We sought to evaluate whether tourniquet use, with the resultant ischemia and reperfusion, during surgical treatment of an open lower-extremity fracture was associated with an increased risk of complications.This is a retrospective cohort study of 1,351 patients who had an open lower-extremity fracture at or distal to the proximal aspect of the tibia and who participated in the FLOW (Fluid Lavage of Open Wounds) trial. The independent variable was intraoperative tourniquet use, and the primary outcome measures were adjudicated unplanned reoperation within 1 year of the injury and adjudicated nonoperative wound complications.Unplanned reoperation and nonoperative wound complications were roughly even between the no-tourniquet (18.7% and 19.1%, respectively) and tourniquet groups (17.8% and 20.8%) (p = 0.78 and p = 0.52). Following matching, as determined by model interactions, tourniquet use was a significant predictor of unplanned reoperation in Gustilo Type-IIIA (odds ratio, 3.60; 95% confidence interval, 1.16 to 11.78) and IIIB fractures (odds ratio, 16.61; 95% confidence interval, 2.15 to 355.40).The present study showed that tourniquet use did not influence the likelihood of complications following surgical treatment of an open lower-extremity fracture. However, in cases of severe open fractures, tourniquet use was associated with increased odds of unplanned reoperation; surgeons should be cautious with regard to tourniquet use in this setting.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Background: Value-based health-care delivery is a framework for restructuring our health-care systems with the goal of providing better outcomes for patients at lower cost. Value is determined by patient health outcomes per dollar spent on health services. We sought to develop a value dashboard that could be used to easily track and improve the value of total hip and knee arthroplasty (THA and TKA). Methods: We created a value dashboard for TKAs and THAs at our institution. Value was defined as quality of outcomes per dollar spent. The dashboard for each procedure displayed the average value by surgeon, compared with institutional averages for physical function scores and cost. Quality metrics were determined by weighted surgeon ranking using a modified Delphi process and included both clinical and patient-reported outcomes, as measured by the mean change in the Patient-Reported Outcomes Measurement Information System Global-10 (PROMIS-10) physical function score, mean change in the Hip disability and Osteoarthritis Outcome Score-Joint Replacement (HOOS-JR) or the Knee injury and Osteoarthritis Outcome Score-Joint Replacement (KOOS-JR), mean change in the modified Single Assessment Numeric Evaluation (SANE) score, complication rate, periprosthetic joint infection (PJI) rate, and 30-day readmission rate. Average direct costs per surgeon were used. Data from January 2017 through April 2018 were included to ensure 1-year follow-up. Results: Six surgeons were included in the value dashboard for TKA, and 5 were included in the THA dashboard. The value for TKA by surgeon ranged from 7% below to 12% above the institutional benchmark. The value for THA by surgeon ranged from 12% below to 7% above the institutional benchmark. Conclusions: The proposed dashboard utilizes value in a health-care framework and could be used for comparing and improving value for THA and TKA. This dashboard successfully combined patient outcome metrics and direct costs of surgical procedures. Future studies should focus on involving patients in this process and using national data to create benchmarks, which could provide a more accurate representation of value than using institutional averages.
Debridement of the surgical site during open fracture reduction and internal fixation is important for preventing surgical site infection; the risk of subsequent fracture-associated infection for a particular area of tissue is assessed by the surgeon based on multi-level variables, including demographics and laboratory results. Intraoperative fluorescence imaging can contribute additional information at a more localized level. Here we present a fluorescence-based predictive model using features from dynamic contrast enhanced-fluorescence imaging (DCE-FI), as well as patient-level variables associated with infection risk. Regions-of-interest were selected from thirty-eight enrolled open fracture patients. Spatial and kinetic features were extracted from DCE-FI, and combined with patient infection risk factor describing the possibility of getting surgical-site-infection. The model was evaluated for ability to predict composite outcome scores—intra-operative surgeon assessment coupled with post-operative confirmed infection outcome. This proposed model demonstrates high predictive performance with an accuracy of 0.86, evaluated with a cross-validation approach, and is a promising approach for early and quick identification of tissue prone to infection.
Symptoms of stress, depression, and burnout are prevalent in medicine, adversely affecting physician performance. We investigated real-time measurements of physiological strain in orthopaedic resident and faculty surgeon volunteers and identified potential daily stressors.We performed a prospective blinded cohort pilot study in our academic orthopaedic department. Physicians used a wearable fitness device for 12 weeks to objectively measure heart rate variability (HRV), a documented parameter of overall well-being. Baseline burnout levels were assessed using the Maslach Burnout Inventory questionnaire. Daily surveys inquiring on work responsibilities (clinic, operating room [OR], or "other") were correlated with physiological parameters of strain. Descriptive statistics and linear mixed effects modeling were used to evaluate bivariate relationships.Of the 21 participating surgeons, 9 faculty and 12 residents, there was a response rate of 95.2% for the initial burnout survey. Daily surveys were completed for 63.8% (54.9 ± 22.3 days) of the total collection window, and surgeons wore the device for 83.2% of the study (71.6 ± 25.0 days). Residents trended toward lower personal accomplishment and greater psychological detachment on the Maslach Burnout Inventory, with 5 surgeons including 1 faculty surgeon (11.1%) and 4 resident surgeons (33.3%) found to have negatively trending HRV throughout the study period demonstrating higher physiological strain. Time in the OR led to increased next-day HRV (y-intercept = 47.39; B = 4.90; 95% confidence interval, 2.14-7.66; P < 0.001), indicative of lower physiological strain. An increase in device-reported sleep from a surgeon's baseline resulted in a significant increase in next-day HRV (y-intercept = 50.46; B = 0.64; 95% confidence interval, 0.11-1.17; P = 0.02).Orthopaedic residents, more than faculty, had physiologic findings suggestive of burnout. Time in the OR and increased sleep improved physiological strain parameters. Real-time biometric measurements can identify those at risk of burnout and in need of well-being interventions.Level III.
Abstract Information and communication technologies (ICTs) are rapidly becoming indispensable organizational tools. Though the benefits of such technologies have been trumpeted, recent research has examined the unique pressures that may be introduced through the lens of a construct called workplace telepressure , defined as an urge for and preoccupation with quickly responding to ICTs (e.g., email). The current study further explores the workplace telepressure construct as a unique contributor to measures of workplace well‐being over and above perceived workplace demands and individual differences, introducing new constructs into the study of workplace telepressure. Furthermore, the study critically evaluates the term “telepressure” as applied to the underlying construct, as “pressure” may connote a perception of external force being placed on an individual, whereas the definition offered by past research identifies a preoccupation and urge to respond immediately to ICT messages, which may be internally generated. Finally, the ability of workplace telepressure to account for unique variance in workplace subjective well‐being measures is investigated.
Curative surgery for other many cancers requires that the tumor be removed with a zone of normal tissue surrounding the tumor with 'negative' margins. Sarcomas, cancers of the bones, muscles, and fat, require WLE for cure. Unfortunately, 'positive' margins occur in 20-25% of sarcoma surgeries, associated with cancer recurrence and reduced survival. Our group successfully tested a small-molecule fluorophore (ABY-029) in sarcomas that targets the epidermal growth factor receptor. We sought to evaluate human sarcoma xenografts for epidermal growth factor receptor expression and binding of ABY-029 with and without exposure to standard presurgical chemotherapy and radiation. We inoculated groups of 24 NSG mice with five cell lines (120 mice total). Eight mice from each cell line received: 1) radiation alone; 2) chemotherapy alone; or 3) chemotherapy and radiation. We administered ABY-029 2-4 hours before surgery. Tumor and biopsy portions of background tissues were removed. All tissues were imaged on a LI-COR Odyssey and processed in pathology. There were no significant reductions in epidermal growth factor receptor expression or in ABY-029-mediated fluorescence in tumors exposed to chemotherapy, radiation, or both. fluorescence-guided surgery demonstrates strong promise to improve curative surgical cancer care, particularly for sarcomas where the positive margin rate is substantial. Fluorophore performance must be evaluated under circumstances that duplicate accurately the biological milieu relevant to a particular cancer. This work shows that human sarcoma xenografts subjected to standard therapies do not demonstrate a change in epidermal growth factor receptor expression or in epidermal growth factor receptor-targeted fluorescence, thereby indicating that epidermal growth factor receptor-targeted fluorescence-guided surgery should be feasible under normal therapeutic conditions in the clinic.
Abstract Background Imaging‐based navigation technologies require static referencing between the target anatomy and the optical sensors. Imaging‐based navigation is therefore well suited to operations involving bony anatomy; however, these technologies have not translated to soft‐tissue surgery. We sought to determine if fluorescence imaging complement conventional, radiological imaging‐based navigation to guide the dissection of soft‐tissue phantom tumors. Methods Using a human tissue‐simulating model, we created tumor phantoms with physiologically accurate optical density and contrast concentrations. Phantoms were dissected using all possible combinations of computed tomography (CT), magnetic resonance, and fluorescence imaging; controls were included. The data were margin accuracy, margin status, tumor spatial alignment, and dissection duration. Results Margin accuracy was higher for combined navigation modalities compared to individual navigation modalities, and accuracy was highest with combined CT and fluorescence navigation ( p = 0.045). Margin status improved with combined CT and fluorescence imaging. Conclusions At present, imaging‐based navigation has limited application in guiding soft‐tissue tumor operations due to its inability to compensate for positional changes during surgery. This study indicates that fluorescence guidance enhances the accuracy of imaging‐based navigation and may be best viewed as a synergistic technology, rather than a competing one.
We appreciate the response from Pegreffi et al. (F. Pegreffi et al., unpublished data) to the article "The Effect of Intra-articular Hyaluronic Acid Injections and Payer Coverage on Total Knee Arthroplasty Procedures: Evidence From Large U.S. Claims Database." We agree there are several limitations associated with the use of administrative data, as stated within the article and noted by Pegreffi et al. We are unable to comment on noncoded factors that may influence the utilization of viscosupplementation, including severity of the disease, previous nonoperative management, the patient mindset toward treatment, and the operative provider's practice model. To minimize bias, we utilized a large national commercial claims administrative database that provides coverage to over 45 million U.S. members. In addition, we controlled for the age of the patient at the time of diagnosis of knee pain/osteoarthritis, and the year of the procedure to account for temporal changes. While there are conflicting publications regarding the utilization of intra-articular hyaluronic acid injections for knee osteoarthritis, many major governing bodies and organizations do not recommend unconditional use of intra-articular hyaluronic acid, including the American Academy of Orthopaedic Surgeons [[1]Jevsevar D.S. Brown G.A. Jones D.L. Matzkin E.G. Manner P.A. Mooar P. et al.American Academy of Orthopaedic SThe American academy of orthopaedic surgeons evidence-based guideline on: treatment of osteoarthritis of the knee.J Bone Joint Surg Am. 2013; 95: 1885-1886Crossref PubMed Google Scholar], the United Kingdom's National Institute for Health and Care Excellence [[2]National Institute for Health and Care ExcellenceOsteoarthritis: care and management [CG177]. (NICE) NIfHaCE, London2014Google Scholar], American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee [[3]Kolasinski S.L. Neogi T. Hochberg M.C. Oatis C. Guyatt G. Block J. et al.2019 American College of rheumatology/arthritis foundation guideline for the management of osteoarthritis of the Hand, Hip, and knee.Arthritis Rheumatol. 2020; 72: 220-233Crossref PubMed Scopus (700) Google Scholar], and the Osteoarthritis Research Society International [[4]McAlindon T.E. Bannuru R.R. Sullivan M.C. Arden N.K. Berenbaum F. Bierma-Zeinstra S.M. et al.OARSI guidelines for the non-surgical management of knee osteoarthritis.Osteoarthritis Cartilage. 2014; 22: 363-388Abstract Full Text Full Text PDF PubMed Scopus (2051) Google Scholar]. Within the scope of our research, TKA procedures have continued to increase regardless of intra-articular hyaluronic acid utilization and varying levels of payer coverage. Other studies have also failed to demonstrate a clinically important benefit from hyaluronic acid compared to placebo [5Gregori D. Giacovelli G. Minto C. Barbetta B. Gualtieri F. Azzolina D. et al.Association of pharmacological treatments with long-term pain control in patients with knee osteoarthritis: a systematic review and meta-analysis.JAMA. 2018; 320: 2564-2579Crossref PubMed Scopus (181) Google Scholar, 6Hunter D.J. Viscosupplementation for osteoarthritis of the knee.N Engl J Med. 2015; 372: 2570Crossref PubMed Scopus (83) Google Scholar, 7Jevsevar D. Donnelly P. Brown G.A. Cummins D.S. Viscosupplementation for osteoarthritis of the knee: a systematic review of the evidence.J Bone Joint Surg Am. 2015; 97: 2047-2060Crossref PubMed Scopus (147) Google Scholar, 8Jevsevar D.S. Shores P.B. Mullen K. Schulte D.M. Brown G.A. Cummins D.S. Mixed treatment comparisons for nonsurgical treatment of knee osteoarthritis: a network meta-analysis.J Am Acad Orthop Surg. 2018; 26: 325-336Crossref PubMed Scopus (38) Google Scholar, 9Juni P. Hari R. Rutjes A.W. Fischer R. Silletta M.G. Reichenbach S. et al.Intra-articular corticosteroid for knee osteoarthritis.Cochrane Database Syst Rev. 2015; 10: CD005328Google Scholar]. Additional clinical trials should be employed to identify the role of hyaluronic acid injections in the treatment armamentarium for knee osteoarthritis, after appropriately defining a clinically important treatment effect and accounting for relevant conflicts of interest by those who are publishing the data. The authors declare there are no conflicts of interest. For full disclosure statements refer to https://doi.org/10.1016/j.artd.2023.101129. Download .docx (.02 MB) Help with docx files Conflict of Interest Statement for Parker Download .pdf (.08 MB) Help with pdf files Conflict of Interest Statement for Molloy Download .docx (.02 MB) Help with docx files Conflict of Interest Statement for ZhaoConflict of Interest Statement for HolteView Large Image Figure ViewerDownload Hi-res image Download (PPT)Conflict of Interest Statement for JevsevarView Large Image Figure ViewerDownload Hi-res image Download (PPT) Comment on: The Effect of Intra-articular Hyaluronic Acid Injections and Payer Coverage on Total Knee Arthroplasty Procedures: Evidence From Large US Claims DatabaseArthroplasty TodayVol. 21PreviewWe read with great interest the article recently published in your journal, entitled "The Effect of Intra-articular Hyaluronic Acid Injections and Payer Coverage on Total Knee Arthroplasty Procedures: Evidence From Large US Claims Database". [1] Even if the interest in intra-articular hyaluronic acid in the treatment of knee osteoarthritis (OA) is of clinical importance, we sincerely believe this work presents some important limitations. The first important limitation is that no idea of the severity of knee OA [2], at the time of diagnosis or when the Intraarticular Hyaluronic Acid (IAHA) administrations were initiated, was reported. Full-Text PDF Open Access
