Carmen E. Quatman

Commercially available gaming systems as clinical assessment tools to improve value in the orthopaedic setting: A systematic review

INTRODUCTIONnCommercially available gaming systems (CAGS) such as the Wii Balance Board (WBB) and Microsoft Xbox with Kinect (Xbox Kinect) are increasingly used as balance training and rehabilitation tools. The purpose of this review was to answer the question, Are commercially available gaming systems valid and reliable instruments for use as clinical diagnostic and functional assessment tools in orthopaedic settings? and provide a summary of relevant studies, identify their strengths and weaknesses, and generate conclusions regarding general validity/reliability of WBB and Xbox Kinect in orthopaedics.nnnMATERIALS AND METHODSnA systematic search was performed using MEDLINE (1996-2013) and Scopus (1996-2013). Inclusion criteria were minimum of 5 subjects, full manuscript provided in English or translated, and studies incorporating investigation of CAG measurement properties. Exclusion criteria included reviews, systematic reviews, summary/clinical commentaries, or case studies; conference proceedings/presentations; cadaveric studies; studies of non-reversible, non-orthopaedic-related musculoskeletal disease; non-human trials; and therapeutic studies not reporting comparative evaluation to already established functional assessment criteria. All studies meeting inclusion and exclusion criteria were appraised for quality by two independent reviewers. Evidence levels (I-V) were assigned to each study based on established methodological criteria.nnnRESULTSn3 Level II, 7 level III, and 1 Level IV studies met inclusion criteria and provided information related to the use of the WBB and Xbox Kinect as clinical assessment tools in the field of orthopaedics. Studies have used the WBB in a variety of clinical applications, including the measurement of center of pressure (COP), measurement of medial-to-lateral (M/L) or anterior-to-posterior (A/P) symmetry, assessment anatomic landmark positioning, and assessment of fall risk. However, no uniform protocols or outcomes were used to evaluate the quality of the WBB as a clinical assessment tool; therefore a wide range of sensitivities, specificities, accuracies, and validities were reported.nnnCONCLUSIONnCurrently it is not possible to make a universal generalization about the clinical utility of CAGS in the field of orthopaedics. However, there is evidence to support using the WBB and the Xbox Kinect as tools to obtain reliable and valid COP measurements. The Wii Fit Game may specifically provide reliable and valid measurements for predicting fall risk.

Fear of Falling Correlates with Subtle Neuromuscular Balance and Strength Deficits of Fragility Fracture Patients

Fragility fractures, or fractures occurring from a low-trauma event, are extremely prevalent among the elderly population worldwide and associated with significant mortality and morbidity. This study evaluated the relationship between FES-I Fear of Falling Survey results, self-reported activity restrictions via the SF-36 survey, and scores recorded by portable, inexpensive clinical assessment tools (CATs) during dynamic functional tasks. Low scores during these tasks may indicate functional deficits that put patients at risk for falls and subsequent fragility fractures. Forty-one subjects (20 fragility fracture patients, 21 controls without history of fragility fractures) over the age of 50 were recruited from three outpatient orthopaedic clinics. All subjects were administered a FES-I Fear of Falling Survey, a portion of an SF-36 survey, and tested using three different portable CATs: the Wii Balance Board, iPod Level Belt and Saehan Squeeze Hand Grip Dynamometer. There were several measured variables that showed a moderate correlation with Fear of Falling scores. Of note, correlations between FES-I scores and maximum hand grip strength for both the dominant hand (R= -0.302, p=0.069) and non-dominant hand (R= -0.309, p=0.059), as well as maximum anterior-posterior sway measured by the iPod Level Belt (R=0.320, p=0.056) were found to be marginally significant. In addition, the correlation between FES-I and average anterior-posterior sway was found to be significant (R=0.416, p=0.012). The Nintendo Wii and iPod Level Belt are relatively inexpensive, portable tools that can assess patients for subtle deficits during dynamic functional tasks. The results indicate that these tools can provide a more objective measure of a patient’s limitations during daily activities such as walking by assigning them a numerical value and correlating this value to physical deficits that impact balance and coordination. In the future, CATs may also have a role in predicting outcomes and in individualizing care, therapy, and at-home preventive measures.

Training Advanced Practice Providers to Collect Functional Outcomes After Fragility Fractures

Objective: The objective of this study was to determine whether advanced practice providers could learn to collect objective functional assessment data accurately and efficiently with commercially available devices that measure kinematics and kinetics (Nintendo Wii Balance Board [WBB] and Level Belt [LB]) to aid in the assessment of fall risk and outcomes after fragility fractures. Methods: Nine advanced practice providers participated in a 1-hour clinical assessment tools (CATs) training session on equipment use, providing standardized instructions, and practice of the testing procedures. Afterward, they participated in a skills demonstration evaluation and completed a postsession survey. Results: Participants successfully achieved a mean of 18.22 (standard deviation 1.56) of 20 performance measures. Of the incomplete or omitted tasks, the majority (10 of 16) occurred within the first of 3 CATs activities. Postsession survey results revealed that 9 of 9 participants reported that the 1 hour provided for training on the CATs was sufficient. All participants reported that after the training, they felt confident they could reliably carry out the tasks to test patients on both the WBB and the LB. The majority of participants reported that they believed that the WBB (7 of 9) and LB (8 out of 9) would be good assets to clinics in assessing patient functionality after fragility fractures. Conclusion: These results indicate that advanced practice providers can confidently learn and effectively test patients with the WBB and LB within 1 hour of training. In the future, adoption of CATs in the clinical setting may allow for objective, easy-to-use, portable, noninvasive, and relatively inexpensive measures to assess functional outcomes in patients with fragility fracture.

Ten years of EMS Fall Calls in a Community: An Opportunity for Injury Prevention Strategies

Objective: To determine whether fall calls, lift assists, and need for transport to the hospital over the past 10 years in one emergency medical services (EMS) system have altered coincident with demographic changes and to estimate health-care cost for lift assists. Methods: We conducted a retrospective chart review of EMS fall-related care. The HealthEMS database for a suburban community surveyed was queried from March 1, 2007, to March 1, 2017. Fall-related calls in patients 60 years or older were identified and determined to be either lift assists (calls that do not result in transport) or fall calls that resulted in transport to the hospital. Results: Of the 38 237 EMS care responses in patients 60 years or older, 11.5% were related to falls. Fall calls increased by 268% over the past 10 years (P = .0006), yet the number of transports to the hospital significantly decreased over time (P = .02). Lift assists increased significantly (P = .0003), nearly doubling over the decade. At the same time, fall calls that did not result in transport to the hospital cost the community an estimated US

The impact of metabolic syndrome on 30-day outcomes in geriatric hip fracture surgeries

1.5 million over a 10-year period. Discussion: There has been a dramatic shift in fall-related calls to EMS in older individuals with more frequent calls for lesser acuity needs. Utilization of EMS for lift assists has substantial financial consequences and diverts care from calls that need immediate triage and transport to care. Conclusion: Future work to reduce the frequency and increase the impact of EMS lift assists could have a significant cost benefit and provide opportunity for enrollment in appropriate community services and fall prevention programs.

Incidence, risk factors and clinical impact of postoperative delirium following open reduction and internal fixation (ORIF) for hip fractures: an analysis of 7859 patients from the ACS-NSQIP hip fracture procedure targeted database

PurposePast literature has reported metabolic syndrome (MetS) to complicate postoperative care in patients undergoing various surgical procedures. We sought to analyze the impact of MetS on 30-day outcomes following hip fracture surgeries in the geriatric population.Materials and methodsThe 2015–2016 ACS-NSQIP database was queried for patients undergoing hip fracture repair using CPT codes for total hip arthroplasty (27130), hemiarthroplasty (27125) and open reduction internal fixation (27236, 27244, 27245). Only patientsu2009≥u200965xa0years of age undergoing surgery due to a traumatic hip fracture were included in the study. MetS was defined using preset criteria used by other NSQIP studies as the presence of—(1) diabetes mellitus AND (2) hypertension requiring medication AND (3) BMIu2009≥u200930xa0kg/m2.ResultsOut of 31,621 patients, a total of 1388 (4.4%) geriatric patients with MetS underwent hip fracture surgery. Following adjusted analysis, the presence of MetS was associated with higher odds of a prolonged length of stayu2009>u20095xa0days (OR 1.14 [95% CI 1.01–1.29]; pu2009=u20090.031), deep SSI (OR 2.48 [95% CI 1.20–5.14]; pu2009=u20090.014), progressive renal insufficiency (OR 3.27 [95% CI 1.98–5.42]; pu2009<u20090.001), acute renal failure (OR 2.08 [95% CI 1.04–4.15]; pu2009=u20090.038), urinary tract infection (OR 1.43 [95% CI 1.12–1.81]; pu2009=u20090.004), 30-day readmissions (OR 1.28 [95% CI 1.08–1.52]; pu2009=u20090.005) and a non-home discharge (OR 1.42 [95% CI 1.18–1.71]; pu2009<u20090.001).ConclusionMetS is associated with a significantly increased risk of several postoperative complications, readmissions and non-home discharge dispositions. Providers can utilize these data to promote the need for better perioperative care in these high-risk patients.

Operating room team member role affects room traffic in orthopaedic surgery: a prospective observational study

ObjectiveDelirium is one of the most common acute psychiatric disturbances taking place in patients, particularly elderly, following hip fractures. Using a validated national surgical database, we sought to define the incidence, risk factors and clinical impact associated with the occurrence of delirium following open reduction and internal fixation (ORIF) for hip fracture.MethodsThe 2016 American College of Surgeons—National Surgical Quality Improvement Program (ACS-NSQIP) Hip Fracture Targeted Procedure file—was retrieved and merged with the ACS-NSQIP 2016 file. A total of 7859 patients were finally included in the study.ResultsA total of 2177 (27.7%) patients experienced an episode of delirium following the procedure. Adjusted analysis showed an increasing ageu2009≥u200965xa0years (pu2009<u20090.001), partially dependent functional health status prior to surgery (pu2009=u20090.001), bleeding disorder (pu2009=u20090.012), preoperative dementia (pu2009<u20090.001), preoperative delirium (pu2009<u20090.001), being bed-ridden postoperatively (pu2009<u20090.001), no weight bearing as tolerated on first postoperative day (pu2009<u20090.001), an ASA gradeu2009>u2009II (pu2009<u20090.001), non-emergency case (pu2009=u20090.010) and a prolonged length of stayu2009>u20093xa0days (pu2009<u20090.001). In addition, Black or African-American ethnicity had a lower odds of developing postoperative delirium (pu2009=u20090.020) as compared to Whites. Moreover, postoperative delirium was significantly associated with non-home discharge disposition (pu2009<u20090.001), higher odds of 30-day readmissions (pu2009<u20090.001) and 30-day mortality (pu2009<u20090.001).ConclusionThis study identifies several risk factors associated with the occurrence of postoperative delirium in patients undergoing ORIF for hip fracture. Surgeons can utilize these data to risk stratify and consequently tailor an appropriate preoperative and postoperative care protocol to prevent the occurrence of delirium.

Cracking the case: should orthopaedic case carts be subjected to more stringent regulations?

Background: Operating room (OR) traffic is an increasing topic of concern for potential risks of surgical site infections (SSIs). We evaluated room traffic rates during orthopaedic surgery cases to better understand how OR team member roles contribute to room traffic. Our hypothesis was that OR traffic differs among team member groups. Methods: We evaluated 46 orthopaedic surgery cases involving implantation of a device at an academic medical center during the summer of 2015. Room traffic rates were recorded as the number of door openings per minute in each case. OR team member groups were defined as follows: Group (A) charge nurse, nurse, scrub technician, scrub technician student; (B) anesthesiology attending physician, anesthesiology resident, anesthesiology medical student, certified nurse anesthetist; (C) orthopaedic surgery attending, orthopaedic surgery resident, orthopaedic surgery medical student; (D) medical sales representative/vendor; (E) radiology technician. Results: The number of door openings ranged from 48 to 259 (mean 127±47). The overall mean room traffic rate per minute per case ranged from 0.2193-1.014 (mean 0.5856±0.1663). Operative length ranged from 90–521 min (mean 226±89.1). There was a statistically significance difference between the median room traffic rate per minute per case by different group (A, B, C, D, and E) types (&khgr;2(4)=127.085, P=0.0001). Conclusions: Room traffic rates and number of door openings per case are different among different OR team member groups. Better understanding of room traffic characteristics allows for strategic intervention to decrease room traffic among team members in each group.

Clinical assessment tools identify functional deficits in fragility fracture patients

Background: Long periods of time with opened, uncovered sterile case carts and high rates of operating room (OR) traffic are correlated with contamination risk. We studied the length of time the case cart was open before incision and compared room traffic frequency before and after surgical incision. Methods: Thirty-three orthopaedic implant cases were observed at three hospitals over an 8-week period. Observation began at the opening of the implant case cart and concluded when the final dressing was placed. The length of time the sterile case cart was open before the patient was in the room and before an incision was made was recorded. Traffic was counted any time a surgical door opened and stratified on a per-hour basis. The traffic rate was counted before and after incision. Results: The average length that the case cart was open prior to the patient being in the room was 43.2 (±29.7) mins, (range, 0-153). On average the case cart was open 91.5 (±31.2) mins, (range, 45-189) prior to the incision. The room traffic was significantly greater during preincision period (45.0±12.8), than during postincision period (26.6±12.8) (P<0.0001). The average number of people in the operating room was 6.9 (±2.7). Conclusions: Room traffic during orthopaedic implant cases is high, with more than one door opening every 2 min. The highest frequencies of traffic occurred before incision but after case carts were opened. Case carts usually were opened more than 1 hr before incision for orthopaedic implant cases.

Urinary tract infection (UTI) at time of geriatric hip fracture surgery increases the risk of experiencing adverse 30-day outcomes

Purpose To identify inexpensive, noninvasive, portable, clinical assessment tools that can be used to assess functional performance measures that may put older patients at risk for falls such as balance, handgrip strength, and lumbopelvic control. Patients and methods Twenty fragility fracture patients and 21 healthy control subjects were evaluated using clinical assessment tools (Nintendo Wii Balance Board [WBB], a handheld dynamometer, and an application for the Apple iPod Touch, the Level Belt) that measure functional performance during activity of daily living tasks. The main outcome measurements were balance (WBB), handgrip strength (handheld dynamometer), and lumbopelvic control (iPod Touch Level Belt), which were compared between fragility fracture patients and healthy controls. Results Fragility fracture patients had lower scores on the vertical component of the WBB Torso Twist task (P=0.042) and greater medial–lateral lumbopelvic sway during a 40 m walk (P=0.026) when compared to healthy controls. Unexpectedly, the fracture patients had significantly higher scores on the left leg (P=0.020) and total components (P=0.010) of the WBB Single Leg Stand task as well as less faults during the left Single Leg Stand task (P=0.003). Conclusion The clinical assessment tools utilized in this study are relatively inexpensive and portable tools of performance measures capable of detecting differences in postural sway between fragility fracture patients and controls.