Sally York

Current practices of AAHKS members in the treatment of adult osteonecrosis of the femoral head.

BACKGROUND There is currently no standardized protocol for evaluating and treating osteonecrosis of the femoral head in adults in the United States. We sought to understand current treatment practices of a group of surgeons who commonly treat this disease to determine if there was agreement on some aspects of care. METHODS We designed a two-staged mixed-mode (mailed and faxed) sixteen-question self-administered descriptive survey questionnaire to be sent to all 753 active members of the American Association of Hip and Knee Surgeons (AAHKS). The survey design was based on Dillmans survey research methodology, and the questionnaire included hypothetical clinical scenarios based on the Steinberg classification system. The responses elucidated the opinions and treatment preferences of high-volume arthroplasty surgeons who treat adult patients with osteonecrosis of the femoral head. RESULTS Of the 753 active members of the AAHKS, 403 (54%) responded to the questionnaire. Total hip replacement was reported to be the most frequent intervention for treatment of postcollapse (Steinberg stage-IIIB, IVB, V, and VI) osteonecrosis; core decompression was reported to be the most commonly offered intervention for symptomatic, precollapse (Steinberg stage-IB and IIB) osteonecrosis. Less frequently offered treatments included nonoperative management, osteotomy, vascularized and non-vascularized bone-grafting, hemiarthroplasty, and arthrodesis. CONCLUSIONS The care of adults with osteonecrosis of the femoral head varies among American orthopaedic surgeons specializing in hip and knee surgery. A consensus may evolve with a continued concerted effort on the part of interested surgeons, but it will require randomized, controlled, prospective studies of treatment of each stage of the disease and collaborative multicenter studies. LEVEL OF EVIDENCE Therapeutic Level V.

Venous thromboembolism: management by American Association of Hip and Knee Surgeons.

A 2008 survey of American Association of Hip and Knee Surgeons membership explored current venous thromboembolism (VTE) protocols for lower-extremity total joint surgery. Fifty-three percent reported a change in VTE-related practices in the last 5 years. More than 70% reported that their primary hospital now mandates VTE prophylaxis. Although 74% of their primary hospitals recognized the American College of Chest Physicians guidelines, 68% of surgeons felt the American Academy of Orthopaedic Surgeons guidelines were more relevant to their practice. Respondents believe low molecular weight heparin to be the most efficacious but aspirin to be the easiest to use and has the lowest risks of bleeding and wound drainage. Warfarin was the most used in hospital prophylaxis, and 90% of respondents targeted an international normalized ratio of 1.6 to 2.5. Practice patterns continue to evolve, and there remains no consensus on specific treatment protocols or preferences.

Career Plans of Current Orthopaedic Residents with a Focus on Sex-Based and Generational Differences

BACKGROUND An orthopaedic workforce shortage has been projected. The purpose of this study is to analyze the supply side of this shortage by ascertaining the career plans of current orthopaedic residents, comparing these plans with the career patterns of practicing orthopaedists, and identifying career-plan differences according to sex. METHODS An online, self-administered survey was e-mailed to U.S. orthopaedic residents in postgraduate year three or higher, querying them about their fellowship specialty choice and their career plans. RESULTS A total of 498 residents completed the online survey; 430 respondents (86%) were male, sixty-three (13%) were female, and five (1%) did not provide information regarding sex. Ninety-one percent of the residents were planning to enroll in a fellowship, with some respondents indicating more than one subspecialty choice: 28% intended to choose sports; 21%, arthroplasty; 14%, hand surgery, 12%, trauma; 8%, pediatrics; 8%, shoulder and elbow surgery; 8%, spine surgery; 6%, foot and ankle surgery; and 2%, oncology. With regard to the top career priorities of residents in selecting a fellowship specialty, 40% indicated intellectual priorities; 36%, educational; 21%, lifestyle; and 4%, economic. Significantly more women than men were planning on pursuing a pediatric fellowship (24% versus 6%, respectively, p < 0.05) and significantly fewer were planning on pursuing a sports fellowship (11% versus 31%, respectively, p < 0.05). Significantly more women than men planned on a subspecialty-only practice (62% versus 34%, respectively, p < 0.05). The projected retirement age of sixty-four years for current residents is roughly equal to that of the previous generation. There was no difference between men and women with regard to leadership and research aspirations, projected retirement age, and projected workdays per week. However, significantly more women than men (65% versus 47%, respectively) planned on reducing their work hours or changing to part-time status at some time during their careers. There is a higher percentage of female residents (13%) than female practicing orthopaedists (4%) in the United States. CONCLUSIONS We should continue efforts to collect workforce data and be proactive to avert or minimize the effect of impending orthopaedic workforce shortages on our patients. Given the trend toward an increasing proportion of female orthopaedists and the higher likelihood that they will reduce their work hours during portions of their career, policymakers should consider training more orthopaedists to ensure patient access to timely, quality orthopaedic care.

Impact of the Economic Downturn on Adult Reconstruction Surgery: A Survey of the American Association of Hip and Knee Surgeons

To evaluate the effects of the economic downturn on adult reconstruction surgery in the United States, a survey of the American Association of Hip and Knee Surgeons (AAHKS) membership was conducted. The survey evaluated surgical and patient volume, practice type, hospital relationship, total joint arthroplasty cost control, employee staffing, potential impact of Medicare reimbursement decreases, attitudes toward health care reform options and retirement planning. A surgical volume decrease was reported by 30.4%. An outpatient visit decrease was reported by 29.3%. A mean loss of 29.9% of retirement savings was reported. The planned retirement age increased to 65.3 years from 64.05 years. If Medicare surgeon reimbursement were to decrease up to 20%, 49% to 57% of AAHKS surgeons would be unable to provide care for Medicare patients, resulting in an unmet need of 92,650 to 160,818 total joint arthroplasty procedures among AAHKS surgeons alone. Decreases in funding for surgeons and inadequate support for subspecialty training will likely impact access and quality for Americans seeking adult reconstruction surgery.

Fall Prevention Knowledge, Attitude, and Practices of Community Stakeholders and Older Adults

We assessed knowledge, attitude, and provision of recommended fall prevention (FP) practices by employees of senior-serving organization and participation in FP practices by at-risk elders. The Washington State Department of Health administered structured telephone surveys to 50 employees and 101 elders in Washington State. Only 38% of employees felt “very knowledgeable” about FP, and a majority of their organizations did not regularly offer FP services. Almost half (48%) of seniors sustained a fall within the past 12 months; however, one-third perceived falling to be among their least important health concerns, and most had minimal working knowledge of proven FP practices. Seniors who perceived avoiding falls as important to their well-being were more likely to participate in practices about which they had the least knowledge (risk assessment, medication management). Increased awareness and availability of FP services might help engage older adults in FP practices and reduce the adverse effects of falls.

A resident survey study of orthopedic fellowship specialty decision making and views on arthroplasty as a career.

A dramatic shortage of total hip arthroplasty (THA) and total knee arthroplasty (TKA) surgeons has been projected because fewer residents enter arthroplasty fellowships, and the demand for THAs/TKAs is rising. The purposes of this study were to ascertain the future supply of THA/TKA surgeons, to identify the criteria residents use to choose their fellowship specialty, and to assess resident perceptions of an arthroplasty career. Four hundred ninety-eight post-graduate year 3 and above residents completed the online survey. Residents most highly prioritize intellectual factors and role models/mentors in determining their fellowship specialty. In the face of a looming patient access-to-care crisis, the data from this study support a policy of highlighting the intellectual challenges and satisfaction of THA/TKA as a career and encouraging mentorship early in a residents training.

A translational research evaluation of the Stay Active and Independent for Life (SAIL) community-based fall prevention exercise and education program.

Falls in older adults are the leading cause of injury hospitalizations and fatalities in the United States; primary risk factors are muscle weakness, impaired mobility, and balance deficits. This article describes the 12-month translational research evaluation of the Stay Active and Independent for Life (SAIL) community-based public health, public domain fall prevention exercise and education program. Recruitment reached the target goal by 154%; 331 adults (mean age = 74.6) attended more than one class (mean classes attended = 24.8, SD = 26.6, range = 1-120) at nine community sites in one county in the 12-month period; 173 completed health and demographic forms, 132 completed program surveys, and 91 completed baseline and follow-up physical function tests. Physical function test results showed significant improvements in strength, balance, and mobility in those who were below normal limits at baseline, and in those who attended classes twice a week or more for more than 2 months. Survey results found that 93% of respondents reported improved performance of daily activities; 92% reported improved strength, balance, fitness, or flexibility; and 80% found the SAIL information guide education component helpful.

Variations in Surgeons' Recovery Expectations for Patients Undergoing Total Joint Arthroplasty: A survey of the AAHKS Membership

Recovery expectations (RE) after total hip and knee arthroplasty (THA-TKA) influence outcomes. We surveyed AAHKS members to determine variation in surgeon RE. Four vignettes depicting patients with high and low expectations after THA and TKA were distributed with a validated RE survey. Responses were analyzed for clinically significant differences between surgeons and within surgeons. Of 1049 surgeons surveyed, 358 (34%) responded. There was a clinically significant difference in 85% (high-THA), 46% (low-THA), 74% (high-TKA), and 57% (low-TKA) of pairs. Disagreement was significantly greater in high expectation vignettes. Individual surgeons distinguished between high and low expectation patients in 76% (THA) and 72% (TKA) of cases. There was no association between surgeon RE and practice demographics. Wide variations in RE were observed, especially among high expectation patients.

Revision total hip and knee arthroplasty implant identification: implications for use of Unique Device Identification 2012 AAHKS member survey results.

FDAs Unique Device Identification (UDI) Rule will mandate manufacturers to assign unique identifiers to their marketed devices. UDI use is expected to improve implant documentation and identification. A 2012 American Association of Hip and Knee Surgeons membership survey explored revision total hip and knee arthroplasty implant identification processes. 87% of surgeons reported regularly using at least 3 methods to identify failed implants pre-operatively. Median surgeon identification time was 20 min; median staff time was 30 min. 10% of implants could not be identified pre-operatively. 2% could not be identified intra-operatively. UDI in TJA registry and UDI in EMR were indicated practices to best support implant identification and save time. FDAs UDI rule sets the foundation for UDI use in patient care settings as standard practice for implant documentation.

Economic Impact of Orthopedic Adult Reconstruction Office Practice: The Implications of Hospital Employment Models on Local Economies

The purpose of this study was to evaluate the economic attributes of private practice adult reconstruction (AR) offices. 458 AAHKS surgeons responded; 65% were in private practice (fee-for-service, non-salaried, non-employed AR surgeons). 54% had considered hospital employment in the past two years. The average group employs 13.4 orthopedic surgeons (3.4 AR), and 105 other employees. The average total budget is