Faculty Bibliography

BACKGROUND:Vancomycin is often used as antimicrobial prophylaxis in patients undergoing total hip or knee arthroplasty. Vancomycin requires longer infusion times to avoid associated side effects. We hypothesized that vancomycin infusion is often started too late and that delayed infusion may predispose patients to increased rates of surgical site infections and prosthetic joint infections. METHODS:We reviewed clinical data for all primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients at our institution between 2013 and 2020 who received intravenous vancomycin as primary perioperative gram-positive antibiotic prophylaxis. We calculated duration of infusion before incision or tourniquet inflation, with a cutoff of 30 minutes defining adequate administration. Patients were divided into two groups: 1) appropriate administration and 2) incomplete administration. Surgical factors and quality outcomes were compared between groups. RESULTS:We reviewed 1047 primary THA and TKA patients (524 THAs and 523 TKAs). The indication for intravenous vancomycin usage was allergy (61%), methicillin-resistant staphylococcus aureus colonization (17%), both allergy and colonization (14%), and other (8%). 50.4% of patients began infusion >30 minutes preoperatively (group A), and 49.6% began infusion <30 minutes preoperatively (group B). Group B had significantly higher rates of readmissions for infectious causes (3.6 vs 1.3%, P = .017). This included a statistically significant increase in confirmed prosthetic joint infections (2.2% vs 0.6%, P = .023). Regression analysis confirmed <30 minutes of vancomycin infusion as an independent risk factor for PJI when controlling for comorbidities (OR 5.22, P = .012). CONCLUSION/CONCLUSIONS:Late infusion of vancomycin is common and associated with increased rates of infectious causes for readmission and PJI. Preoperative protocols should be created to ensure appropriate vancomycin administration when indicated.

AIMS/OBJECTIVE:The COVID-19 pandemic led to a swift adoption of telehealth in orthopaedic surgery. This study aimed to analyze the satisfaction of patients and surgeons with the rapid expansion of telehealth at this time within the division of adult reconstructive surgery at a major urban academic tertiary hospital. METHODS:A total of 334 patients underging arthroplasty of the hip or knee who completed a telemedicine visit between 30 March and 30 April 2020 were sent a 14-question survey, scored on a five-point Likert scale. Eight adult reconstructive surgeons who used telemedicine during this time were sent a separate 14-question survey at the end of the study period. Factors influencing patient satisfaction were determined using univariate and multivariate ordinal logistic regression modelling. RESULTS:A total of 68 patients (20.4%) and 100% of the surgeons completed the surveys. Patients were "Satisfied" with their telemedicine visits (4.10/5.00 (SD 0.98)) and 19 (27.9%) would prefer telemedicine to in-person visits in the absence of COVID-19. Multivariate ordinal logistic regression modelling revealed that patients were more likely to be satisfied if their surgeon effectively responded to their questions or concerns (odds ratio (OR) 3.977; 95% confidence interval (CI) 1.260 to 13.190; p = 0.019) and if their visit had a high audiovisual quality (OR 2.46; 95% CI 1.052 to 6.219; p = 0.042). Surgeons were "Satisfied" with their telemedicine experience (3.63/5.00 (SD 0.92)) and were "Fairly Confident" (4.00/5.00 (SD 0.53)) in their diagnostic accuracy despite finding the physical examinations to be only "Slightly Effective" (1.88/5.00 (SD 0.99)). Most adult reconstructive surgeons, seven of eight (87.5%) would continue to use telemedicine in the future. CONCLUSION/CONCLUSIONS: 2021;103-B(6 Supple A):196-204.

BACKGROUND:To measure functional outcome, patient reported outcome measures (PROMs) are most often used but biomechanical tests can provide valuable supplementary data. The objective of this study was to investigate instrumented insoles for measuring ground-to-foot forces during basic activities. METHODS:Three groups were evaluated: normal controls, preoperative, and postoperative total knees. The Knee Society Scoring System (KSS) Short Form was used, and with foot pressure sensor insoles, a timed-up-and-go (TUG) test and a sit-to-stand (STS) test was used. RESULTS:Comparing preoperative to postoperative and control groups, there were significant differences in most parameters. There were no significant differences between controls and postoperative knees. Of the 33 correlation coefficients between three PROM parameters and six biomechanical parameters for the three groups, only five coefficients were greater than 0.5. CONCLUSIONS:The biomechanical data was substantially independent of the PROM data and provided additional functional evaluation. The most useful parameters were the left-right force ratios during sit-to stand (STS) and the timed-up-and-go (TUG) time.

BACKGROUND:The opioid epidemic in the United States is a public health crisis. As a result, regulatory agencies, including state governments, have enacted initiatives to decrease the use of opioids in the perioperative setting. The purpose of this study was to compare opioid utilization in orthopaedic surgery patients at discrete points after implementation of State regulatory and institution/physician-led initiatives to decrease opioid utilization in the perioperative period. METHODS:We reviewed the electronic medication orders for all patients who underwent orthopaedic surgery procedures between September 2015 and June 2018 at our urban academic medical center. The outcome measures were the number of patients who were prescribed opioid medications, duration of prescription (days), and average milligram morphine equivalents prescribed. Patients were divided into three time cohorts to assess the effect of the NY State (NYS) policy and institutional initiatives to decrease opioid utilization. RESULTS:A total of 20,483 patients met the inclusion criteria over all three time cohorts. After the initiation of the NYS 7-day supply legislation, there was a decrease in the average supply of opioids prescribed from 10.1 to 7.6 days and the average daily milligram morphine equivalent decreased from 67.9 to 56.7 mg (P < 0.0001). However, with the combination of physician education and surgeon-led institutional initiatives, the percentage of patients who were prescribed opioids decreased by over 10% (96% to 84%), with continued decrease in duration of prescription by 1.0 to 6.4 days (P < 0.0001). CONCLUSIONS:The addition of institution-led initiatives and education programs to previously established government-led prescription limits produced a substantial reduction in the amount of opioids prescribed to orthopaedic surgery patients in the perioperative period. Although mandatory limits set by the state government resulted in a decreased amount of opioid medications being prescribed per patient, it was only after the introduction of educational programs and institution- and physician-led programs that perioperative patient exposure to opioids decreased. LEVEL OF EVIDENCE/METHODS:Level III.

BACKGROUND:Preoperative testing costs billions of dollars despite little evidence supporting its utility. The purpose of this study was to determine the relationship between abnormal preoperative laboratory tests and postoperative complications following total joint arthroplasty. METHODS:The NSQIP database was used to identify 45,936 primary total hip arthroplasty (THA) and 76,041 pri-mary total knee arthroplasty (TKA) cases performed between 2006 and 2013. Complications within 30 days of surgery were collected and multivariable regression modeling was performed incorporating all significant laboratory values as well as demographics and preoperative comorbidities. RESULTS:For THA patients, abnormal sodium (p = 0.016, OR = 1.89), white count (p = 0.043, OR = 1.73), and partial thromboplastin time (p = 0.028, OR = 1.43) were significantly associated with complications. For TKA patients, abnormal alkaline phosphatase (p = 0.04, OR = 2.12), creatinine (p = 0.003, OR = 1.56), and INR (p = 0.008, OR = 1.99) were significantly predictive of complications. CONCLUSION/CONCLUSIONS:Of the 13 laboratory values, only six were significantly associated with complications. These findings may have implications for risk stratification in the inpatient setting.

BACKGROUND:Many US patients who undergo total joint arthroplasty have low English proficiency, yet no study has investigated how the need for a translator impacts postoperative outcomes for these patients. We hypothesized that need for an interpreter after total joint arthroplasty would impact discharge disposition and length of stay. METHODS:We performed a retrospective chart review of patients at a single large urban academic institution undergoing single primary total joint replacement from July 2016 to November 2019. Patients were classified as primarily English speaking (E), non-English primary language and did not require an interpreter (NE-N), or non-English primary language and did require an interpreter (NE-I). Data on patient characteristics, length of stay, and discharge disposition were collected. RESULTS:Total hip arthroplasty (THA) patients in the NE-I group had significantly longer length of stay than both the NE-N group (2.85 vs 2.28 days, P = .015) and the E group (2.85 s vs 1.87 days, P < .0001). THA patients who required a translator were also significantly less likely to be discharged to home than those who were primarily English speaking (71.4% vs 88.8%, P < .0001). Total knee arthroplasty (TKA) patients in the NE-I group had significantly longer length of stay than the E group (2.66 vs 2.50 days, P = .009). The TKA patients in the NE-I group were significantly less likely to be discharged home than in the E group (74.5% vs 82.4%, P < .0001). CONCLUSION/CONCLUSIONS:Although interpreter services are provided by the hospital for NE-I patients, the communication barrier that exists affects both length of stay and discharge disposition for both THA and TKA.

Background/UNASSIGNED:The impact of tobacco use on perioperative complications, hospital costs, and survivorship in total joint arthroplasty (TJA) is well established. The aim of this study is to report the impact of tobacco cessation on outcomes after TJA and to measure the impact of a voluntary smoking cessation program (SCP) on self-reported smoking quit rates in a premier academic medical center. Methods/UNASSIGNED:A seven-year (2013-2019) SCP database was provided by the Integrative Health Promotion Department and Infection Prevention and Control Department. We evaluated program and smoking status, patient demographics, length of stay (LOS), and 90-day post-operative infection rates and readmission rates. The primary outcome was quit rates based on SCP enrollment status. The secondary outcomes measured infection rates, readmission rates, and LOS based on enrollment status and/or quit rate. Results/UNASSIGNED:A total of 201 eligible patients were identified: 137 patients in the SCP (intervention) group and 64 in the self-treatment (control) group. SCP patients trended towards higher quit rates (43% vs 33%, p = 0.17), shorter LOS (2.47 vs 2.62 days, p = 0.52), lower infection rates (7.3% vs 12.5%, p = 0.27) and slightly higher readmission rates (5.8% vs 4.7%, p = 0.73). In a sub-analysis, self-reported smokers demonstrated statistically significant decrease in infection (3.7% vs 12.5%, p = 0.03). Conclusion/UNASSIGNED:There was a statistically significant decrease in infection rates in patients who self-reported quitting tobacco prior to TJA. Additionally, quit rates for patients who participated in a voluntary SCP trended towards increased pre-operative cessation. Further efforts to increase tobacco cessation prior to TJA and examine the impact on patient outcomes are needed.

The Political Action Committee (PAC) of the American Association of Orthopaedic Surgeons, also known as the OrthoPAC, is one of the most powerful and well-respected healthcare PACs in Washington, DC. Since its inception in 1999, the OrthoPAC has advocated at the federal level for orthopaedic patients and orthopaedic surgery as a profession. This manuscript will familiarize the reader with PACs, the history and structure of the OrthoPAC, important accomplishments of the OrthoPAC, current legislative positions, and leadership/organization. We also review the various ways that orthopaedic surgeons can engage in advocacy for musculoskeletal care.