Patient Adherence Following Knee Surgery: Evidence-Based Practices to Equip Patients for Success.

Patient adherence with postoperative wound care, activity restrictions, rehabilitation, medication, and follow-up protocols is paramount to achieving optimal outcomes following knee surgery. However, the ability to adhere to prescribed postoperative protocols is dependent on multiple factors both in and out of the patient's control. The goals of this review article are (1) to outline key factors contributing to patient nonadherence with treatment protocols following knee surgery and (2) to synthesize current management strategies and tools for optimizing patient adherence in order to facilitate efficient and effective implementation by orthopaedic health care teams. Patient adherence is commonly impacted by both modifiable and nonmodifiable factors, including health literacy, social determinants of health, patient fear/stigma associated with nonadherence, surgical indication (elective vs. traumatic), and distrust of physicians or the health care system. In addition, health care team factors, such as poor communication strategies or failure to follow internal protocols, and health system factors, such as prior authorization delays, staffing shortages, or complex record management systems, impact patient's ability to be adherent. Because the majority of factors found to impact patient adherence are nonmodifiable, it is paramount that health care teams adjust to better equip patients for success. For health care teams to successfully optimize patient adherence, focus should be paid to education strategies, individualized protocols that consider patient enablers and barriers to adherence, and consistent communication methodologies for both team and patient-facing communication.

Integrated Care for Comprehensive Management of Patients with Osteoarthritis: Program Development and Implementation.

Treatment of symptomatic osteoarthritis (OA) is often complicated by comorbidities, which put patients at potentially higher risks following operative interventions. Management of these comorbidities is usually separate from orthopaedic care, with patients invited to return to their orthopaedic surgeon once surgical risk factors are better controlled. However, this practice can lead to disjointed care, resulting in uncertainty, mistrust, unmanaged pain, and dissatisfaction for patients. Integrated care teams provide an effective option for coordinated comprehensive nonoperative and preoperative management of patients with knee OA and medical comorbidities. The objective of this article is to summarize the process for implementation of an integrated program to manage patients with symptomatic knee OA and the initial outcomes at our institution as an example of the effects of integrated patient management in orthopaedics. At the author's institution, an integrated program was implemented, successfully addressing the unmet need for coordinated care for patients with bone and joint health problems and medical comorbidities. Patients who completed the full program experienced significant improvements in both pain and function. Potential applications for knee surgeons considering implementing integrated care models could include pre- and postoperative management programs, nonoperative management program, and programs seeking to meet key metrics such as improved readmission rates, patient satisfaction, or value-based care. For effective program implementation, careful planning with convenient referral mechanisms, leadership buy-in, and patient-centered communication protocols are required.

Effects of Patient Assessment and Education by an Integrated Care Team on Postoperative Adherence and Failure Rates After Osteochondral Allograft and Meniscal Allograft Transplantation in the Knee.

Background: Patient nonadherence with prescribed rehabilitation protocols is associated with up to 16 times higher likelihood of treatment failure after osteochondral allograft transplantation (OCA) and meniscal allograft transplantation. Hypothesis: Patients who completed counseling with an orthopaedic health behavior psychologist as part of an evidence-based shift in practice at our institution would have significantly lower rates of nonadherence and surgical treatment failure versus patients who did not participate in counseling. Study Design: Cohort study; Level of evidence, 2. Methods: Patients in a prospective registry who underwent OCA and/or meniscal allograft transplantation between January 2016 and April 2021 were included for analysis when 1-year follow-up data were available. Of 292 potential patients, 213 were eligible for inclusion. Patients were categorized based on whether they participated in the preoperative counseling and postoperative patient management program: no health psych group (n = 172) versus health psych group (n = 41). Nonadherence was defined as documented evidence of a deviation from the prescribed postoperative rehabilitation protocol. Results: In this cohort of patients, 50 (23.5%) were documented to be nonadherent. Patients in the no health psych cohort were significantly more likely to be nonadherent (P = .023; odds ratio [OR], 3.4). Tobacco use (OR, 7.9), higher preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference score, lower preoperative PROMIS Mental Health score, older age, and higher body mass index were also significantly associated with nonadherence (P < .001 for all). Patients who were nonadherent with the prescribed postoperative rehabilitation protocol during the first year after transplantation were 3 times more likely (P = .004) to experience surgical treatment failure than those who were adherent. Overall, 26.2% of patients in the no health psych group experienced surgical treatment failure versus 12.2% in the health psych cohort. Conclusion: Data from the present study suggest that preoperative counseling with a health behavior psychologist is associated with an improved rate of patient adherence and a lower proportion of surgical treatment failure after OCA and meniscal allograft transplantation. Patients who remained adherent to the postoperative protocol were 3 times more likely to have a successful short-term (≥1 year) outcome.

Biologic Joint Restoration: A Translational Research Success Story.

Treatment options that result in consistently successful outcomes for young and active patients with joint disorders are needed. This article summarizes two decades of rigorous research using a bedside-to-bench- to-bedside translational approach based on the One Health - One Medicine concept that culminated in successful clinical use of biologic joint restoration options for treatment of knee, hip, ankle, and shoulder problems in this growing patient population.

Perspectives of patients with chronic pain about a pain science education video.

PURPOSE: Patients have responded in variable ways to pain science education about the psychosocial correlates of pain. To improve the effectiveness of pain education approaches, this study qualitatively explored participants' perceptions of and responses to pain science education. METHODS: We conducted a qualitative content analysis of interviews with fifteen, adult patients (73.3% female) who had recently attended a first visit to a chronic pain clinic and watched a pain science educational video. RESULTS: Participants thought it was important to improve their and healthcare providers' understanding of their pain. They viewed the video favorably, learned information from it, and thought it could feasibly facilitate communication with their healthcare providers, but, for many participants, the video either did not answer their questions and/or raised more questions. Participants' responses to the video included negative and positive emotions and were influenced by their need for confirmation that their pain was real and personal relevance of the pain science content. CONCLUSION: Study results support the feasibility and value of delivering pain science education via video and increase our understanding of patients' perceptions of and responses to pain science education. The video's triggering of emotional responses warrants additional research.

Outcomes associated with behavioral evaluation and counseling for patients undergoing orthopaedic surgery - A systematic review.

Osteochondral allograft transplantation can be an effective way to treat cartilage defects in the knee. The objective of this systematic review was to evaluate available research on the effects of preoperative behavioral evaluation and counseling on the outcomes for patients undergoing orthopaedic surgery with emphasis on osteochondral allograft transplantation in the knee. This systematic review of best current evidence indicates that psychological distress and untreated mental health issues are strongly associated with unfavorable outcomes after treatment of orthopaedic disorders, underscoring the need to incorporate behavioral screening and counseling into a comprehensive patient management protocol that improves outcomes for patients.

Effects of Compliance With Procedure-Specific Postoperative Rehabilitation Protocols on Initial Outcomes After Osteochondral and Meniscal Allograft Transplantation in the Knee.

BACKGROUND: Osteochondral and meniscal allograft transplantation have been performed in the knee for more than 40 years, with the number of patients treated each year growing as allograft quantity and quality increase. To date, the effects of postoperative management on outcomes after these procedures have received relatively little focus in the peer-reviewed literature. HYPOTHESIS: Compliance with the recommended postoperative management protocol will be associated with significantly higher initial success and significantly lower revision and failure rates for patients undergoing osteochondral and/or meniscal allograft transplantation in the knee. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients were prospectively enrolled into a dedicated registry designed to follow outcomes after osteochondral and/or meniscal allograft transplantation. Patients were included when at least 1 year of follow-up data were available, including data on complications and reoperations, patient-reported outcome measures, compliance with rehabilitation, revisions, or failures, based on the electronic medical record and communication logs with patients' outpatient physical therapists. RESULTS: For patients meeting the inclusion criteria (N = 162), compliance with the prescribed procedure-specific postoperative management protocol was associated with significantly higher 1- to 3-year success and significantly lower revision and failure rates. Specifically, patients who were compliant were 6.3 times less likely to need allograft revision or total knee arthroplasty and 7.5 times more likely to have a successful outcome at 1 to 3 years after osteochondral and/or meniscal allograft transplantation. In addition to noncompliance, older patient age and higher body mass index were associated with inferior short-term outcomes in this cohort. CONCLUSION: These data suggest that compliance with procedure-specific postoperative rehabilitation protocols is associated with higher success, lower revision, and lower failure rates for patients undergoing osteochondral and meniscal allograft transplantation. Given these results showing the importance of these modifiable risk factors, our center has devoted resources to preoperative patient assessment and communication to provide education, set appropriate expectations, identify and address modifiable risk factors, impediments, and noncompliance, and monitor and adjust postoperative care as indicated.

Neuropsychological decline/improvement in opsoclonus myoclonus ataxia.

Opsoclonus myoclonus ataxia (OMA) is a rare neurological disorder (incidence = approximately 1/5 million) primarily associated with involuntary conjugate saccadic eye movements, involuntary muscle jerks, cerebellar ataxia, and neuropsychological impairments. Unfortunately, there is limited published data regarding the nature and course of neuropsychological impairments following OMA diagnosis and treatment. This study presents neuropsychological data obtained at 1, 4, and 18 months post-diagnosis of a 52-year-old male with OMA. The patient initially demonstrated significant global neurocognitive, psychomotor, and psychological difficulties with substantial improvement over time. Treatment included medication management, physical rehabilitation, and psychological intervention.

Masculine role variables and outcomes among men with spinal cord injury.

PURPOSE: Few studies have considered the impact of masculine role variables on outcome and adjustment to SCI among men. The present study examined the relations among SCI, views of masculinity, psychological adjustment, and rehabilitation outcomes among men with SCI. METHOD: The sample included 20 men with SCI receiving inpatient rehabilitation, with a mean age of 45 years. Data included demographic variables as well as Conformity to Masculine Norms Inventory (CMNI), Gender Role Conflict Scale (GRCS), Functional Independence Measure (FIM), and Satisfaction with Life Scale ratings, and change in marital status. RESULTS: The findings revealed that satisfaction with life was positively related to scores on the CMNI Violence scale, FIM change from admission to discharge was positively related to the CMNI Emotional Control scale and negatively related to the CMNI Dominance scale. Change in marital status was inversely related to the CMNI Emotional Control and Primacy of Work scales and the GRCS Restricted Emotionality and Power, Success, and Competition scales. CONCLUSIONS: The findings show that certain aspects of the traditional masculine role (i.e., ability to modulate strong emotions) may be adaptive in the rehabilitation process, whereas other aspects (i.e., a dominant interpersonal style) may present a barrier to effective rehabilitation.

Outcomes in TBI with violent versus nonviolent etiology in a predominantly rural setting.

OBJECTIVE: To evaluate differences in outcome in persons with violent versus nonviolent traumatic brain injury (TBI) etiology. DESIGN: Two-group (violent vs nonviolent) 1-year follow-up study. SETTING: Midwestern medical center TBI Model System serving a predominantly rural catchment area. PARTICIPANTS: Forty-five (n = 19 violent TBI etiology; n = 26 nonviolent TBI etiology) inpatients with primary diagnosis of TBI followed up as outpatients 1 year after injury. MAIN OUTCOME MEASURES: Substance use, income source, employment status, Wechsler Adult Intelligence Scale--Revised (abbreviated version), Logical Memory I and II from the Wechsler Memory Scale--Revised, Wide Range Achievement Test--Third Edition Reading subtest, Trail-Making Tests A and B, Rey Auditory Verbal Learning Test, Community Integration Questionnaire, Neurobehavioral Functioning Inventory. RESULTS: Members of the violent group were more likely to be men, of a racial minority, unemployed, and have low income. Substance abuse was common among both groups prior to injury, with significant declines at 1 year. Follow-up also revealed significant group differences in verbal intelligence, social integration, productivity, and source of income, but nonsignificant difference in employment. In all comparisons, more favorable outcomes were found for the nonviolent group. CONCLUSIONS: Persons with violent injury etiology have poorer premorbid functioning and are likely to have less favorable outcomes than the general population with TBI. Therefore, persons with violent TBI etiology may require more intensive aftercare programming to promote improved rehabilitation outcomes.