Faculty Bibliography

INTRODUCTION/BACKGROUND:Robotic-assisted technologies provide the ability to avoid soft tissue release by utilizing more accurate bony cuts during total knee arthroplasty (TKA). However, the ideal limb alignment is not yet established. The aim of this study was to predict postoperative Coronal Plane Alignment of the Knee (CPAK) using corresponding native bony measurements. METHODS:This study analyzed a retrospective cohort of 530 primary robotic-assisted TKAs. Machine learning was utilized to predict appropriate target lateral distal femoral angles (LDFA) and medial proximal tibial angles (MPTA). Normalization of LDFA and MPTA alignments was performed using the min-max scaler operation on the training set with feature range [-1, 1] and repeated separately for the input and target distributions. A neural network of hidden dimensions (16, 8, 4) was trained via supervised learning to predict planned LDFA and MPTA values from preoperative LDFA and MPTA measurements. RESULTS:The model converged after 104 epochs and batch size 4 with mean squared error ±1.82°. The model's regression agrees with the hypothesized change in preoperative to planned coronal alignment: valgus measurements are translated to neutral/aligned targets while varus alignments are translated to varus alignment of lesser severity. Evaluative statistics demonstrate this method for planning knee morphologies is significantly more accurate than making predictions about the mean (RMSE 1.440; R-squared 0.444; Nash Sutcliffe 0.579). CONCLUSION/CONCLUSIONS:This study's model provides accurate predictions for target knee alignment morphologies. Future work is warranted to evaluate this method's usefulness for planning robotic TKA.

BACKGROUND:Femoral neck fractures pose a notable health challenge globally, with a projected rise in cases due to aging populations. While treatment protocols are established, the effect of surgeon training on treatment decisions, particularly trauma versus arthroplasty fellowship training, remains less clear. METHODS:This study, using data from the Statewide Planning and Research Cooperative System in New York State, examined 26,761 patients meeting inclusion criteria. Among 951 treating surgeons, 20.6% had no subspecialty fellowship training while 4.6% had training in multiple subspecialties, with arthroplasty (232 surgeons, 24.4%), sports (230 surgeons, 24.2%), and trauma (93 surgeons, 9.8%) being the most common. RESULTS:Analysis revealed notable differences in surgical treatments based on subspecialty, with trauma surgeons favoring fixation and arthroplasty surgeons favoring total hip arthroplasty (THA). Even after adjusting for covariates, patients treated by arthroplasty-trained surgeons were more likely to receive THA. In addition, there was consistency between trauma and arthroplasty surgeons in treating lower functional demand patients with hemiarthroplasty. While trauma surgeons performed more fixations and arthroplasty surgeons more THAs, baseline characteristics and perioperative outcomes between fixation and THA patients were similar, indicating comparable baseline health despite treatment differences. Multivariable logistic regression confirmed that treatment by an arthroplasty surgeon markedly increased the odds of receiving THA. CONCLUSION/CONCLUSIONS:This study underscores the complexity added by surgeon subspecialty in femoral neck fracture management and emphasizes the importance of recognizing how surgeon-specific factors influence treatment decisions. Understanding these nuances can inform training optimization and promote collaborative approaches within the orthopaedic community, ultimately contributing to enhanced patient outcomes as femoral neck fracture management evolves.

Health equity is the fair and just opportunity for every individual to achieve their full potential in all aspects of health and well being. The combination of the COVID-19 pandemic and increased awareness of social injustice shed critical light on health inequities. DEI efforts in health care directly affect patient outcomes and quality of life. By creating and implementing high-quality DEI programs, our orthopedic surgery practices and organizations can help ameliorate healthcare inequities and deliver inclusive, person-centered, and culturally competent patient care. Substantial variability in definition, data collection, methodology, and goals exist between organizations that measure health equity. DEI metrics and targets will be used to measure quality, but reliance on data acquired through patient questionnaires or through their interaction with technology may exclude the most at-risk populations. The purpose of this review is to outline the various organizations involved in evaluating DEI metrics so that orthopaedic teams can better measure and more effectively report the effect of DEI efforts on patient outcomes.

BACKGROUND:A frequently stated goal of an artificial knee arthroplasties is to achieve normal kinematics. However, this is not easily defined based on variations in motions previously measured for a range of activities. For activities such as crouching up and down, a fan pattern has been measured, where the lateral femoral contact displaces progressively posteriorly with flexion, and the medial contact remains almost constant. In walking and other activities, femoral-tibial contacts vary considerably in position, and even lateral pivoting has been measured at the start of the motion cycle. Fluoroscopic studies of total knee arthroplasty (TKA) patients have shown that such kinematics are not usually achieved for most TKA designs. In recent years, there has been an increasing interest in non-cruciate retaining knee arthroplasties, where both cruciate ligaments are resected. A challenge with such designs is to define the design criteria, taking account of the extensive kinematic data of normal knees, as well as clinical factors. METHODS:A TKA design was formulated where the main bearing surfaces produced medial stability and lateral mobility, but where the addition of an offset cylindrical bearing surface in the center induced progressive axial rotation and lateral 'rollback' with flexion. At the same time, anterior-posterior (A-P) and rotational laxity were provided, as in the normal knee. The new design was compared experimentally with four types of contemporary non-cruciate total knee arthroplasties. Three-dimensional printed models were fabricated. A test machine was constructed where shear and torque forces were applied at a range of flexion angles, and contact positions were determined. RESULTS:It was found that the design with the intercondylar cylindrical surface satisfied the design criteria more closely compared with the other designs. CONCLUSION/CONCLUSIONS:For non-cruciate designs to produce more normal motion characteristics, some mechanical configuration acting in concert with the lateral and medial condyles is likely to be necessary.

PURPOSE/OBJECTIVE:The purpose of this study was to assess the 10-year arthroplasty-free survivorship of patients over 50 years of age who underwent knee arthroscopy and to assess whether this survivorship is affected by the diagnoses of knee osteoarthritis (OA) or obesity at the time of arthroscopy. METHODS:The New York Statewide Planning and Research Cooperative System (SPARCS) administrative database from 2010 to 2020 was queried to identify all patients over the age of 50 who underwent knee arthroscopy. Kaplan-Meier survival analysis was used to assess arthroplasty-free survivorship. Cox proportional hazards models were performed to assess the effect of the diagnoses of knee OA and obesity at the time of arthroscopy based on ICD-9 and 10 codes. RESULTS:A total of 300,587 patients aged 50 years or older underwent knee arthroscopy. The arthroplasty-free survivorship rate following knee arthroscopy is 83.0% at 5 years. However, at 10 years, the arthroplasty-free survivorship decreased to 66.6%. Patients without knee OA nor obesity had an arthroplasty-free survivorship of 84.1% at 5 years and 68.5% at 10 years. However, patients with a diagnosis of both knee OA and obesity based on ICD-9 and 10 codes had an arthroplasty-free survivorship of 66.2% at 5 years and 15.4% at 10 years. (HR: 2.38; 95% CI: 2.18, 2.60; p < 0.001) CONCLUSION: At five years there is an 83% rate of arthroplasty-free survivorship. This effect deteriorates at the 10-year mark, and many are eventually destined for knee arthroplasty. Presence of diagnosis codes for both knee OA and obesity are risk factors for knee arthroplasty following knee arthroscopy in patients 50 years and older. LEVEL OF EVIDENCE/METHODS:IV, Prognostic, Case Series.

BACKGROUND:Despite advances in surgical techniques and postoperative prophylactic protocols, venous thromboembolism (VTE) events remain an important source of morbidity following total hip arthroplasty (THA). Prior research in cardiology and other surgical fields has suggested that statin medications may have a protective effect against VTE. Our study aimed to: 1) Assess if preoperative statin use was associated with decreased rates of VTE following THA, and 2) conduct a subgroup analysis of statin intensity and VTE events. METHODS:A total of 1,154 patients who had preoperative statin use for at least four weeks before surgery and who underwent primary THA at a large, urban academic center between January 1, 2012, and June 1, 2023, were identified. The 90-day postoperative VTE events, deep vein thrombosis (DVT), pulmonary embolism (PE), emergency department (ED) visits, reoperations, and readmission rates were collected from institutional coding software. Mortality rate in the 90-day postoperative period was also measured. Propensity matching was used to control for demographics and selected comorbidities. RESULTS:Preoperative statin use was associated with significantly lower rates of 90-day VTE events (Statin: 0.43% versus No-Statin: 1.13%, P = 0.047). There were no significant differences in 90-day PE, DVT, ED visit, readmission, or reoperation rates. There were no deaths within 90 days of THA in either group. Subgroup analysis of statin intensity revealed no significant differences in any outcomes measured between high-intensity, medium-intensity, and low-intensity statin groups. CONCLUSION/CONCLUSIONS:Preoperative statin use is associated with significantly lower rates of VTE events in the 90-day postoperative period following THA. Further research into the effect of statins on post-THA VTE is warranted.

Orthopaedic surgeons face increasing pressure to meet quality metrics due to regulatory changes and payment policies. Poor outcomes, including patient mortality, can result in financial penalties and negative ratings. Importantly, adverse outcomes often increase surgeon stress level and lead to job dissatisfaction and burnout. Despite optimization efforts, some orthopaedic patients remain at high risk for complications. In this article, we explore the ethical considerations when surgeons are presented with high-risk surgical candidates. We examine how the ethical tenets of patient interests, namely beneficence, nonmaleficence, autonomy, and justice, apply to such patients. We discuss external forces such as the malpractice environment, financial challenges in health-care delivery, and quality rankings. Informed consent and the challenges of communicating risks to patients are discussed, as well as the role of modifiable and nonmodifiable risk factors. Case examples with varied outcomes highlight the complexities of decision-making with high-risk patients and the potential role of palliative care. We provide recommendations for surgeons and care teams, including the importance of justifiable reasons for not operating, the utilization of institutional resources to help make care decisions, and the robust communication of risks to patients.

BACKGROUND:Since 2021, the Centers for Medicare and Medicaid Services have mandated that patients have open access to their medical records. Many institutions use online portals, which allow patients to access their health information and communicate with care teams. Our research aimed to evaluate demographic patterns for online patient portal utilization in patients undergoing total knee arthroplasty (TKA). Further, we assessed if and how portal engagement contributes to perioperative outcomes. METHODS:This study retrospectively reviewed primary and elective TKA from 2017 to 2022 at a single academic institution. Patients were stratified into 2 groups based on their online portal status: activated (A) or not-activated (NA). Baseline characteristics and postoperative outcomes were collected from the electronic medical record and compared. RESULTS:In total, 10,995 patients were included: 8,330 (75.8%) were A and 2,625 (24.2%) were NA. The NA group was significantly older (P < .001); more likely to be Black (P < .001), women (P < .001), single/divorced/widowed (P < .001), non-English speaking (P < .001), and Medicare or Medicaid insured (P < .001); from zip codes with median incomes below $50,000 (P < .001), and more likely to be American Society of Anesthesiologists class III or IV (P < .001). Patient-reported outcome measure completion rates were significantly lower in the NA group (15.3 versus 47.7%, P < .001). Lengths of stay (LOS) were significantly higher in the NA group (2.7 versus 2.1 days, P < .001). The NA group was significantly more likely to be discharged to skilled nursing facilities (P < .001). Comparable rates of 90-day emergency department visits, readmissions, as well as 90-day and 2-year revisions, were observed across groups. CONCLUSIONS:There are significant disparities in online portal activation status based on patient demographics. Patients who have A portals had significantly higher Patient-reported outcome measure completion rates, shorter LOS, and higher rates of home discharge. Further research should determine which other factors may affect patient portal utilization and inform interventions to improve portal utilization among minority populations.

BACKGROUND:Though previous studies have demonstrated improved cost benefits associated with simultaneous versus staged bilateral total hip arthroplasty (simBTHA and staBTHA), further investigation is needed regarding the revenues and contribution margins (CMs) of these procedures. In this study, we compared revenue, CM, and surgical outcomes between simBTHA and staBTHA. METHODS:All patients who underwent simBTHA (both procedures completed the same day) and staBTHA (procedures completed on different days within one year) between 2011 and 2021 at a single high-volume orthopedic specialty hospital were identified. Of the 1,517 identified patients (n = 139 simBTHA, n = 1,378 staBTHA), 232 were included in a 1:1 propensity match based on baseline demographics (116 per cohort). Revenue, costs, CM, and surgical outcomes were compared between cohorts. RESULTS:Compared to staBTHA, simBTHA procedures had significantly lower total costs (P < .001), direct costs (P < .001), and patient revenue. There was no significant difference in CM between groups (P = .361). Additionally, there were no significant differences in length of stay (P = .173), operative time (P = .438), 90-day readmissions (P = .701), 90-day revisions (P = .313), or all-cause revisions (P = .701) between cohorts. CONCLUSIONS:Though simBTHA procedures have lower revenues than staBTHA, they also have lower costs, resulting in similar CM between procedures. As both procedures have similar postoperative complication rates, further research is required to evaluate specifically which patients may benefit from simBTHA versus staBTHA regarding clinical and patient-reported outcomes. LEVEL OF EVIDENCE/METHODS:III.