpose of this systematic review was to evaluate the safety and cost of outpatient TSA by assessing associated complication rates, clinical outcomes, and total treatment charges.

Methods: The MEDLINE, Embase, and Cochrane Library online databases were queried in March 2020 for studies on outpatient shoulder arthroplasty. Inclusion criteria were (1) a study population undergoing TSA, (2) discharge on the day of surgery, and (3) inclusion of at least 1 reported outcome.

Results: Of 20 studies identified that met inclusion criteria, 14 were comparative studies involving an inpatient control group, 2 of which were matched by age and comorbidities. The remaining studies used control groups consisting of inpatient TSAs who were older or more medically infirm according to American Society of Anesthesiologists (ASA) or Charlson Comorbidity Index (CCI) scores. The combined average age of the outpatient and inpatient groups was 66.5 and 70.1 years, respectively. Patients who underwent outpatient TSA had similar rates of readmissions, emergency department visits, and perioperative complications in comparison to inpatients. Patients also reported comparably high levels of satisfaction with outpatient procedures. Four economic analyses demonstrated substantial cost savings with outpatient TSA in comparison to inpatient surgery.

Conclusion: In carefully selected patients, outpatient TSA appears to be equally safe but less resource intensive than inpatient arthroplasty. Nonetheless, there remains a need for larger prospective studies to decisively characterize the relative safety of outpatient TSA among patients with similar baseline health.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/15563316211019398DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9247601PMC
August 2022

Online Crowdsourcing Survey of United States Population Preferences and Perceptions Regarding Outpatient Hip and Knee Arthroplasty.

J Arthroplasty 2022 Jun 20. Epub 2022 Jun 20.

Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.

Background: Outpatient total joint arthroplasty (TJA) has been shown to be both safe and cost-effective in appropriately selected patients and continues to expand substantially across the United States. Using online crowdsourcing, we aimed to assess population perceptions regarding outpatient TJA and to determine factors associated with preference for outpatient versus inpatient arthroplasty.

Methods: A closed-ended survey consisting of 39 questions was administered to members of a public platform. Study participants responded to questions regarding demographic factors and outpatient TJA. Validated assessments to capture health literacy and engagement were also used. To determine factors associated with preference for outpatient TJA, multivariable logistic regression analyses were performed.

Results: In total, 900 participants completed the survey. After exclusion of surveys with incomplete data, 725 responses remained for analysis (80.6%). Over half (59.9%) of the survey participants would feel comfortable going home the same day of surgery following TJA. However, two-thirds (64.6%) would prefer to stay in the hospital following TJA. The majority (68.0%) of respondents perceive a hospital setting as the safest location for TJA. The 3 major concerns regarding outpatient TJA were cost, post-operative pain control, and post-operative complication. Among the 111 respondents (15.3%) who would prefer outpatient TJA, 45% would pay more out-of-pocket, 63.1% travel further, and 55.9% would be willing to wait longer to have their surgery performed as an outpatient. On multivariable regressions, those living in a suburban setting (adjusted odds ratios, 95% confidence intervals: 4.2 [1.3-2.7], P = .02) and >60 year old adjusted odds ratios (95% confidence intervals: 8 [2-33.1], P = .004) were more likely to prefer outpatient TJA.

Conclusion: Despite the rise in outpatient TJA, the majority of the public appears to prefer inpatient TJA and the minority would expect to be discharged home the same day. Our data can be used to address specific patient concerns regarding outpatient TJA and set realistic expectations for hospital systems and ambulatory facilities.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2022.06.011DOI Listing
June 2022

Neighborhood socioeconomic disadvantage does not predict outcomes or cost after elective shoulder arthroplasty.

J Shoulder Elbow Surg 2022 Jun 6. Epub 2022 Jun 6.

Midwest Orthopaedics at Rush, Rush University, Chicago, IL, USA; Oregon Shoulder Institute at Southern Oregon Orthopedics, Medford, OR, USA.

Background: There is growing evidence that the variation in value of shoulder arthroplasty may be mediated by factors external to surgery. We sought to determine if neighborhood-level socioeconomic deprivation is associated with postoperative outcomes and cost among patients undergoing elective shoulder arthroplasty.

Methods: We identified 380 patients undergoing elective total shoulder arthroplasty (anatomic or reverse) between 2015 and 2018 in our institutional registry with minimum 2-year follow-up. Each patient's home address was mapped to the area deprivation index in order to determine the level of socioeconomic disadvantage. The area deprivation index is a validated composite measure of 17 census variables encompassing income, education, employment, and housing conditions. Patients were categorized into 3 groups based on socioeconomic disadvantage (least disadvantaged [deciles 1-3], middle group [4-6], and most disadvantaged [7-10]). Bivariate analysis was performed to determine associations between the level of socioeconomic deprivation with hospitalization time-driven activity-based costs and 2-year postoperative American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE), and pain intensity scores.

Results: Overall 19% of patients were categorized as most disadvantaged. These patients were found to have equivalent preoperative pain intensity (P = .51), SANE (P = .50), and ASES (P = .72) scores compared to the middle and least disadvantaged groups, as well as similar outcome improvement at 2 years postoperatively (ASES): least disadvantaged group [35.7-84.3], middle group [35.1-82.4], and most disadvantaged group [37.1-84.0] [P = .56]; SANE: least disadvantaged group [31.8-87.1], middle group [30.8-84.8], and most disadvantaged group [34.2-85.1] [P = .42]; and pain: least disadvantaged group [6.0-0.97], middle group [6-0.97], and most disadvantaged group [5.6-0.80] [P = .88]. No differences in hospitalization costs were noted between groups (P = .77).

Conclusions: Patients undergoing elective shoulder arthroplasty residing in the most disadvantaged neighborhoods demonstrate equivalent preoperative and postoperative outcomes as others, without incurring higher costs. These findings support continued efforts to provide equitable access to orthopedic care across the socioeconomic spectrum.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jse.2022.04.023DOI Listing
June 2022

Fracture Dislocations of the Proximal Humerus Treated with Open Reduction and Internal Fixation: A Systematic Review.

J Shoulder Elbow Surg 2022 May 20. Epub 2022 May 20.

Department of Orthopedic Surgery, Tufts Medical Center, Boston, MA, USA. Electronic address:

Background: The treatment of proximal humerus fracture-dislocations can be challenging given the extensive injury to the proximal humeral anatomy and increased risk of devascularization of the humeral head often seen in these injuries. The purpose of this study is to undertake a systematic review of the literature on the functional outcomes, rate of revision, and short- and long-term complications for proximal humerus fracture-dislocations treated with open reduction and internal fixation (ORIF).

Methods: The PubMed and OVID Embase databases were queried for literature reporting on proximal humerus fracture dislocations treated with ORIF. Data including study design, patient demographics, functional outcomes, and complications were recorded.

Results: Twelve studies including 294 patients with Neer type 2-, 3-, or 4-part proximal humerus fracture-dislocations met the criteria for inclusion. The mean patient age was 53.4 years (19-89 years) with an average follow-up of 2.9 years (1.15-4.9 years). At final follow-up, the mean Constant Score was 73.2 (52 - 87.3) and the mean Disabilities of the Arm Shoulder and Hand (DASH) score was 26.6 (17.5- 32). Avascular necrosis (AVN) was observed in 20.0% (0%-82.3%) and non-union was observed in 3.0% (0% - 7.7%) of patients. Conversion to arthroplasty was observed in 10.7% (5% - 20%) and a total reoperation was observed in 35.6% (11.8%-89.1%) of patients in studies explicitly reporting these outcomes. In addition to conversion to arthroplasty, common causes of reoperation were revision ORIF (5.2%) and hardware removal (22.2%).

Conclusion: Patients undergoing ORIF for proximal humerus fracture-dislocations have reasonable functional outcomes but relatively high AVN and reoperation rates. This information can be used to counsel patients and set expectations about the potential for further surgeries.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jse.2022.04.018DOI Listing
May 2022

The Cost-Effectiveness of Extended Oral Antibiotic Prophylaxis for Infection Prevention After Total Joint Arthroplasty in High-Risk Patients.

J Arthroplasty 2022 Apr 25. Epub 2022 Apr 25.

Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts.

Background: Extended oral antibiotic prophylaxis may decrease rates of prosthetic joint infection (PJI) after total joint arthroplasty (TJA) in patients at high risk for infection. However, the cost-effectiveness of this practice is not clear. In this study, we used a break-even economic model to determine the cost-effectiveness of routine extended oral antibiotic prophylaxis for PJI prevention in high-risk TJA patients.

Methods: Baseline PJI rates in high-risk patients, the cost of revision arthroplasty for PJI, and the costs of extended oral antibiotic prophylaxis regimens were obtained from the literature and institutional purchasing records. These variables were incorporated in a break-even economic model to calculate the absolute risk reduction (ARR) in infection rate necessary for extended oral antibiotic prophylaxis to be cost-effective. ARR was used to determine the number needed to treat (NNT).

Results: Extended oral antibiotic prophylaxis with Cefadroxil in patients at high risk for PJI was cost-effective at an ARR in baseline infection rate of 0.187% (NNT = 535) and 0.151% (NNT = 662) for TKA and THA, respectively. Cost-effectiveness was preserved with varying costs of antibiotic regimens, PJI treatment costs, and infection rates.

Conclusion: The use of extended oral antibiotic prophylaxis may reduce PJI rates in patients at high risk for infection following TJA and appears to be cost-effective. However, the current evidence supporting this practice is limited in quality. The use of extended oral antibiotic prophylaxis should be weighed against the possible development of future antimicrobial resistance, which may change the value proposition.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2022.04.025DOI Listing
April 2022

Adverse Events Associated With Robotic-Assisted Joint Arthroplasty: An Analysis of the US Food and Drug Administration MAUDE Database.

J Arthroplasty 2022 08 21;37(8):1526-1533. Epub 2022 Mar 21.

Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA.

Background: The use of robotic assistance in arthroplasty is increasing; however, the spectrum of adverse events potentially associated with this technology is unclear. Improved understanding of the causes of adverse events in robotic-assisted arthroplasty can prevent future incidents and enhance patient outcomes.

Methods: Adverse event reports to the US Food and Drug Administration Manufacturer and User Facility Device Experience database involving robotic-assisted total hip arthroplasty (THA), total knee arthroplasty (TKA), and partial knee arthroplasty were reviewed to determine causes of malfunction and related patient impact.

Results: Overall, 263 adverse event reports were included. The most frequently reported adverse events were unexpected robotic arm movement for TKA (59/204, 28.9%) and retained registration checkpoint for THA (19/44, 43.2%). There were 99 reports of surgical delay with an average delay of 20 minutes (range 1-120). Thirty-one cases reported conversion to manual surgery. In total, 68 patient injuries were reported, 7 of which required surgical reintervention. Femoral notching (12/36, 33.3%) was the most common for TKA and retained registration checkpoint (19/28, 67.9%) was the most common for THA. Although rare, additional reported injuries included femoral, tibial, and acetabular fractures, MCL laceration, additional retained foreign bodies, and an electrical burn.

Conclusion: Despite the increasing utilization of robotic-assisted arthroplasty in the United States, numerous adverse events are possible and technical difficulties experienced intraoperatively can result in prolonged surgical delays. The events reported herein seem to indicate that robotic-assisted arthroplasty is generally safe with only a few reported instances of serious complications, the nature of which seems more related to suboptimal surgical technique than technology. Based on our data, the practice of adding registration checkpoints and bone pins to the instrument count of all robotic-assisted TJA cases should be widely implemented to avoid unintended retained foreign objects.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2022.03.060DOI Listing
August 2022

Performance Outcomes and Return to Sport Following Metacarpal Fractures in Major League Baseball Players.

Hand (N Y) 2022 Mar 21:15589447221081565. Epub 2022 Mar 21.

Newton-Wellesley Hospital, MA, USA.

Background: Major League Baseball (MLB) players are at risk for metacarpal fractures; however, little is known regarding the impact of these injuries on future performance. The purpose of this study was to determine whether MLB players who sustain metacarpal fractures demonstrate decreased performance on return to competition in comparison to the performance of control-matched peers.

Methods: Data for MLB position players with metacarpal fractures incurred over 17 seasons were obtained from injury reports, press releases, and player profiles. Age, position, career experience, body mass index (BMI), injury mechanism, handedness, and treatment were recorded. Individual season statistics for the 2 seasons immediately before injury and the 2 seasons after injury were obtained. Controls matched by player position, age, BMI, career experience, and performance statistics were identified. A performance comparison of the cohorts was performed.

Results: Overall, 24 players met inclusion criteria. Eleven players with metacarpal fractures were treated with surgery (46%) and 13 (54%) were treated nonoperatively. Players treated nonoperatively missed significantly fewer games following injury compared with those treated operatively (35.5 vs 52.6 games, = .04). There was no significant difference in postinjury performance when compared with preinjury performance among the fracture cohorts. Players with metacarpal fractures treated nonoperatively had a significant decline in their Wins Above Replacement (WAR) 2 seasons postinjury (1.37 point decline) in comparison to matched controls (0.84 point increase) ( = .02). There was no significant difference in WAR 1 or 2 seasons postinjury for players with metacarpal fractures treated operatively in comparison to the control cohort.

Conclusions: Major League Baseball players sustaining metacarpal fractures can expect to return to their preinjury performance levels following both nonoperative and operative treatment. However, players treated nonoperatively may witness a decline in their performance compared with peers over the long term. Orthopedic surgeons treating professional athletes with metacarpal fractures should consider these outcomes when counseling their patients and making treatment recommendations.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/15589447221081565DOI Listing
March 2022

Substantial Inconsistency and Variability Exists Among Minimum Clinically Important Differences for Shoulder Arthroplasty Outcomes: A Systematic Review.

Clin Orthop Relat Res 2022 07 17;480(7):1371-1383. Epub 2022 Mar 17.

Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, MA, USA.

Background: As the value of patient-reported outcomes becomes increasingly recognized, minimum clinically important difference (MCID) thresholds have seen greater use in shoulder arthroplasty. However, MCIDs are unique to certain populations, and variation in the modes of calculation in this field may be of concern. With the growing utilization of MCIDs within the field and value-based care models, a detailed appraisal of the appropriateness of MCID use in the literature is necessary and has not been systematically reviewed.

Questions/purposes: We performed a systematic review of MCID quantification in existing studies on shoulder arthroplasty to answer the following questions: (1) What is the range of values reported for the MCID in commonly used shoulder arthroplasty patient-reported outcome measures (PROMs)? (2) What percentage of studies use previously existing MCIDs versus calculating a new MCID? (3) What techniques for calculating the MCID were used in studies where a new MCID was calculated?

Methods: The Embase, PubMed, and Ovid/MEDLINE databases were queried from December 2008 through December 2020 for total shoulder arthroplasty and reverse total shoulder arthroplasty articles reporting an MCID value for various PROMs. Two reviewers (DAK, MAM) independently screened articles for eligibility, specifically identifying articles that reported MCID values for PROMs after shoulder arthroplasty, and extracted data for analysis. Each study was classified into two categories: those referencing a previously defined MCID and those using a newly calculated MCID. Methods for determining the MCID for each study and the variability of reported MCIDs for each PROM were recorded. The number of patients, age, gender, BMI, length of follow-up, surgical indications, and surgical type were extracted for each article. Forty-three articles (16,408 patients) with a mean (range) follow-up of 20 months (0.75 to 68) met the inclusion criteria. The median (range) BMI of patients was 29.3 kg/m2 (28.0 to 32.2 kg/m2), and the median (range) age was 68 years (53 to 84). There were 17 unique PROMs with MCID values. Of the 112 MCIDs reported, the most common PROMs with MCIDs were the American Shoulder and Elbow Surgeons (ASES) (23% [26 of 112]), the Simple Shoulder Test (SST) (17% [19 of 112]), and the Constant (15% [17 of 112]).

Results: The ranges of MCID values for each PROM varied widely (ASES: 6.3 to 29.5; SST: 1.4 to 4.0; Constant: -0.3 to 12.8). Fifty-six percent (24 of 43) of studies used previously established MCIDs, with 46% (11 of 24) citing one study. Forty-four percent (19 of 43) of studies established new MCIDs, and the most common technique was anchor-based (37% [7 of 19]), followed by distribution (21% [4 of 19]).

Conclusion: There is substantial inconsistency and variability in the quantification and reporting of MCID values in shoulder arthroplasty studies. Many shoulder arthroplasty studies apply previously published MCID values with variable ranges of follow-up rather than calculating population-specific thresholds. The use of previously calculated MCIDs may be acceptable in specific situations; however, investigators should select an anchor-based MCID calculated from a patient population as similar as possible to their own. This practice is preferable to the use of distribution-approach MCID methods. Alternatively, authors may consider using substantial clinical benefit or patient-acceptable symptom state to assess outcomes after shoulder arthroplasty.

Clinical Relevance: Although MCIDs may provide a useful effect-size based alternative to the traditional p value, care must be taken to use an MCID that is appropriate for the particular patient population being studied.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/CORR.0000000000002164DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9191322PMC
July 2022

Patient Perceptions of Telehealth Orthopedic Services in the Era of COVID-19 and Beyond.

Orthopedics 2021 Sep-Oct;44(5):e668-e674. Epub 2021 Sep 1.

The coronavirus disease 2019 (COVID-19) pandemic necessitated an unprecedented increase in the use of telehealth services in orthopedics. Patient attitudes toward and satisfaction with virtual orthopedic services remain largely unexplored. A prospective study of all orthopedic patients at a tertiary academic medical center who had a telehealth appointment between April 1, 2020, and May 5, 2020, was performed to assess patients' experience with a validated 21-item telehealth satisfaction questionnaire. The survey contained statements designed to assess patients' level of agreement with numerous aspects of telehealth, including convenience, the surgeon's ability to engage in care, ease of use, and future use of telehealth. Most respondents (86.7%) were satisfied with the telehealth system. The majority of patients expressed that the system is easy to use (90.0%), is convenient (86.7%), and saves them time (83.3%). Nearly all (95%) patients agreed that their surgeon could answer their questions with the use of this technology, although nearly half (46.6%) identified the lack of physical contact during the examination as problematic. Only 46.7% of patients agreed that telehealth should be a standard form of health care delivery in the future; these patients were found to have significantly longer commute times compared with those who did not (52.1±58.2 vs 28.3±19.2, =.03). Patient perspectives on the widespread adoption of telehealth, such as ease of use, privacy protection, and convenience, showed that these anticipated barriers may be some of the greatest advantages of telehealth. The COVID-19 pandemic may have provided the momentum for telehealth to become a mainstay of orthopedic health care delivery in the future. [. 2021;44(5):e668-e674.].
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3928/01477447-20210817-07DOI Listing
October 2021

Rotator cuff fatty infiltration and muscle atrophy: relation to glenoid deformity in primary glenohumeral osteoarthritis.

J Shoulder Elbow Surg 2022 Feb 12;31(2):286-293. Epub 2021 Aug 12.

Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, MA, USA; Boston Sports and Shoulder Center, Waltham, MA, USA. Electronic address:

Background: Muscle atrophy (MA) and fatty infiltration (FI) are degenerative processes of the rotator cuff musculature that have incompletely understood relationships with the development of eccentric glenoid wear in the setting of primary glenohumeral osteoarthritis (GHOA).

Methods: All patients with GHOA and an intact rotator cuff who underwent both magnetic resonance imaging and computed tomography scans of the affected shoulder prior to total shoulder arthroplasty between 2015 and 2020 were identified from a prospectively maintained registry. Rotator cuff MA was measured quantitatively on sequential sagittal magnetic resonance images, whereas FI was assessed on sagittal magnetic resonance imaging slices using the Goutallier classification. Preoperative computed tomography scans were reconstructed using automated 3-dimensional software to determine glenoid retroversion, glenoid inclination, and humeral head subluxation. Glenoid deformity was classified according to the Walch classification. Univariate and multivariable regression analyses were performed to characterize associations between age, sex, muscle area, FI, and glenoid morphology.

Results: Among the 127 included patients, significant associations were found between male sex and larger overall rotator cuff musculature (P < .01), increased ratio of the posterior rotator cuff (PRC) to the subscapularis area (P = .01), and glenoid retroversion (19° vs. 14°, P < .01). Larger supraspinatus and PRC muscle size was correlated with increased retroversion (r = 0.23 [P = .006] for supraspinatus and r = 0.25 [P = .004] for PRC) and humeral head subluxation (r = 0.25 [P = .004] for supraspinatus and r = 0.28 [P = .001] for PRC). The ratio of PRC muscle size to anterior rotator cuff muscle size was not associated with evidence of eccentric glenoid wear (P > .05). After we controlled for confounding factors, increasing glenoid retroversion was associated with high-grade infraspinatus FI (β, 6.8; 95% confidence interval, 2.9-10.7; P < .01) whereas larger PRC musculature was predictive of a Walch type B (vs. type A) glenoid (odds ratio, 1.3; 95% confidence interval, 1.0-1.5; P = .04).

Conclusion: Patients with eccentric glenoid wear in the setting of primary GHOA and an intact rotator cuff appear to have both larger PRC musculature and higher rates of infraspinatus FI. Although the temporal and causal relationships of these associations remain ambiguous, MA and FI should be considered 2 discrete processes in the natural history of GHOA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jse.2021.07.007DOI Listing
February 2022

A break-even analysis of tranexamic acid for prevention of periprosthetic joint infection following total hip and knee arthroplasty.

J Orthop 2021 Jul-Aug;26:54-57. Epub 2021 Jul 13.

Tufts Medical Center, Boston, MA, USA.

Purpose: Despite the commonplace use of tranexamic acid in total joint arthroplasty, much of the current data regarding its cost-effectiveness examines savings directly related to its hemostatic properties, without considering its protective effect against periprosthetic joint infections. Using break-even economic modeling, we calculated the cost-effectiveness of routine tranexamic acid administration for infection prevention in total joint arthroplasty.

Materials And Methods: The cost of intraoperative intravenous tranexamic acid, the cost of revision arthroplasty for periprosthetic joint infections, and the baseline rates of periprosthetic joint infections in patients who did not receive intraoperative tranexamic acid were obtained from the literature and institutional purchasing records. Break-even economic modeling incorporating these variables was performed to determine the absolute risk reduction in infection rate to make routine intraoperative tranexamic acid use economically justified. The number needed to treat was calculated from the absolute risk reduction.

Results: Routine use of intraoperative tranexamic acid is economically justified if it prevents at least 1 infection out of 3125 total joint arthroplasties (absolute risk reduction = 0.032%). Cost-effectiveness was maintained with varying costs of tranexamic acid, infection rates, and periprosthetic joint infection costs.

Conclusion: The routine use of intraoperative tranexamic acid is a highly cost-effective practice for infection prevention in primary and revision total joint arthroplasty. The use of tranexamic acid is warranted across a wide range of costs of tranexamic acid, initial infection rates, and costs of periprosthetic joint infection treatment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jor.2021.07.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8283265PMC
July 2021

Gross Trunnion Failure of a Type 1 Taper After Metal-on-Polyethylene Total Hip Arthroplasty: A Report of 2 Cases.

JBJS Case Connect 2021 06 24;11(2). Epub 2021 Jun 24.

Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, Massachusetts.

Case: We describe 2 cases of gross trunnion failure (GTF) in males with Centers for Disease Control and Prevention Class 3 obesity 10 years after metal-on-polyethylene total hip arthroplasty (THA) with a titanium-alloy femoral stem and Type 1 taper. One patient received a large diameter cobalt-chromium femoral head, whereas the other received a smaller diameter head, both with high-offset femoral stems.

Conclusion: This is the first report of GTF involving the Echo Bi-Metric femoral stem after metal-on-polyethylene THA, and surgeons should consider the potential complication of GTF when using this specific femoral stem with metal heads in obese male patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2106/JBJS.CC.21.00098DOI Listing
June 2021

Public Opinion and Expectations of Stem Cell Therapies in Orthopaedics.

Arthroscopy 2021 12 12;37(12):3510-3517.e2. Epub 2021 Jun 12.

Department of Orthopaedic Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, U.S.A.. Electronic address:

Purpose: To explore public opinion, understanding, and preferences regarding the use of stem cell therapies for the treatment of joint and tendon pathologies using online crowdsourcing.

Methods: A 30-question survey was completed by 931 members of the public using Amazon Mechanical Turk, a validated crowdsourcing method. Outcomes included perceptions and preferences regarding the use of stem cells therapies for the nonsurgical treatment of orthopaedic conditions. Sociodemographic factors and a validated assessment of health literacy were collected. Inclusion criteria were adult participants 18 years or older, residence within the United States, and a valid Social Security number. Multivariable logistic regression modeling was used to determine population characteristics associated with the belief that stem cells represent the most effective treatment for long-standing joint or tendon disorders.

Results: Most respondents reported that stem cell therapies have convincing evidence to support their use for orthopaedic conditions (84.5%) and are approved and regulated by the Food and Drug Administration (65%). About three-quarters of respondents reported that stem cells can stop the progression of and alleviate pain from arthritis or damaged tendons, and over half (53.5%) reported that stem cells can cure arthritis. Factors with the greatest influence on respondents' decision to receive stem cell therapies are research supporting their safety and effectiveness and doctor recommendation. However, 63.3% of respondents stated that they would consider stem cells if their doctor recommended it, regardless of evidence supporting their effectiveness, and over half would seek another doctor if their orthopaedic surgeon did not offer this treatment option.

Conclusions: The public's limited understanding regarding the current evidence associated with stem cell therapies for osteoarthritis and tendinous pathologies may contribute to unrealistic expectations and misinformed decisions. This study highlights the importance of patient education and expectation setting, as well as evidence transparency, as stem cell therapies become increasingly accessible.

Level Of Evidence: Level IV, case series.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arthro.2021.05.058DOI Listing
December 2021

Functional somatic syndromes are associated with suboptimal outcomes and high cost after shoulder arthroplasty.

J Shoulder Elbow Surg 2022 Jan 9;31(1):48-55. Epub 2021 Jun 9.

Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, MA, USA. Electronic address:

Background: The presence of functional somatic syndromes (chronic physical symptoms with no identifiable organic cause) in patients undergoing elective joint arthroplasty may affect the recovery experience. We explored the prevalence of functional somatic syndromes among shoulder arthroplasty patients, as well as their association with postoperative outcomes and costs.

Methods: We identified 480 patients undergoing elective total shoulder arthroplasty (anatomic or reverse) between 2015 and 2018 in our institutional registry with minimum 2-year follow-up. Medical records were queried for the presence of 4 well-recognized functional somatic syndromes: fibromyalgia, irritable bowel syndrome, chronic headaches, and chronic low-back pain. Multivariable linear regression modeling was used to determine the independent association of these diagnoses with hospitalization time-driven activity-based costs and 2-year postoperative American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and pain scores.

Results: Nearly 1 in 5 patients (17%) reported at least 1 functional somatic syndrome. These patients were more likely to be women, to be chronic opioid users, to report more allergies, to have a diagnosis of anxiety, and to have shoulder pathology other than degenerative joint disease (all P ≤ .001). After multivariable adjustment, the presence of at least 1 functional somatic syndrome was independently predictive of lower 2-year ASES (-9.75 points) and SANE (-7.63 points) scores and greater residual pain (+1.13 points) (all P ≤ .001). When considered cumulatively, each additional functional disorder was linked to a stepwise decrease in ASES and SANE scores and an increase in residual pain (P < .001). These patients also incurred higher hospitalization costs, with a stepwise rise in costs with an increasing number of disorders (P < .001).

Conclusions: Functional somatic syndromes are common in patients undergoing shoulder arthroplasty and correlate with suboptimal outcomes and greater resource utilization. Efforts to address the biopsychosocial determinants of health that affect the value proposition of shoulder arthroplasty should be prioritized in the redesign of care pathways and bundling initiatives.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jse.2021.05.015DOI Listing
January 2022

Variation in perioperative opioid use after total joint arthroplasty.

J Orthop 2021 May-Jun;25:162-166. Epub 2021 May 7.

Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

Objective: We studied variation in perioperative opioid use after total joint arthroplasty with respect to patient and procedure characteristics in order to inform initiatives to optimize pain relief.

Methods: We recorded perioperative opioid consumption for a cohort of total joint arthroplasty patients to identify factors underlying variation in perioperative opioid use.

Results: Younger patient age, tobacco use, greater symptoms of depression, private insurance, and knee arthroplasty were associated with increased opioid consumption.

Conclusions: Awareness of the patient characteristics associated with increased perioperative opioid use can help inform implementation of targeted strategies for safe, optimal pain relief and satisfaction.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jor.2021.05.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8131953PMC
May 2021

Vancomycin Presoaking of Anterior Cruciate Ligament Tendon Grafts Is Highly Cost-Effective for Preventing Infection.

Arthroscopy 2021 10 19;37(10):3152-3156. Epub 2021 Apr 19.

Department of Orthopaedic Surgery, Tufts University Medical Center, Boston, Massachusetts, U.S.A.. Electronic address:

Purpose: This study aimed to (1) determine whether intraoperative graft soaking with vancomycin is a cost-effective measure for preventing infection after arthroscopic anterior cruciate ligament (ACL) reconstruction and (2) provide an adaptable model for providers and institutions to determine the cost effectiveness of this strategy over a range of initial infection rates, infection-related care costs, and vancomycin costs.

Methods: Baseline postoperative infection rates and the costs of antibiotics and infection-related care were gathered from the literature. The cost of treating infection was determined for 2 alternative protocols-irrigation and debridement with revision ACL reconstruction or ACL graft retention. Using a break-even economic analysis, we developed an equation to determine the absolute risk reduction (ARR) in infection rate required for the use of vancomycin graft soaking to be deemed cost-effective. To provide a widely applicable robust model, multiple simulations were performed at varying unit costs, infection rates, and ACL reconstruction postoperative infection related care costs. The number needed to treat was calculated from the ARR.

Results: Intraoperative vancomycin was determined to be cost-effective if it prevents 1 infection in 550 cases (ARR = 0.182%), given costs of $24,178 and $44/1,000 mg for revision ACL reconstruction and vancomycin, respectively. If the ACL graft is retained following infection, intraoperative vancomycin was considered cost-effective if it prevents 1 infection in 146 cases (ARR = 0.685%), given costs of $6,424 and $44/1,000 mg for arthroscopic debridement and vancomycin prophylaxis, respectively. For any specific cost of treating infection and cost of vancomycin, variation in baseline infection rates did not influence the economic viability of vancomycin graft soaking. This intervention remained economically viable over a wide range of unit costs of vancomycin.

Conclusions: Through break-even economic analysis, this study demonstrates that the use of intraoperative graft preparation with vancomycin is a highly cost-effective prophylactic measure for infection prevention in arthroscopic ACL reconstruction.

Level Of Evidence: IV, economic analysis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arthro.2021.04.005DOI Listing
October 2021

Public perceptions and disparities in access to telehealth orthopaedic services in the COVID-19 era.

J Natl Med Assoc 2021 Aug 2;113(4):405-413. Epub 2021 Apr 2.

Department of Orthopaedic Surgery, Tufts Medical Center, Tufts University School of Medicine, 800 Washington St, Boston, MA, USA; New England Baptist Hospital, 125 Parker Hill Ave, Boston, MA, USA. Electronic address:

Background: We used online crowdsourcing to explore public perceptions and attitudes towards virtual orthopaedic care, and to identify factors associated with perceived difficulty navigating telehealth services during the COVID-19 pandemic.

Methods: A modified version of the validated Telemedicine Satisfaction and Usefulness Questionnaire was completed by 816 individuals using crowd-sourcing methods. Multivariable logistic regression modelling was used to determine population characteristics associated with perceived difficulty using telehealth technology.

Results: Most respondents (85%) believed that telehealth visits would be a convenient form of healthcare delivery, and 64% would prefer them over in-person office visits. The majority (92%) agreed that telehealth would save them time, but 81% had concerns regarding the lack of physical contact during a musculoskeletal examination. More respondents would feel comfortable using telehealth for routine follow-up care (81%) compared to initial assessment visits (59%) and first postoperative appointments (60%). Roughly 1 in 15 (7%) expressed difficulty with using telehealth; these respondents were more often unmarried, lower-income, and more medically infirm, and reported greater symptoms of depression. After multivariable adjustment, lower income and poor health were retained as predictors of difficulty with navigating telehealth technology (p = 0.027,p = 0.036, respectively).

Conclusion: The majority of the public appears receptive to telehealth for orthopaedic care for both new patient visits and follow-up appointments. The finding that people with multiple chronic conditions and psychosocial needs struggle to engage with telehealth suggests that those who arguably stand to benefit the most from continued care are the ones being unintentionally left out of this digitization boom.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jnma.2021.02.007DOI Listing
August 2021

Perioperative Medical Optimization of Symptomatic Benign Prostatic Hyperplasia Is an Economically Justified Infection Prevention Strategy in Total Joint Arthroplasty.

J Arthroplasty 2021 07 27;36(7):2551-2557. Epub 2021 Feb 27.

Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR.

Background: Abnormal voiding dynamics may be a modifiable risk factor for prosthetic joint infection (PJI) after total joint arthroplasty (TJA), but the cost-effectiveness of their optimization in the perioperative setting is unknown. Using a break-even analysis, we calculated the economic viability of perioperative voiding optimization for infection prevention after TJA in patients with symptomatic benign prostatic hyperplasia (BPH).

Methods: A perioperative voiding optimization algorithm was created to represent a common approach to treating symptomatic BPH before TJA. Treatment is initiated with a 6-week trial of tamsulosin (pathway 1), followed by 6 months of combination tamsulosin/finasteride therapy (pathway 2) if symptoms persist. Patients with unremitting symptoms after medical management undergo surgical correction with transurethral resection of the prostate (pathway 3). Costs associated with each pathway were derived from the literature and institutional purchasing records. A break-even economic model was constructed to calculate the absolute risk reduction (ARR) in the infection rate and number needed to treat necessary for cost-effectiveness.

Results: Pathway 1 was cost-effective if it prevented 1 infection of 113 (ARR = 0.883%) TKAs or 140 (ARR = 0.714%) THAs. Pathway 2 was cost-effective if it obviated infection in 1 of 69 TKAs (ARR = 1.445%) or 86 THAs (ARR = 1.169%). Pathway 3 was only deemed cost-effective assuming a cost of $400,000 to treat a PJI (number needed to treat = 71, ARR = 1.406%). Cost-effectiveness for pathways 1 and 2 was maintained with varying voiding optimization costs, infection rates, and PJI costs.

Conclusion: Perioperative medical management of symptomatic BPH is an economically justified PJI prevention strategy, whereas surgical interventions appear to be financially substantiated only when considering the long-term societal costs of a PJI.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2021.02.059DOI Listing
July 2021

Online Crowdsourcing to Explore Public Perceptions of Robotic-Assisted Orthopedic Surgery.

J Arthroplasty 2021 06 15;36(6):1887-1894.e3. Epub 2021 Feb 15.

Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA.

Background: The clinical benefits of robotic-assisted technology in total joint arthroplasty are unclear, but its use is increasing. This study employed online crowdsourcing to explore public perceptions and beliefs regarding robotic-assisted orthopedic surgery.

Methods: A 30-question survey was completed by 588 members of the public using Amazon Mechanical Turk. Participants answered questions regarding robotic-assisted orthopedic surgery, sociodemographic factors, and validated assessments of health literacy and patient engagement. Multivariable logistic regression modeling was used to determine population characteristics associated with preference for robotic technology.

Results: Most respondents believe robotic-assisted surgery leads to better results (69%), fewer complications (69%), less pain (59%), and faster recovery (62%) than conventional manual methods. About half (49%) would prefer a low-volume surgeon using robotic technology to a high-volume surgeon using conventional manual methods. The 3 main concerns regarding robotic technology included lack of surgeon experience with robotic surgery, robot malfunction causing harm, and increased cost. Only half of respondents accurately understand the actual role of the robot in the operating room. Overall, 34% of participants have a clear preference for robotic-assisted surgery over a conventional manual approach. After multivariable regression analysis, Asian race, working in healthcare, early technology adoption, and prior knowledge of robotic surgery were independent predictors of preferring robotic-assisted surgery.

Conclusion: The public's unawareness of the dubious outcome superiority associated with robotic-assisted orthopedic surgery may contribute to misinformed decisions in some patients. Robotic-assisted technology appears to be a powerful marketing tool for surgeons and hospitals.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2021.02.027DOI Listing
June 2021

The Cost-Effectiveness of Closed Incisional Negative Pressure Wound Therapy for Infection Prevention after Revision Total Knee Arthroplasty.

J Knee Surg 2021 Jan 28. Epub 2021 Jan 28.

Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts.

Recent investigations have shown that closed incisional negative pressure wound therapy (ciNPWT) decreases the rate of postoperative wound complications following revision total knee arthroplasty (TKA). In this study, we used a break-even analysis to determine whether ciNPWT is a cost-effective measure for reducing prosthetic joint infection (PJI) after revision TKA. The cost of ciNPWT, cost of treatment for PJI, and baseline infection rates following revision TKA were collected from institutional data and the literature. The absolute risk reduction (ARR) in infection rate necessary for cost-effectiveness was calculated using break-even analysis. Using our institutional cost of ciNPWT ($600), this intervention would be cost-effective if the initial infection rate of revision TKA (9.0%) has an ARR of 0.92%. The ARR needed for cost-effectiveness remained constant across a wide range of initial infection rates and declined as treatment costs increased. The use of ciNPWT for infection prevention following revision TKA is cost-effective at both high and low initial infection rates, across a broad range of treatment costs, and at inflated product expenses.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0041-1724137DOI Listing
January 2021

The Cost-Effectiveness of Silver-Impregnated Occlusive Dressings for Infection Prevention After Total Joint Arthroplasty.

J Arthroplasty 2021 05 16;36(5):1753-1757. Epub 2020 Nov 16.

Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA.

Background: Prosthetic joint infection (PJI) is a catastrophic complication after total joint arthroplasty that exacts a substantial economic burden on the health-care system. This study used break-even analysis to investigate whether the use of silver-impregnated occlusive dressings is a cost-effective measure for preventing PJI after primary total knee arthroplasty (TKA) and total hip arthroplasty (THA).

Methods: Baseline infection rates after TKA and THA, the cost of revision arthroplasty for PJI, and the cost of a silver-impregnated occlusive dressing were determined based on institutional data and the existing literature. A break-even analysis was then conducted to calculate the minimal absolute risk reduction needed for cost-effectiveness.

Results: The use of silver-impregnated occlusive dressings would be economically viable at an infection rate of 1.10%, treatment costs of $25,692 for TKA PJI, and $31,753 for THA PJI and our institutional dressing price of $38.05 if it reduces infection rates after TKA by 0.15% (the number needed to treat [NNT] = 676) and THA by 0.12% (NNT = 835). The absolute risk reduction needed to maintain cost-effectiveness did not change with varying initial infection rates and remained less than 0.40% (NNT = 263) for infection treatment costs as low as $10,000 and less than 0.80% (NNT = 129) for dressing prices as high as $200.

Conclusion: The use of silver-impregnated occlusive dressings is a cost-effective measure for infection prophylaxis after TKA and THA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2020.11.017DOI Listing
May 2021

The Telehealth Paradox in the Neediest Patients.

J Natl Med Assoc 2021 Jun 20;113(3):351-352. Epub 2020 Oct 20.

Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, TX, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jnma.2020.09.144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7572298PMC
June 2021

Preoperative Allergy Testing for Patients Reporting Penicillin and Cephalosporin Allergies is Cost-Effective in Preventing Infection after Total Knee and Hip Arthroplasty.

J Arthroplasty 2021 02 27;36(2):700-704. Epub 2020 Aug 27.

Tufts Medical Center, Department of Orthopaedic Surgery, Boston, MA.

Background: Routine preoperative allergy testing in patients reporting penicillin and cephalosporin allergies increases the number able to receive cefazolin, which should reduce the risk of infection after total knee and hip arthroplasty (TKA/THA), but it remains unclear whether this practice is cost-effective. Using a break-even analysis, we calculated the cost-effectiveness of routine preoperative allergy testing for infection prevention in total joint arthroplasty patients reporting penicillin and cephalosporin allergies.

Methods: The cost of a penicillin allergy evaluation, the cost of revision arthroplasty for prosthetic joint infection (PJI), and baseline rates of PJI in patients receiving a noncefazolin antibiotic in the perioperative period were derived from existing literature. A break-even economic model using these variables was constructed to calculate the absolute risk reduction (ARR) in infection rate needed for preoperative allergy testing to be cost-effective. The number needed to treat (NNT) was calculated from the ARR.

Results: Preoperative allergy testing before TKA and THA in patients reporting penicillin and cephalosporin allergies was cost-effective if the initial infection rate decreased by an ARR of 0.810% (NNT = 123) and 0.655% (NNT = 153) for TKA and THA, respectively. Cost-effectiveness was maintained with varying allergy consultation costs, infection rates, and costs associated with PJI treatment.

Conclusion: Routine preoperative allergy testing and clearance are cost-effective infection prevention strategies among patients reporting penicillin and cephalosporin allergies in the setting of elective joint arthroplasty. Widespread adoption of this practice may considerably reduce the economic and societal burden associated with prosthetic infections.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2020.08.045DOI Listing
February 2021

Nationwide Analysis of Lower Extremity Periprosthetic Fractures.

J Arthroplasty 2021 01 25;36(1):317-324. Epub 2020 Jul 25.

Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA.

Background: Although the annual incidence of primary total joint arthroplasty is increasing, trends in the annual incidence of periprosthetic fractures have not been established. This study aimed to define the annual incidence of periprosthetic fractures in the United States.

Methods: Inpatient admission data for 60,887 surgically treated lower extremity periprosthetic fractures between 2006 and 2015 were obtained from the National Inpatient Sample database. The annual incidence of periprosthetic fractures was defined as the number of new cases per year and presented as a population-adjusted rate per 100,000 US individuals. Univariable methods were used for trend analysis and comparisons between groups.

Results: The national annual incidence of periprosthetic fractures presented as a population-adjusted rate of new cases per year peaked in 2008 (2.72; 95% confidence interval [95% CI], 2.39-3.05), remained stable from 2010 (1.65; 95% CI, 1.45-1.86) through 2013 (1.67; 95% CI, 1.55-1.8) and increased in 2014 (1.99; 95% CI, 1.85-2.13) and 2015 (2.47; 95% CI, 2.31-2.62). The proportion of femoral periprosthetic fractures managed with total knee arthroplasty revision remained stable (P = .97) with an increase in total hip arthroplasty (THA) revision (P < .001) and concurrent decrease in open reduction and internal fixation (ORIF) (P < .001). Revision THA was significantly more costly than revision total knee arthroplasty (P = .004), and both were significantly more costly than ORIF (P < .001 for both).

Conclusion: The annual incidence of periprosthetic fractures remained relatively stable throughout our study period. The proportion of periprosthetic fractures managed with revision THA increased, whereas ORIF decreased. Our findings are encouraging considering the significant burden an increase in periprosthetic fracture incidence would present to the health care system in terms of both expense and patient morbidity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2020.07.050DOI Listing
January 2021

Public Perceptions of Resuming Elective Surgery During the COVID-19 Pandemic.

J Arthroplasty 2021 02 20;36(2):397-402.e2. Epub 2020 Jul 20.

Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, MA.

Background: Many U.S. health systems are grappling with how to safely resume elective surgery amid the COVID-19 pandemic. We used online crowdsourcing to explore public perceptions and concerns toward resuming elective surgery during the pandemic, and to determine factors associated with the preferred timing of surgery after health systems reopen.

Methods: A 21-question survey was completed by 722 members of the public using Amazon Mechanical Turk. Multivariable logistic regression analysis was performed to determine factors associated with the timing of preferred surgery after health systems reopen.

Results: Most (61%) participants were concerned with contracting COVID-19 during the surgical process, primarily during check-in and in waiting room areas, as well as through excessive interactions with staff. Overall, 57% would choose to have their surgery at a hospital over an outpatient surgery center. About 1 in 4 (27%) would feel comfortable undergoing elective surgery in the first month of health systems reopening. After multivariable adjustment, native English speaking (OR, 2.6; 95% CI, 1.04-6.4; P = .042), male sex (OR, 1.9; 95% CI, 1.3-2.7; P < .001), and Veterans Affairs insurance (OR, 4.5; 95% CI, 1.1-18.7; P = .036) were independent predictors of preferring earlier surgery.

Conclusion: Women and non-native English speakers may be more hesitant to undergo elective surgery amid the COVID-19 pandemic. Despite concerns of contagion, more than half of the public favors a hospital setting over an outpatient surgery center for their elective surgery. Concerted efforts to minimize patient congestion and unnecessary face-to-face interactions may prove most effective in reducing public anxiety and concerns over the safety of resuming elective care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2020.07.037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7369592PMC
February 2021

Return to play and performance after surgical repair of distal biceps tendon ruptures in National Football League athletes.

J Shoulder Elbow Surg 2021 Feb 7;30(2):346-351. Epub 2020 Jul 7.

Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Tufts University School of Medicine, Hand Surgery, PC, Newton, MA, USA. Electronic address:

Background: The purpose of this study was to determine whether surgical repair of distal biceps tendon ruptures in professional football players would lead to a decrease in postinjury performance when compared to preinjury performance and control-matched peers. We also sought to define return to sport, postinjury career length, and games played per season in National Football League players following surgical repair of distal biceps tendon ruptures.

Methods: Data for National Football League players who underwent surgical repair of distal biceps tendon ruptures during a 20-year time period were collected. A total of 25 cases in 22 players were included in the analysis. Matched controls based on player position, age, experience, and performance statistics were identified. Performance scores for cases and controls were calculated using a standardized scoring system specific to player position.

Results: Of the 25 cases, 21 (84%) were able to return to sport in the National Football League. The overall 1-year survival rate of return to play in players undergoing surgical repair of distal biceps tendon ruptures was 76% and overall 2-year survival was 56%. Players who underwent surgical repair of distal biceps tendon ruptures had significantly shorter postinjury career lengths and played fewer games per season postinjury than matched controls. There was no significant difference by position in postinjury performance scores when compared to matched controls.

Conclusion: National Football League players undergoing surgical repair of distal biceps tendon ruptures have a high rate of return to sport, though many retire within the next few seasons following surgery. Players who do return to competition can be expected to perform at a level comparable to their peers.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jse.2020.06.023DOI Listing
February 2021

A break-even analysis of benzoyl peroxide and hydrogen peroxide for infection prevention in shoulder arthroplasty.

J Shoulder Elbow Surg 2020 Nov 7;29(11):2185-2189. Epub 2020 Jul 7.

Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA.

Background: Newer strategies to decolonize the shoulder of Cutibacterium acnes may hold promise in minimizing the occurrence of infections after shoulder arthroplasty, but little is known about their cost-effectiveness. Break-even models can determine the economic viability of interventions in settings with low outcome event rates that would realistically preclude a randomized clinical trial. We used such modeling to determine the economic viability of benzoyl peroxide and hydrogen peroxide for infection prevention in shoulder arthroplasty.

Methods: Skin decolonization protocol costs ($11.76 for benzoyl peroxide; $0.96 for hydrogen peroxide), baseline infection rates for shoulder arthroplasty (0.70%), and infection-related care costs ($50,230) were derived from institutional records and the literature. A break-even equation incorporating these variables was developed to determine the absolute risk reduction (ARR) in the infection rate to make prophylactic use economically justified. The number needed to treat was calculated from the ARR.

Results: Topical benzoyl peroxide is considered economically justified if it prevents at least 1 infection out of 4348 shoulder arthroplasties (ARR = 0.023%). Hydrogen peroxide is economically justified if it prevents at least 1 infection out of 50,000 cases (ARR = 0.002%). These protocols remained economically viable at varying unit costs, initial infection rates, and infection-related care costs.

Conclusions: The use of topical benzoyl peroxide and skin preparations with hydrogen peroxide are highly economically justified practices for infection prevention in shoulder arthroplasty. Efforts to determine drawbacks of routine skin decolonization strategies are warranted as they may change the value analysis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jse.2020.06.019DOI Listing
November 2020

Inflammatory and Coagulative Considerations for the Management of Orthopaedic Trauma Patients With COVID-19: A Review of the Current Evidence and Our Surgical Experience.

J Orthop Trauma 2020 08;34(8):389-394

Department of Orthopaedic Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA.

Mounting evidence suggests that the pathogenesis of coronavirus disease 2019 (COVID-19) involves a hyperinflammatory response predisposing patients to thromboembolic disease and acute respiratory distress. In the setting of severe blunt trauma, damaged tissues induce a local and systemic inflammatory response through similar pathways to COVID-19. As such, patients with COVID-19 sustaining orthopaedic trauma injuries may have an amplified response to the traumatic insult because of their baseline hyperinflammatory and hypercoagulable states. These patients may have compromised physiological reserve to withstand the insult of surgical intervention before reaching clinical instability. In this article, we review the current evidence regarding pathogenesis of COVID-19 and its implications on the management of orthopaedic trauma patients by discussing a case and the most recent literature. LEVEL OF EVIDENCE:: Prognostic Level V. See Instructions for Authors for a complete description of levels of evidence.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BOT.0000000000001842DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7302072PMC
August 2020

Latissimus Dorsi Tendon Transfer With Acromial Osteotomy for Massive Irreparable Rotator Cuff Tear.

Arthrosc Tech 2018 Feb 8;7(2):e105-e112. Epub 2018 Jan 8.

School of Medicine, Boston University, Boston, Massachusetts, U.S.A.

Latissimus dorsi tendon transfer is an effective option for young and active patients with massive irreparable posterosuperior rotator cuff tears and intact subscapularis tendon. This approach has been shown to relieve pain and improve shoulder function in both the short and long term. We describe a surgical technique using an acromial osteotomy to better expose the greater tuberosity for the tendon transfer without disrupting the deltoid muscle. The latissimus dorsi tendon is reinforced with a human dermal collagen matrix (GraftJacket; Wright Medical Group) for additional augmentation of the muscle to gain more excursion for the tendon transfer to the greater tuberosity. The transferred tendon is fixed to the supraspinatus and infraspinatus footprints on the greater tuberosity using suture anchors. The acromial osteotomy is repaired back anatomically with several No. 5 braided sutures (FiberWire; Arthrex).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.eats.2017.08.059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5850886PMC
February 2018
-->