Keith A. Fehring

Irrigation and Debridement for Periprosthetic Infections : Does the Organism Matter?

Irrigation and debridement (I&D) is an attractive treatment alternative for periprosthetic joint infection (PJI). Irrigation and debridement failure rates average 64% (range, 10.5%-84%) and may be associated with causative organism type and virulence. The study objective was to compare revision rates for PJI caused by streptococcal organisms to other organisms treated with I&D. A multicenter retrospective cohort study of 200 consecutive PJIs treated with I&D was performed. Failure was defined as reoperation for PJI. Failure rate for streptococcal infections was 65% (20/31) compared with 71% (84/119) for other organisms. Failure rate for sensitive Staphylococcus was 72% (48/67) compared with a 76% (22/29) failure rate for resistant Staphylococcus. These results indicate that eradication rates of I&D for a streptococcal PJI are comparable with other causative organisms. Irrigation and debridement should play a limited role in the PJI treatment algorithm regardless of organism type.

Cobalt to Chromium Ratio is Not a Key Marker for Adverse Local Tissue Reaction (ALTR) in Metal on Metal Hips

The diagnosis of adverse local tissue reaction (ALTR) after metal-on-metal total hip arthroplasty (MoMTHA) presents a significant challenge. No single biomarker is specific for ALTR. The purpose of this study was to determine if the ratio of cobalt to chromium ions is useful for diagnosing ALTR in MoMTHA. In 89 bearing-related revision THAs, preoperative cobalt and chromium ion levels were compared to an intraoperative soft tissue damage grading scale. The average cobalt to chromium ratio was 2.96 (0-20). There was no correlation between the tissue scale and the cobalt to chromium ratio (R=0.095; P=0.41). Many variables affecting ion production/excretion mitigate the use of the ion ratio. The cobalt to chromium ratio is not a predictive biomarker for ALTR in MoMTHA.

Metal Artifact Reduction Sequence MRI Abnormalities Occur in Metal-on-polyethylene Hips

BackgroundTo determine the importance of MRI abnormalities in metal-on-metal (MoM) bearings, it is important to understand the baseline features of this diagnostic tool in conventional metal-on-polyethylene (MoP) bearings.Questions/purposesWhat are the frequency, size, and types of MRI-documented adverse local tissue reactions in asymptomatic patients with MoP bearings?MethodsWe recruited 50 patients 5 years after a MoP total hip arthroplasty from a pool of patients in our joint registry who had a Harris hip score of > 90. To be included, patients had to be without pain and have adequate radiographs. Our data set included 50 asymptomatic patients with MoP bearings who underwent a metal artifact reduction sequence MRI.ResultsMRI abnormalities were seen in 14 of 50 (28%) asymptomatic patients who were studied. Thirteen of the 14 abnormalities were cystic thin-walled lesions with a mean of 18 cm3 (range, 1–79 cm3).ConclusionsMRI abnormalities were noted in nearly one-third of asymptomatic patients with MoP bearings. Decisions concerning revision of MoM bearings should not be based on isolated MRI findings because MRI abnormalities are commonly seen regardless of bearing type. A number of factors should determine the need for intervention including pain, mechanical symptoms, abductor weakness, component type, component position, and ion levels as well as MRI findings.Level of EvidenceLevel IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Mortality Following Revision Joint Arthroplasty: Is Age a Factor?

With the demand for total joint arthroplasty and overall life expectancy increasing, there will be an increase in the need for revision arthroplasty surgeries. Given that revision joint surgeries are more demanding for both surgeon and patient with longer operative times, increased blood loss, and multiple patient comorbidities, the current mindset is that older patients who undergo a total hip revision or total knee revision have higher mortality rates than younger patients. We identified 1737 revision total joint patients who were at least 2 years postoperative for inclusion in the study. The overall perioperative mortality rate (defined as deaths occurring between 0 and 3 months following revision joint surgery) was calculated and then stratified by revision knee surgery, revision hip surgery, and age. In addition, mortality rates were compared for patients younger than 70 years, between 70 and 80 years and older than 80 years. The overall perioperative mortality rate after revision total hip or knee surgery was 0.7%. After stratifying by age, the perioperative mortality rate was 0.2% in patients younger than 70 years, 0.8% in patients 70 to 79 years, and 2.63% in patients older than 80 years. Of the 1737 patients, 541 died >1 year following their revision surgery at an average time to death of 6.9 years. The observed perioperative mortality rates following revision total joint surgery at a single center were extremely low among all age groups. Therefore, the age of patients undergoing revision surgery should not be the sole determinant of perioperative survival. Additionally, it appears that the mean postoperative survival noted here seems to justify the additional resources used in revision surgery regardless of age. As limited resources exert pressure on an already overburdened healthcare system, rationing of care for certain procedures may ensue using age as a specific criteria. This study should add clarity to this issue.

Social media for patients: benefits and drawbacks

Purpose of reviewSocial media is increasingly utilized by patients to educate themselves on a disease process and to find hospital, physicians, and physician networks most capable of treating their condition. However, little is known about quality of the content of the multiple online platforms patients have to communicate with other potential patients and their potential benefits and drawbacks.Recent findingsPatients are not passive consumers of health information anymore but are playing an active role in the delivery of health services through an online environment. The control and the regulation of the sources of information are very difficult. The overall quality of the information was poor. Bad or misleading information can be detrimental for patients as well as influence their confidence on physicians and their mutual relationship.SummaryOrthopedic surgeons and hospital networks must be aware of these online patient portals as they provide important feedback on the patient opinion and experience that can have a major impact on future patient volume, patient opinion, and perceived quality of care.

Initial Stability of Press-Fit Acetabular Components Under Rotational Forces

The primary goal of this study was to determine the initial press-fit stability in acetabular components without screw fixation. Mechanical testing was performed with the implantation of press-fit acetabular components in cadaveric specimens. No significant difference was found in load to failure testing between 1 and 2 mm of under-reaming. However, there was significant variability in bending forces required to create 150 μm of micromotion ranging from 49.3 N to 214.4 N. This study shows that cups implanted in a press-fit fashion, which are felt to be clinically stable, have high degrees of variability in resisting load and may be at risk for loosening. There is a need for more objective intra-operative techniques to test cup stability.

Social media and your practice: navigating the surgeon-patient relationship

Utilization of social media both in the private and professional arenas has grown rapidly in the last decade. The rise of social media use within health care can be viewed as the Internet-based corollary of the patient-centered care movement, in which patient perspectives and values are central to the delivery of quality care. For orthopedic surgeons and their practices, general-purpose online social networks, such as Facebook and Twitter, are convenient platforms for marketing, providing patient education and generating referrals. Virtual health communities are used less frequently by orthopedic surgeons but provide forums for patient engagement and active surgeon-to-patient communication via blogs and ask-the-doctor platforms. This commentary reviews the current state of social media use in orthopedic practice, with particular emphasis on managing the extension of the surgeon-patient relationship online, including the unique practice risks social media poses, such as privacy concerns, potential liability, and time consumption.

Physical Therapy Mandates by Medicare Administrative Contractors: Effective or Wasteful?

Documentation of medical necessity for arthroplasty has come under scrutiny by Medicare. In some jurisdictions three months of physical therapy prior to arthroplasty has been mandated. The purpose of this study was to determine the efficacy and cost of this policy to treat advanced osteoarthritis. A systematic review was performed to assimilate efficacy data for physical therapy in patients with advanced osteoarthritis. The number of arthroplasties performed annually was obtained to calculate cost. Evidence-based studies documenting the efficacy of physical therapy in treating advanced arthritis are lacking with a potential cost of 36-68 million dollars. Physical therapy mandates by administrative contractors are not only ineffective but are costly without patient benefit. Medical necessity documentation should be driven by orthopedists not retroactively by Medicare contractors.

Social media: physicians-to-physicians education and communication

Purpose of reviewPhysician to physician communication is essential for the transfer of ideas, surgical experience, and education. Social networks and online video educational contents have grown exponentially in recent years changing the interaction among physicians.Recent findingsSocial media platforms can improve physician-to-physician communication mostly through video education and social networking. There are several online video platforms for orthopedic surgery with educational content on diagnosis, treatment, outcomes, and surgical technique. Social networking instead is mostly centered on sharing of data, discussion of confidential topics, and job seeking. Quality of educational contents and data confidentiality represent the major drawbacks of these platforms.SummaryOrthopedic surgeons must be aware that the quality of the videos should be better controlled and regulated to avoid inaccurate information that may have a significant impact especially on trainees that are more prone to use this type of resources. Sharing of data and discussion of confidential topics should be extremely secure according the HIPAA regulations in order to protect patients’ confidentiality.

The future of social media in orthopedic surgery

In 2015, 84% of adults used the Internet on a regular basis and 80% of these user references online sources for health-related information [1, 2]. There has been a corresponding growth in online social networking and social media outlets, in the form of websites, online social networks, and mobile applications [3]. These social media platforms have expanded to become vital networks for patients and physicians to communicate with each other, among each other, and learn from each other’s experiences. With an estimated 6.5 million health-related search engine queries per day [4], we believe that the contemporary practicing physician must be aware of these social media outlets and ideally have a deeper understanding and utilization that will allow for the improvement of patient care, patient and physician education, and increases in practice outreach, scope, and volume. As previously discussed, social media grew with the development of Web 2.0 which allowed for a more dynamic interaction between the user and the web. Web 2.0 allowed for the Internet user to create content in the form of personal blogs, to post messages in online discussion boards, and to create online profiles, and eventually online social networks. Going forward, practicing orthopedic surgeons, physician groups, and hospital networks have a decision, either control social media outlets or be controlled by them. Current social media platforms such as Facebook, Twitter, YouTube, and Instagram offer far-reaching online social networks that will grow in usage over the next few years. These social media outlets will continue to be a platform for physicians to improve practice visibility with each application potentially serving its own function. Facebook will provide an online social network for the practice. YouTube will provide preoperative, perioperative, and postoperative video instructions. Instagram will serve as a way to share patient photos and progress and provide helpful information during the recovery process. The benefit of increasing physician-specific online content is that patient education and the surgeon-patient engagement can potentially occur remotely. Social media will evolve into a form of telemedicine where patients will be guided through the preoperative, perioperative, and postoperative period with a digital assistant or orthopedic avatar. Patients will be able to post their results on a physician-controlled or hospitalcontrolled health care network. Radiographic and clinical performance can then be tracked remotely and patients will have the choice to follow up in the physician office or remotely from home. It is likely than in the next 5 years, telemedicine and remote follow-up will be a common practice for standard follow-up of the orthopedic patient. In addition, the additional online content in the form of patient education forms, online videos, physical therapy exercises, and motivation milestones will allow the patient to have more digital contact with the physician office without an increase in overall face-to-face time. Increased patient engagement without an increase in physician involvement allows for potentially more costeffective care delivery. In the era of bundles payments, any technology that continues to provide a high level of patient This article is part of the Topical Collection on Social Media and Orthopedics