Faculty Bibliography

As the world grapples with the COVID-19 pandemic, we as health care professionals thrive to continue to help our patients, and as orthopedic surgeons, this goal is ever more challenging. As part of a major academic tertiary medical center in New York City, the orthopedic department at New York University (NYU) Langone Health has evolved and adapted to meet the challenges of the COVID pandemic. In our report, we will detail the different aspects and actions taken by NYU Langone Health as well as NYU Langone Orthopedic Hospital and the orthopedic department in particular. Among the steps taken, the department has reconfigured its staff's assignments to help both with the institution's efforts and our patients' needs from reassigning operating room nurses to medical COVID floors to having attending surgeons cover urgent care locations. We have reorganized our residency and fellowship rotations and assignments as well as adapting our educational programs to online learning. While constantly evolving to meet the institution's and our patient demands, our leadership starts planning for the return to a new "normal".

There has been an upsurge in the number of practices owned by non-physicians. With orthopaedic surgery as the next frontier in this market, orthopaedists need to consider the ethical consequences of such acquisitions. The history and trends of practice ownership are reviewed alongside how laws shifted to reflect a changing health-care climate. The 4 tenets of bioethics (beneficence, nonmaleficence, autonomy, and justice) are explored with regard to practice acquisition by non-physician entities. Although non-physician-owned corporations and private equity firms provide liquidity to the health-care sector, there are ethical concerns that may ultimately impact patient care. Orthopaedic surgeons must be cautious when engaging in acquisitions with non-physician-owned entities, as the goals of each party may not align. This may yield situations that infringe on the basic principles of bioethics for both physician and patient.

PURPOSE/OBJECTIVE:Wide-awake local anesthesia no tourniquet (WALANT) is an increasingly popular surgical technique. However, owing to surgeon preference, patient factors, or hospital guidelines, it may not be feasible to inject patients with solutions containing epinephrine the recommended 25 minutes prior to incision. The purpose of this study was to assess pain and patient experience after short hand surgeries done under local anesthesia using a tourniquet rather than epinephrine for hemostasis. METHODS:Ninety-six consecutive patients undergoing short hand procedures using only local anesthesia and a tourniquet (LA-T) were assessed before and after surgery. A high arm pneumatic tourniquet was used in 73 patients and a forearm pneumatic tourniquet was used in 23. All patients received a local, unbuffered plain lidocaine injection. No patients received sedation. Pain related to local anesthesia, pneumatic tourniquet, and the procedure was assessed using a visual analog scale (VAS). Patient experience was assessed using a study-specific questionnaire based on previous WALANT studies. Tourniquet times were recorded. RESULTS:Mean pain related to anesthetic injection was rated 3.9 out of 10. Mean tourniquet related pain was 2.9 out of 10 for high arm pneumatic tourniquets and 2.3 out of 10 for forearm pneumatic tourniquets. Patients rated their experience with LA-T favorably and 95 of 96 patients (99%) reported that they would choose LA-T again for an equivalent procedure. Mean tourniquet time was 9.6 minutes and only 1 patient had a tourniquet inflated for more than 20 minutes. Tourniquet times less than 10 minutes were associated with less pain than tourniquet times greater than 10 minutes (P < .05); however, both groups reported the tourniquet to be on average less painful than the local anesthetic injection. CONCLUSION/CONCLUSIONS:Short wide-awake procedures using a tourniquet are feasible and well accepted. Local anesthetic injection was reported to be more painful than pneumatic tourniquet use. Tourniquets for short wide-awake procedures can be used in settings in which preprocedure epinephrine injections are logistically difficult or based on surgeon preference. TYPE OF STUDY/LEVEL OF EVIDENCE/METHODS:Therapeutic IV.

Background/UNASSIGNED:We describe surgeon-specific patient and procedure variability in a single center to determine how much variability exists between surgeons. Methods/UNASSIGNED:Data was analyzed from 2009 to 2013 at a single center. The total number of primary and revision hip and knee arthroplasty surgeries were quantified for each surgeon. Results/UNASSIGNED:Surgeon caseload varied significantly, with the largest differences observed in primary TKA caseload. The largest patient differences were in regards to percentage of patients with diabetes mellitus amongst primary TKA patients. Conclusion/UNASSIGNED:Significant differences in patient characteristics that could significantly impact outcomes after total joint arthroplasty were found amongst surgeons.

BACKGROUND:Access to elective total knee arthroplasty is important in the treatment of end-stage arthritis, and numerous initiatives, including Medicaid expansion, have sought to improve patients' ability to undergo this procedure. However, despite this, the role of Medicaid insurance in patient outcomes remains unclear. The purpose of this study was to perform a systematic review of the literature to explore the relationship between preoperative Medicaid insurance status and outcomes following primary total knee arthroplasty. METHODS:A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies examining outcomes in patients who had Medicaid and were undergoing total knee arthroplasty. Studies including complex revision operations or less common indications for total knee arthroplasty were excluded. Data on insurance status, postoperative complications, length of stay, readmissions, and subsequent revision surgical procedures were collected for each article. RESULTS:A total of 13 studies showing 6.18 million patients undergoing total knee arthroplasty were included in the qualitative synthesis. Seven analyses described an important association between Medicaid coverage and short-term readmissions, and 2 analyses showed a relationship between Medicaid and prolonged length of stay. However, the included studies did not describe a significant association between Medicaid and postoperative mortality or revision rates. CONCLUSIONS:Patients with Medicaid undergoing total knee arthroplasty may be more likely to experience an increased length of stay and to be readmitted postoperatively. The unique factors associated with these patients may help to inform customized perioperative surveillance and optimization to improve outcomes in this group. LEVEL OF EVIDENCE/METHODS:Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:This study evaluates the incidence of bariatric surgery (BS) before total joint arthroplasty (TJA) in New York State and compares patient comorbidities and 90-day postoperative complications of patients with and without BS before TJA. METHODS:The NY Statewide Planning and Research Cooperative System database between 2005 and 2014 was reviewed and 343,710 patients with TJA were identified. Patients were stratified into the following three cohorts: group 1 (patients who underwent BS < 2 years before TJA [N = 1,478]); group 2 (obese patients without preoperative BS [N = 60,259]); and group 3 (nonobese patients without preoperative BS [N = 281,973]). Principal outcomes measured were patient comorbidities, 90-day complication rates, length of inpatient stay, discharge disposition, mortality rate, and total hospital costs. RESULTS:BS before TJA incidence increased from 0.11 of 100,000 to 2.4 of 100,000 from 2006 to 2014. Preoperative BS did not notably change the number of patient comorbidities at the time of TJA. Group 1 had more patients with 90-day complications (40.7% versus 36.0%, P < 0.001) than group 2. No difference was found between group 1 and the other groups in home discharge, pulmonary embolism, deep vein thrombosis, and mortality rates. Total hospital costs were higher for group 1 ($18,869 ± 9,022 versus $17,843 ± 8,095, P < 0.001) compared with those for group 2. CONCLUSION/CONCLUSIONS:BS before TJA has increased annually over a 10-year period in New York State and is associated with greater 90-day postoperative complication rates and higher immediate hospital costs when compared with obese patients without BS.

BACKGROUND:There is an increasing utilization of same-day discharge total hip arthroplasty (SDD THA). As the Center for Medicare and Medicaid Services considers removing THA from the inpatient-only list, there is likely to be a significant increase in the number of Medicare patients undergoing SDD THA. Thus, there is a need to report on outcomes of SDD THA in this population. METHODS:A retrospective review was performed on 850 consecutive SDD THA patients including 161 Medicare patients. We compared failure to launch, complication, emergency department visit, and 90-day readmission rates between the Medicare and non-Medicare cohorts. RESULTS:The Medicare group was older and had less variability in their admission diagnosis. There was no significant difference in failure to launch, complication, emergency department visit, or 90-day readmission rates between Medicare and non-Medicare groups. CONCLUSION/CONCLUSIONS:The benefits of SDD THA can be safely extended to the carefully indicated and motivated Medicare patient.

BACKGROUND:Dilute betadine wash has been used for the prevention of prosthetic joint infection (PJI). Appropriateness for this purpose has recently come into question as the Food and Drug Administration determined that several commercial products did not pass the standards of proper sterility. The goal of this study is to determine if change in our institution's perioperative infection protocol to sterile chlorhexidine gluconate wash affected rates of PJI. METHODS:This is a retrospective study of prospectively collected data for patients who underwent unilateral primary total knee arthroplasty and total hip arthroplasty. Chart review was performed to determine 90-day and 1-year readmissions and the development of PJI as per the diagnostic criteria of the Musculoskeletal Infection Society. RESULTS:A total of 2386 consecutive patients were included in this study. There were no significant demographic differences between the 2 groups. There was no statistically significant difference in the rate of PJI requiring a return trip to the operating room between the 2 cohorts: 4 in chlorhexidine vs 7 in betadine at 3 months (P = .61); and 9 in chlorhexidine and 14 in betadine at 1 year (P = .48, respectively). There was also no difference in the rate of wound complications between the betadine and chlorhexidine use (P = .93). CONCLUSION/CONCLUSIONS:When comparing patients who received a betadine wash intraoperatively to those who received a chlorhexidine gluconate wash, there were no statistically significant differences in the rate of postoperative PJIs or return trips to the operating room. Although chlorhexidine gluconate and betadine have equal efficacy in the prevention of PJI, betadine is a far less expensive alternative if their sterility concerns are unwarranted LEVEL OF EVIDENCE: Therapeutic Level III.