Miguel E. Cabanela

Medical and Surgical Comanagement after Elective Hip and Knee Arthroplasty: A Randomized, Controlled Trial

Context No large studies evaluate potential benefits and costs of internists and surgeons comanaging postoperative patients. Contribution In this single-center trial, high-risk patients undergoing elective hip or total knee arthroplasty were randomly assigned to either standard surgical care or comanagement care by a team of general internal medicine faculty and orthopedic physicians and nurses. Compared with standard care, comanagement care reduced the number of postoperative complications but did not affect overall length of stay or costs. Clinicians strongly preferred comanagement care. Cautions Costs of comanagement were not captured fully because physicianpatient interaction time was not tracked. The Editors Hospitalists are increasingly delivering inpatient care. Fueled by data supporting improved efficiency with improved quality, there are now 6000 hospitalists in the United States, with expected growth to nearly 20000 (1, 2). The hospitalists traditional role has expanded beyond the care of hospitalized medical patients (3-5). In many systems, hospitalists have partnered with surgeons to provide perioperative care. In a national survey, 44% of hospitalists reported serving as the primary physician for surgical patients (6). Other studies have analyzed the effects of hospitalist models on patient outcomes in medical settings (7-16). We sought to identify their impact in a surgical setting. Specifically, a multidisciplinary, collaborative HospitalistOrthopedic Team was compared with standard orthopedist-managed practice in the care of patients undergoing elective lower-extremity joint replacement. Primary end points were perioperative medical morbidity and length of hospitalization; secondary end points were patient and provider satisfaction and direct costs of hospital care. Methods We conducted a randomized, controlled trial at Rochester Methodist Hospital, a tertiary care, primarily surgical, teaching hospital with 794 beds and an average of more than 15000 admissions per year. The Department of Orthopedic Surgery consists of 46 faculty surgeons and 50 residents. Twelve of the faculty surgeons perform lower-extremity major joint procedures at Rochester Methodist Hospital. The orthopedic residents rotate with the faculty for blocks of 3 months. We obtained institutional review board approval to conduct this study. Participants Patients undergoing elective adult primary or revision total knee or hip arthroplasties (diagnosis-related group 209) who were at elevated risk for perioperative complications were eligible for participation. Patients older than 75 years of age with either 1 or more major comorbid conditions or 2 or more less disabling comorbid conditions were considered at elevated risk. Major comorbid conditions were diabetes mellitus, congestive heart failure, history of coronary artery bypass grafting (CABG), history of myocardial infarction, history of stroke, dementia, immunosuppression, severe chronic obstructive pulmonary disease, substantial renal insufficiency with a serum creatinine level greater than 176.80 mol/L (2.0 mg/dL) or use of dialysis, obstructive sleep apnea, or severe atherosclerosis obliterans. Less disabling comorbid conditions were hypertension, cardiac arrhythmia, history of venous thromboembolic disease or other coagulation abnormality, mild chronic obstructive pulmonary disease, or mild renal insufficiency (serum creatinine level between 123.76 and 176.80 mol/L [1.4 and 2.0 mg/dL]). Patients younger than 18 years of age, non-U.S. residents, and inmates of the local correctional facility at the time of surgery were excluded. Interventions Consent and Randomization We identified patients during their initial outpatient orthopedic evaluation. Before surgery, the nurse study coordinator asked patients to participate, and the patients provided written consent for trial participation and access to their medical and administrative records. We used concealed, computerized dynamic allocation (17) to randomly assign patients and to maintain balance between study groups within the 4 strata: primary hip, revision hip, primary knee, and revision knee arthroplasty (18-20). The study coordinator entered relevant procedure information for each enrolled patient, and the program returned the study group assignment. The dynamic allocation process randomly assigned the first enrolled patient in each stratum to 1 of the study groups. Each new patient was assigned to the study group with the fewest patients in the appropriate stratum. The HospitalistOrthopedic Team model required nurses and surgeons to know whom to call with patients medical concerns; therefore, we could not blind providers. Because hospitalists saw patients daily and responded directly to medical concerns, the treatment group was also apparent to patients and families. Trial Pilot Phase We allowed for a 2-week pilot phase to evaluate whether changes in process and implementation of the study protocol could improve the efficiency and accuracy of this effort. Therefore, as per protocol, we removed patients in the pilot phase from the analyzed cohort because they may have been exposed to a different process of study implementation. Standard Care and Comanagement Care We randomly assigned trial participants to either the standard orthopedic practice or the HospitalistOrthopedic Team model (Table 1). Certain aspects of care delivery were similar between the 2 models of care. These included composition of orthopedic surgical team; nursing personnel; anesthetic care; deep venous prophylaxis; and initial postoperative recovery care, including hemoglobin levels and electrolytes in the 2 to 3 days after surgery. The study protocol did not influence the room allocation of the patients. In both groups of the trial, patients undergoing total hip or knee arthroplasties were placed on the respective postoperative clinical pathway, which was developed by the orthopedic surgical department several years before this study. This pathway includes recommendations for routine postoperative laboratory studies, initiation of physical therapy, and nursing education. In addition, standard nurse-directed protocol for urinary catheter management was used for all patients. This included suprapubic ultrasound determination of urinary retention and guidelines for nursing-initiated urinary catheterization. The standard postoperative order set used in both groups included vital sign and temperature monitoring, medication regimens for pain control, pulmonary hygiene, diet, and activity. Table 1. Standard Care and Comanagement Care In the standard model of perioperative care, the orthopedic surgical team was responsible for any postoperative patient issue that required additional diagnostic evaluation or treatment throughout the hospitalization. For example, work-up of fever, shortness of breath, nausea, or chest pain was at the discretion of the orthopedic residents under the supervision of their faculty. Nurses directed all concerns (medical or surgical) to orthopedic surgery residents. Subspecialty medical consultation was at the discretion of the orthopedists; the subspecialist typically saw patients once daily, as needed, until the medical condition in question resolved or stabilized. These subspecialty consulting teams provide written recommendations in the medical record and, in most cases, do not actually write orders, help prepare discharge summaries, or participate in discharge planning or contacting local referring physicians. The HospitalistOrthopedic Team model of perioperative care was designed to integrate general internal medicine faculty hospitalists with the orthopedic surgical team (largely interfacing with the surgical residents) and the orthopedic surgery nurses. Three hospitalists rotated throughout the study year to provide clinical care. The mean length of postgraduate clinical experience for the hospitalists was 6.2 years. Their duties also included medical consultation for nonorthopedic patients and care of patients in a transitional skilled-nursing facility. Unlike standard practice, the hospitalists (rather than the orthopedic surgeons) provided all indicated postoperative medical care after the surgical team completed initial postoperative orders. The hospitalists frequently saw patients more than once daily and wrote orders (for example, for laboratory tests, fluid and electrolyte management, and medications). Outcomes Assessment Primary outcomes were inpatient postoperative overall medical complication rate and hospital length of stay. The study nurse identified the occurrence of a complication through chart abstraction from laboratory and test results as well as medical records. Postoperative medical complications were categorized a priori into composite end points, including major (death, myocardial infarction, renal failure requiring dialysis, or respiratory failure-required ventilatory support), intermediate (congestive heart failure, pulmonary embolus, ileus, or pneumonia), or minor (electrolyte abnormalities, fever, or urinary tract infection) to allow for subanalysis (Appendix Table). These complications were assessed on the basis of confirmable, objective criteria (laboratory and test results). For patients with multiple complications, only the most severe one was included. Surgical complications (wound infection, hemarthrosis, hematoma, dislocation, or prosthesis failure) were not included as a study end point. We defined hospital mortality as any death during hospitalization for the incident procedure. Length of stay was assessed in 2 ways: unadjusted (days from admission to discharge) and adjusted (days from admission to the date when there was documented consensus among all hospital staff, including nurses, social workers, surgeons, and hospitalists, that the patient was ready for discharge, pending appropriate skilled-nursing placement). The study coordinator assessed these data on potential dismissal date thr

Total hip arthroplasty after failed intertrochanteric osteotomy

From 1969 through 1982, 305 hips in 290 patients had total hip arthroplasty for failed femoral intertrochanteric osteotomy. Of these, we reviewed 215 hips (70.5%) with a minimum follow-up of five years. The results were good or excellent in 79%, but there were technical problems at operation in 23% and a total perioperative complication rate of 11.8%. Late complications occurred in 13.1% including seven late infections (3.2%). At a mean follow-up of ten years, 39 hips had been revised (18.1%), there was probable loosening in 19.5% of stems and 12.6% of cups and possible loosening in 11.4% of stems and 7.2% of cups. The cumulative probability of failure at ten years was 20.6%. We recommend that intertrochanteric osteotomy be advised, planned and executed bearing in mind the possible need for a subsequent total hip arthroplasty, and that screws and plates should be routinely removed soon after union of the osteotomy.

Elective total hip arthroplasty in patients older than 80 years of age.

Elective total hip arthroplasties (THA) were performed in 91 patients (101 hips) older than 80 years of age at operation. A control group of 87 patients (102 hips) aged 64 to 67 years who had elective THA was chosen statistically to represent the average THA patient. There were 51 minor and eight major perioperative complications in the elderly group and 26 minor and two major complications in the control group. The only in-hospital death was in the control group. The mean hospital stay was two days longer in the elderly group. Five years postoperatively, 83% of the patients in both groups were ambulating without pain. The mean hip score improved from 49 to 84 points in the elderly group and from 52 to 88 points in the control group. These functional results justify elective THA in patients older than 80 years of age.

External fixation for arthrodesis of the knee and ankle.

In a series of 74 knee and ankle arthrodeses the Vidal-Adrey quadrilateral mounting of the Hoffmann device was employed for arthrodesis of the knee in 50 cases. Union occurred in 80%. The union rate was highest (86.2%) when arthrodesis was attempted for infection after total knee arthroplasty. The complication rate was 24%. Most of the complications were related to pin sites. In eight patients knee arthrodesis was performed by multiplanar pin insertion and external fixation with either the Hoffmann or Fischer device; union occurred in all patients; pin site infection occurred in one. In 13 tibiotalar arthrodeses a modified quadrilateral frame was utilized, sparing the subtalar joint; union occurred in all of these cases. For tibiocalcaneal arthrodesis, attempted in five patients, a triangular mounting based on pins placed through the tibia, calcaneus, and metatarsals was necessary. Union occurred primarily in four of the five patients. This study indicates the superiority of multiplanar pin insertion for knee arthrodesis for treatment of failed total knee arthroplasty. The use of larger pins manufactured from relatively nonreactive metal alloys seems to decrease the incidence of pin site problems.

Hybrid primary total hip arthroplasty : A 5- to 9-year followup study

One hundred fifty-two hips were reviewed at a minimum of 5 years after hybrid primary total hip arthroplasty using uncemented porous coated acetabular components and cemented femoral stems to determine the intermediate term durability of this method of fixation. Five hips (3.6%) have been revised: 1 for dislocation (0.7%), 1 for cup loosening (0.7%), and 3 for femoral loosening (2.2%). Clinical results proved to be extremely reliable in this series with 78% of the patients reporting no pain and 19.7% reporting slight or occasional pain. Radiographic evidence of polyethylene wear was evident in more than 1/2 of cups, but significant osteolysis or component loosening was not commonly seen on the cup side. On the femoral side incomplete radiolucencies were present in 31%, and focal osteolysis in 12.2%, nearly always proximally in Zones 1 and 7. These intermediate term results compare favorably on the femoral side and very favorably on the acetabular side to prior reported series. These results support the continued use of this combination of fixation methods for primary arthroplasty, but polyethylene wear and its effects remain a concern regarding the long term performance of these arthroplasties.

Intraoperative electromyographic monitoring during periacetabular osteotomy.

Periacetabular osteotomy has become the procedure of choice in many centers for the treatment of symptomatic hip dysplasia. Intraoperative real-time nerve monitoring has been advocated during acetabular fracture repair and complex total hip arthroplasties to prevent iatrogenic sciatic nerve injury. To the authors’ knowledge there is no information concerning the use of intraoperative electromyographic monitoring during periacetabular osteotomy. The purpose of the current study was to investigate the use of intraoperative continuous electromyographic monitoring during periacetabular osteotomy in a relatively large consecutive series of patients as a mechanism to prevent nerve injury during surgery and as a prognostic indicator of neurologic function after periacetabular osteotomy. From September 1992 to July 1999, 140 consecutive periacetabular osteotomies were done in 127 patients at the authors’ institution. There were 96 females and 31 males, with an average age of 32 years at the time of surgery. All patients had intraoperative electromyographic monitoring of femoral and sciatic innervated muscles. All patients were followed up for a minimum of 1 year, until complete resolution of neurologic deficits, or both. Thirty-six patients (26%) had abnormal electromyographic activity recorded during surgery. Seven patients (5%) had peroneal nerve deficits postoperatively including extensor hallucis longus and tibialis anterior weakness with loss of sensation in the first web space. Abnormal electromyographic activity was observed intraoperatively in five of the seven patients with postoperative deficits. Six of the seven injuries resolved completely. One patient with intraoperative electromyographic activity (0.7%) had a postoperative foot drop that persisted for greater than 1 year. There were no femoral, tibial, or obturator nerve deficits observed. Electromyographic monitoring appears to provide prediction of postoperative neurologic deficit.

Results of treatment of tibial and femoral osteomyelitis in adults.

From January 1, 1971, to December 31, 1985, 425 patients with chronic osteomyelitis of the femur or tibia were seen at the authors institution. The success rate in this recent experience was 84.4% compared with 50.9% in the authors results published in 1970. A classification of chronic osteomyelitis is as follows: (1) hematogenous osteomyelitis; (2) osteomyelitis in united fractures (fracture with union); (3) osteomyelitis in nonunion (fracture with nonunion); and (4) postoperative or posttraumatic osteomyelitis in which bone was not fractured. For management of the scarring of surrounding soft tissue, there has been a change to excision of the scarred tissue and reliance on muscle flap, free-tissue transfer, or closure of soft tissues without irrigation with antibiotic solution. In recent years, free microvascular osseous grafts have permitted more aggressive resection of the involved osseous tissue. The predominance of gram-negative organisms and penicillin-resistant Staphylococcus aureus and the occurrence of methicillin-resistant S. aureus continue.

Respiratory arrest following posteriorly displaced odontoid fractures. Case reports and review of the literature.

Posterior displacement of the odontoid after fracture occurs much less frequently than does anterior displacement. Experience with four patients suggests that anatomic reduction may not be possible and prolonged attempts to gain reduction are not advisable. Those cases should be managed with early application of a halo vest. A rotating frame should be avoided. The potential for respiratory arrest, at least in the older individual, is great and can be precipitated even by a change of position in the process of turning on the rotating frame. The mechanism of the respiratory failure is obscure.