Protocols for Management of Underserved Patients Undergoing Arthroplasty: A National Survey of Safety Net Hospitals.

BACKGROUND: Although it has been shown that perioperative protocols enhance arthroplasty care and safety, it is not known how prevalent their use is in safety net hospitals, which operate with a mandate to treat the poor and underserved. Understanding the elements currently included in standard perioperative arthroplasty protocols at various institutions may help guide future interventions and policy aimed at improving underserved patients' outcomes. METHODS: In this cross-sectional study, safety net hospitals were asked to complete a survey over the phone, via email or in person regarding existence and elements of perioperative management protocols for total hip arthroplasty (THA) and total knee arthroplasty (TKA). Implementation barriers were also addressed. Specifically, survey questions sought to determine the total yearly number of arthroplasty procedures performed at each institution and better understand, among other elements, the following: presence of preoperative pain management protocols, inpatient care pathways, use of social workers and involvement of physical therapy services. Descriptive statistics were calculated and reported. RESULTS: Over 90% of safety net hospitals performing arthroplasty utilized regional anesthetic techniques, inpatient clinical care pathways and inpatient physical therapy. However, 16.7%, 20.0%, 23.3% and 73% lacked social services, anesthesia preoperative clinics, inpatient pain management protocols and preoperative sobriety pathways, respectively. CONCLUSION: Barriers to receiving arthroplasty care included lack of qualified surgical personnel and concerns about surgical risk in vulnerable patient populations. These findings suggest that further effort is warranted to expand and improve arthroplasty care for the underserved to ensure safety and high quality outcomes.

Primary Hip and Knee Arthroplasty in a Safety Net Hospital: Substance Abuse and Other Factors Affecting Short-term Complications.

BACKGROUND: Arthroplasty outcomes and patient risk factors have not been studied in detail in safety net hospital settings. This study examines the relationship between selected risk factors and short-term complications in such a population, including a large subgroup with treated substance abuse. METHODS: This retrospective cohort study contains 486 consecutive patients after primary hip and knee arthroplasty. One hundred three of these had a history of substance abuse and completed a 1-year sobriety pathway preoperatively. Primary outcomes included the presence of any complication, deep infection, and reoperation. Bivariable analyses were used to compare outcomes with demographic and health risk factors. A multivariate analysis was performed to identify independent risk factors. RESULTS: Adverse outcomes were more common in patients with higher rates of substance abuse, mental illness, and infection with human immunodeficiency virus (HIV) and hepatitis C virus (HCV). Substance abuse alone was not an independent risk factor for the occurrence of complications, but infections with HIV and HCV were. In the substance abuse subgroup, with its higher prevalence of risk factors, complications were more frequent (31.1% vs 16.4%, P = .0009), and, in particular, deep infections (5.8% vs 1.8%, P = .0256). CONCLUSIONS: Specific risk factors were associated with short-term complications in safety net arthroplasty patients. Despite having completed a preoperative sobriety pathway, substance abuse patients had more complications than did others. However, substance abuse alone was not an independent risk factor for adverse surgical outcomes. Other factors, notably HCV and HIV infection that were more common in patients with substance abuse, were most closely associated with adverse outcomes.

Early Complications in Hip and Knee Arthroplasties in a Safety Net Hospital vs a University Center.

BACKGROUND: Indigent populations face unique challenges that may increase surgical risk and adversely affect the outcomes of hip and knee arthroplasties. This study examines whether there is a difference in early postoperative complications in patients treated in a safety net hospital and in a nearby university center. METHODS: A retrospective review was undertaken of 533 consecutive hip and knee arthroplasties performed by a single experienced surgeon in a safety net hospital and in a university medical center from 2008 to 2012. Patients were followed for a minimum of 2 years. The primary outcomes evaluated were total complications, deep infections, and reoperations. Statistical comparison of the data from the 2 patient groups was carried out using Fisher exact test. RESULTS: Despite the lower percentage of index revision procedures in the safety net group (8% vs 20.5%; P = .0003), the incidence of adverse outcomes was higher in this group than in the university group: for total complications, 12.3% vs 4.9% (P = .003); for deep infections, 3.2% vs 0.6% (P = .025); and for reoperations, 7.5% vs 2.6% (P = .009). For primary procedures in particular, differences in the incidences of these outcomes were even more significant. CONCLUSIONS: In this study, early complications were more frequent in patients who underwent hip and knee arthroplasties in a safety net hospital compared with those who underwent the same procedures in a nearby university center. Future prospective studies are warranted to determine which patient-related or care process-related factors should be optimized to improve arthroplasty outcomes in vulnerable, safety net populations.

Representation of developing countries in orthopaedic journals: a survey of four influential orthopaedic journals.

BACKGROUND: The developing world contains more than ¾ of the world's population, and has the largest burden of musculoskeletal disease. Published studies provide crucial information that can influence healthcare policies. Presumably much information regarding burden in the developing world would arise from authors from developing countries. However, the extent of participation of authors from the developing world in widely read orthopaedic journals is unclear. PURPOSE: We surveyed four influential English-language orthopaedic journals to document the contributions of authors from developing countries. METHODS: We surveyed Clinical Orthopaedics and Related Research, Journal of Orthopaedic Trauma, and the American and British volumes of The Journal of Bone and Joint Surgery, from May 2007 through May 2010. The country of origin of all authors was identified. We used the designations provided by the International Monetary Fund to define countries as either developed or developing. RESULTS: Two hundred sixty-five of 3964 publications (7%) included authors from developing countries. Ninety percent of these had authors from developing countries with industrialized and emerging-market economies. Publications from Sub-Saharan Africa accounted for only 0.4% of the 3964 articles reviewed and 5.6% of the 265 articles with developing world authorship. Countries with the least robust economies were least represented. Less than 1/3 of articles with authors from the developing world had coauthors from developed or other developing countries. CONCLUSION: Additional studies are needed to determine the reasons for the low representation noted and to establish strategies to increase the number of orthopaedic publications from parts of the world where the burden of musculoskeletal disease is the greatest.

Physical therapy alone compared with core decompression and physical therapy for femoral head osteonecrosis in sickle cell disease. Results of a multicenter study at a mean of three years after treatment.

BACKGROUND: Osteonecrosis of the femoral head is a common complication in patients with sickle cell disease, and collapse of the femoral head occurs in 90% of patients within five years after the diagnosis of the osteonecrosis. However, the efficacy of hip core decompression to prevent the progression of osteonecrosis in these patients is still controversial. METHODS: In a prospective multicenter study, we evaluated the safety of hip core decompression and compared the results of decompression and physical therapy with those of physical therapy alone for the treatment of osteonecrosis of the femoral head in patients with sickle cell disease. Forty-six patients (forty-six hips) with sickle cell disease and Steinberg Stage-I, II, or III osteonecrosis of the femoral head were randomized to one of two treatment arms: (1) hip core decompression followed by a physical therapy program or (2) a physical therapy program alone. Eight patients withdrew from the study, leaving thirty-eight who participated. RESULTS: Seventeen patients (seventeen hips) underwent decompression combined with physical therapy, and no intraoperative or immediate postoperative complications occurred. Twenty-one patients (twenty-one hips) were treated with physical therapy alone. After a mean of three years, the hip survival rate was 82% in the group treated with decompression and physical therapy and 86% in the group treated with physical therapy alone. According to a modification of the Harris hip score, the mean clinical improvement was 18.1 points for the patients treated with hip core decompression and physical therapy compared with 15.7 points for those treated with physical therapy alone. With the numbers studied, the differences were not significant. CONCLUSIONS: In this randomized prospective study, physical therapy alone appeared to be as effective as hip core decompression followed by physical therapy in improving hip function and postponing the need for additional surgical intervention at a mean of three years after treatment.

Clinical evaluation of avascular necrosis in patients with sickle cell disease: Children's Hospital Oakland Hip Evaluation Scale--a modification of the Harris Hip Score.

OBJECTIVE: To establish the validity and reliability of the Children's Hospital Oakland Hip Evaluation Scale (CHOHES), a modification of the Harris Hip Score, for the evaluation of avascular necrosis (AVN) in sickle cell disease (SCD). DESIGN: Nonrandomized test-retest. SETTING: Outpatient clinic. PARTICIPANTS: Forty patients with SCD and 3 healthy controls participated. Twenty-six SCD patients (15 males, 11 females; mean age, 25 y) had been diagnosed with AVN. This group was compared with 14 SCD patients without AVN and 3 healthy controls (8 males, 9 females; mean age, 16 y). INTERVENTION: On average, subjects were assessed by 2 physical therapists by using the CHOHES on 3 separate outpatient visits within a 2-week period. MAIN OUTCOME MEASURES: A mixed model with random effects was constructed to compare patient scores on the CHOHES with disease severity as estimated by Ficat staging on plain radiographs. Correlations between and within physical therapists using the CHOHES were calculated to assess intra- and interrater reliability. RESULTS: From the random effects model, the CHOHES mean score was 88 for Ficat stage 0, 75 for Ficat stage I or II, and 61 for Ficat stages III or IV (P < .05). Intrarater reliability estimates for the total CHOHES score were very good (r > or = .87) as were interrater reliability estimates (r > or = .90) between therapists who measured hips with a wide range of CHOHES scores. CONCLUSIONS: The CHOHES appears to be an easy-to-use, valid, and reliable assessment tool and should be considered for use in the routine clinical evaluation of SCD patients with AVN.

Clinical outcome in total hip arthroplasty using a cemented titanium femoral prosthesis.

Between 1988 and 1993, 118 total hip arthroplasties were carried out using cemented titanium alloy stems with modular cobalt-chrome heads. At a mean follow-up of 66.2 months, the overall clinical failure rate as a result of aseptic loosening of the femoral stem was 11.5%. Most failures occurred with smaller stems, especially in heavier patients. Clinical and radiographic data suggest that failure of femoral component fixation was due to high stresses in the cement mantle associated with the increased flexibility of the smaller stems. Radiographs of successful arthroplasties in patients with larger stems showed proximal stress shielding in most. The findings in this study do not support the contention that titanium alloys provide an advantage over more rigid materials in the manufacture of cemented femoral components for total hip arthroplasty.

Association between human immunodeficiency virus and osteonecrosis of the femoral head.

The records of a consecutive series of 50 patients treated operatively for osteonecrosis of the femoral head were reviewed to determine the prevalence of human immunodeficiency virus (HIV) as an isolated risk factor for osteonecrosis. Twelve patients had a history of trauma to the hip and were excluded from the study. The remaining 38 patients were treated operatively for nontraumatic osteonecrosis of the femoral head. Of these, 7 patients were HIV positive, and 31 were HIV negative. Of the 7 patients who were HIV positive, 4 (57%) had none of the known risk factors for osteonecrosis. Of the 31 patients who were HIV negative, 4 (13%) had none of the known risk factors for osteonecrosis. The difference between the groups was statistically significant, suggesting that HIV infection is a risk factor for the development of osteonecrosis of the femoral head.