Faculty Bibliography

BACKGROUND:At our institution, all postoperative total hip arthroplasty (THA) candidates have received home health services (HHS), consisting of visiting nurses, physical and occupational therapists. However, with a more technologically inclined patient population, electronic patient rehabilitation applications (EPRAs) can be used to deliver perioperative care at the comfort of the patient's home. The aim of this study is to investigate the clinical utility and economic burden associated with digital rehabilitation applications in primary THA recipients. METHODS:We conducted a single-center, retrospective review of patients operated between November 2016 and November 2017. Before surgery, and at the discretion of the surgeon, patients were assigned to EPRA with HHS or EPRA alone. Patient baseline demographics, EPRA engagement, and validated patient-reported outcomes (PROs) were (Veterans Rand 12-Item Health Survey [VR-12] and Hip Disability and Osteoarthritis Outcome Score Junior) at baseline and 12 weeks. These PRO scores were correlated with cohort assignments to assess noninferiority of EPRA alone. RESULTS:In total, 268 patients received either EPRA-HHS (n = 169) or EPRA (n = 99) alone. Patients receiving EPRA only were on average younger (60.8 vs 65.8; P < .0001), but otherwise similar to patients in the EPRA-HHS cohort. EPRA-only patients demonstrated no differences in VR-12 (P > .05) and Hip Disability and Osteoarthritis Outcome Score Junior (P > .05) when compared with EPRA-HHS. CONCLUSION/CONCLUSIONS:The integration of electronic rehabilitation tools is gaining acceptance within the orthopedic community. Our study demonstrated that EPRA alone was clinically noninferior while substantially less costly than EPRA-HHS.

BACKGROUND: The frequency of total joint arthroplasties (TJAs) performed in ambulatory surgery centers (ASCs) is increasing. However, not all TJA patients are healthy enough to safely undergo these procedures in an ambulatory setting. We examined the percentage of arthroplasty patients who would be eligible to have the procedure performed in a free-standing ASC and the distribution of comorbidities making patients ASC-ineligible. METHODS: We reviewed the charts of 3444 patients undergoing TJA and assigned ASC eligibility based on American Society of Anesthesiologists (ASA) status, a set of exclusion criteria, and any existing comorbidities. RESULTS: Overall, 70.03% of all patients undergoing TJA were eligible for ASC. Of the ASA class 3 patients who did not meet any exclusion criteria but had systemic disease (51.11% of all ASA class 3 patients), 53.69% were deemed ASC-eligible because of sufficiently low severity of comorbidities. The most frequent reasons for ineligibility were body mass index >40 kg/m2 (32.66% of ineligible patients), severity of comorbidities (28.00%), and untreated obstructive sleep apnea (25.19%). CONCLUSION: A large proportion of TJA patients were found to be eligible for surgery in an ASC, including over one-third of ASA class 3 patients. ASC performed TJA provides an opportunity for increased patient satisfaction and decreased costs, selecting the right candidates for the ambulatory setting is critical to maintain patient safety and avoid postoperative complications.

OBJECTIVES: To determine the efficacy of liposomal bupivacaine compared to placebo for post-operative pain control in patients undergoing operative fixation of ankle fractures. DESIGN: Prospective single blinded randomized control trial SETTING:: Academic Medical CenterPatients/Participants: After IRB approval, seventy-six patients who sustained an acute ankle fracture (OTA 44A-C) requiring operative fixation met inclusion criteria. INTERVENTION: Patients were randomly assigned to one of two groups, control (local intra-operative sterile saline injection under general anesthesia) or interventional (local intra-operative liposomal bupivacaine and bupivacaine injection under general anesthesia). Injections were administered in a standardized fashion and included injection of a 1:1 mixture of a 40cc solution consisting of 1.3% Exparel and sterile saline (interventional) or a 40 cc injection of normal saline (control) into the surrounding periosteal, peritendinous, surrounding muscles and subcutaneous tissue of the surgical incision(s). MAIN OUTCOME MEASUREMENTS: Pain medications administered and pain according to the Visual Analogue Scale (VAS) was recorded at scheduled post-operative time points: 4, 24, 48, 72, and 336 hours (14 days). RESULTS: Thirty-nine patients were randomized to the control group and thirty-seven to the interventional group (mean age= 42 +/- 15 years), with no statistically significant differences between groups with regards to severity of injury and patient demographics. Pain scores were significantly lower in the interventional group versus control up to two weeks after surgery. Percocet ingestion at four hours was significantly lower in the interventional group (0.7 vs. 1.3, p=0.004), while it approached significance at forty-eight hours post-operatively (2.8 vs. 3.69, p=0.07). No other significant differences were noted for Percocet ingestion post-operatively at other time points assessed. The overall satisfaction with pain control was not statistically different between the two groups (p=0.93). CONCLUSION: Local intra-operative infiltration of liposomal bupivacaine administered with standard bupivacaine for ankle fractures requiring ORIF affords improved pain relief in the immediate post-operative period resulting in a reduction in Percocet ingestion, with resultant effects seen up to two days post-operatively. Continued investigation of this drug for use with extremity fractures is warranted. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES: To examine 1-year functional and clinical outcomes in patients with tibial plateau fractures with tibial eminence involvement. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Academic Medical Center. PATIENTS/PARTICIPANTS: All patients who presented with a tibial plateau fracture (Orthopaedic Trauma Association (OTA) 41-B and 41-C). INTERVENTION: Patients were divided into fractures with a tibial eminence component (+TE) and those without (-TE) cohorts. All patients underwent similar surgical approaches and fixation techniques for fractures. No tibial eminence fractures received fixation specifically. MAIN OUTCOME MEASUREMENTS: Short musculoskeletal functional assessment (SMFA), pain (Visual Analogue Scale), and knee range-of-motion (ROM) were evaluated at 3, 6, and 12 months postoperatively and compared between cohorts. RESULTS: Two hundred ninety-three patients were included for review. Patients with OTA 41-C fractures were more likely to have an associated TE compared with 41-B fractures (63% vs. 28%, P < 0.01). At 3 months postoperatively, the +TE cohort was noted to have worse knee ROM (75.16 +/- 51 vs. 86.82 +/- 53 degree, P = 0.06). At 6 months, total SMFA and knee ROM was significantly worse in the +TE cohort (29 +/- 17 vs. 21 +/- 18, P