Tony H. Tzeng

Biomaterial hypersensitivity: is it real? Supportive evidence and approach considerations for metal allergic patients following total knee arthroplasty.

The prospect of biomaterial hypersensitivity developing in response to joint implant materials was first presented more than 30 years ago. Many studies have established probable causation between first-generation metal-on-metal hip implants and hypersensitivity reactions. In a limited patient population, implant failure may ultimately be related to metal hypersensitivity. The examination of hypersensitivity reactions in current-generation metal-on-metal knee implants is comparatively limited. The purpose of this study is to summarize all available literature regarding biomaterial hypersensitivity after total knee arthroplasty, elucidate overall trends about this topic in the current literature, and provide a foundation for clinical approach considerations when biomaterial hypersensitivity is suspected.

Treating periprosthetic joint infections as biofilms: key diagnosis and management strategies

Considerable evidence suggests that microbial biofilms play an important role in periprosthetic joint infection (PJI) pathogenesis. Compared to free-floating planktonic bacteria, biofilm bacteria are more difficult to culture and possess additional immune-evasive and antibiotic resistance mechanisms, making infections harder to detect and eradicate. This article reviews cutting-edge advances in biofilm-associated infection diagnosis and treatment in the context of current PJI guidelines and highlights emerging technologies that may improve the efficacy and reduce costs associated with PJI. Promising PJI diagnostic tools include culture-independent methods based on sequence comparisons of the bacterial 16S ribosomal RNA gene, which offer higher throughput and greater sensitivity than culture-based methods. For therapy, novel methods based on disrupting biofilm-specific properties include quorum quenchers, bacteriophages, and ultrasound/electrotherapy. Since biofilm infections are not easily detected or treated by conventional approaches, molecular diagnostic techniques and next-generation antibiofilm treatments should be integrated into PJI clinical practice guidelines in the near future.

Caring for the surgically anxious patient: a review of the interventions and a guide to optimizing surgical outcomes

BACKGROUND Preoperative surgical anxiety is an unpleasant and common reaction exhibited by patients who are scheduled for surgical procedures. Beyond emotional effects on the patient, it can also have negative repercussions on the surgery including longer hospital stays and poorer outcomes. Given the widespread impacts of preoperative anxiety, it is critical for surgeons to gain a better understanding of how to identify and reduce surgical anxiety in their patients. DATA SOURCES This study used the PubMed database to review the current literature to evaluate screening tools and interventions for surgically anxious patients. CONCLUSIONS Psychiatric anxiety surveys are currently the most appropriate form of assessment for surgical anxiety. Patient education is important for preventing and reducing anxiety levels in patients. Both nonpharmacological and pharmacological interventions have been shown to be effective in reducing patient anxiety and treatment should be based on patient preference, resources available, and the surgeons experience.

The Role of Patient Activation in Achieving Better Outcomes and Cost-Effectiveness in Patient Care

Patient X, a fifty-two-year-old Caucasian male, presents in clinic with a chief symptom of ongoing intermittent pain, radiating along the ilioinguinal area toward the groin, bilaterally for the past year with the left side more severe than the right side. His current medical issues include alcoholism; a thirty-five-year, three-pack-a-day smoking history; and morbid obesity with a body mass index of 55 kg/m2. He has hyperglycemia, hypercholesterolemia, and hypertension. After all other diagnoses are ruled out, the magnetic resonance imaging (MRI) scan and radiographs show a classic Association Research Circulation Osseous (ARCO) stage-II osteonecrosis on the right hip with no femoral head collapse and ARCO stage-III …

Acrylic bone cement in total joint arthroplasty: A review

Acrylic bone cement has a variety of applications in orthopedic surgery. Primary uses in total arthroplasties are limited to prostheses fixation and antibiotic delivery. With the large number of total joint arthroplasties expected to continue to rise, understanding the role bone cement plays in the success of total joint arthroplasty can have a significant impact on daily practice. The literature is inconclusive on whether cemented or cementless fixation technique is superior, and choice of fixation type is mainly determined by surgeon preference and experience. Surgeons should understand that if poor techniques exist, short‐term outcomes of the replaced joint may be at risk. Statement of clinical significance: This article attempts to clarify some points of bone cement use through a review of the mechanical properties related to bone cement, a comparison to alternative materials, influence of additives, and the effects on surgical outcomes.

Impact of diabetes on early postoperative outcomes after total elbow arthroplasty

BACKGROUND Diabetes is known to be associated with poorer perioperative outcomes after hip, knee, and shoulder arthroplasty. This study is the first, to our knowledge, to examine the association between diabetes and in-hospital complications, length of stay, non-homebound discharge, transfusion risk, and total charges after total elbow arthroplasty (TEA). METHODS By use of International Classification of Diseases, Ninth Revision codes, epidemiologic as well as patient and hospital demographic data for all patients undergoing TEA were extracted from the Nationwide Inpatient Sample from 2007 through 2011. We found 13,698 patients who underwent TEA and subsequently separated them into 2 cohorts, those patients with (16.5%) and without (83.5%) diabetes. Specific outcome measures between the diabetic and nondiabetic cohorts were compared through bivariate and multivariate analyses. RESULTS Diabetic patients had significantly longer lengths of stay, increased rates of needing a transfusion perioperatively, and higher rates of a number of complications after TEA compared with the nondiabetic group. Significant differences in demographic factors in diabetic patients compared with nondiabetic patients included age, gender, insurance type, and geography. Diabetes was an independent predictor of both prolonged hospital stay and non-homebound discharge after TEA. DISCUSSION Diabetic patients have significantly higher rates of several perioperative complications, and diabetes is an independent risk factor for prolonged hospital stay, as well as increased risk of non-homebound discharge. Future studies need to further investigate this relationship between diabetes and poorer TEA outcomes.

Teaming: An Approach to the Growing Complexities in Health Care

Confronted with rising costs and patients who often have multiple comorbidities, the orthopaedic surgeon needs to face the challenge of providing high-quality health care. One solution is to increase and improve coordination, communication, and teamwork. The orthopaedic surgeon also needs to work effectively and efficiently to manage a fluid and shifting mix of health-care personnel partners from other disciplines and specialties to deliver high-quality patient care. The orthopaedic surgeon must collaborate in a new way with fellow health-care professionals, providing care by following teaming protocols. In the appropriate leadership role and employing the necessary motivational, communication, and conflict-management skills, the orthopaedic surgeon must build the proper foundations for teaming through the selection of compatible, effective team members and establish the necessary collaborative teaming environment. The orthopaedic surgeon needs to lead these teams and promote communication, listening, and collaboration. The emphasis on effective communication through a horizontal hierarchy rather than an autocratic management style by the orthopaedic surgeon allows the seamless incorporation of specialty physicians as needed and facilitates teaming among orthopaedic staff. With a facilitative environment and clear communications, teaming in patient care will occur as a learning cycle of diagnosis, design, action, and reflection. Each of these steps is critical for teaming to be successful. During diagnosis, the orthopaedic surgeon needs to effectively frame the situation. In design, the orthopaedic surgeon needs to encourage participation in the determination of the next appropriate steps for patient care. During the action step, teaming protocol emphasizes both the process of care through care-tracking and the result of that care, which is critical for reflection. Reflection is necessary for the team to improve its effectiveness and learn from its experience. However, for successful reflection and learning, the orthopaedic surgeon needs to be truly open to criticism. To face the challenges currently within the …

The Impact of Tort Reform and Quality Improvements on Medical Liability Claims A Tale of 2 States

The purpose of this study was to determine the effect of tort reform and quality improvement measures on medical liability claims in 2 groups of hospitals within the same multihospital organization: one in Texas, which implemented medical liability tort reform caps on noneconomic damages in 2003, and one in Louisiana, which did not undergo significant tort reform during the same time period. Significant reduction in medical liability claims per quarter in Texas was found after tort reform implementation (7.27 to 1.4; P < .05). A significant correlation was found between the increase in mean Centers for Medicare & Medicaid Services performance score and the decrease in the frequency of claims observed in Louisiana (P < .05). Although tort reform caps on noneconomic damages in Texas caused the largest initial decrease, increasing quality improvement measures without increasing financial burden also decreased liability claims in Louisiana. Uniquely, this study showed that increasing patient quality resulted in decreased medical liability claims.

Rheumatoid Arthritis vs Osteoarthritis: Comparison of Demographics and Trends of Joint Replacement Data from the Nationwide Inpatient Sample

Current literature regarding complications following total joint arthroplasty have primarily focused on patients with osteoarthritis (OA), with less emphasis on the trends and in-hospital outcomes of rheumatoid arthritis (RA) patients undergoing these procedures. The purpose of this study is to analyze the outcomes and trends of RA patients undergoing total knee arthroplasty (TKA) or total hip arthroplasty (THA) compared to OA patients. Data from the Nationwide Inpatient Sample from 2006 to 2011 was extracted using the International Classification of Diseases, Ninth Revision codes for patients that received a TKA or THA. Outcome measures included cardiovascular complications, cerebrovascular complications, pulmonary complications, wound dehiscence, and infection. Inpatient and hospital demographics including primary diagnosis, age, gender, primary payer, hospital teaching status, Charlson Comorbidity Index score, hospital bed size, location, and median household income were analyzed. Logistic regression analysis of OA vs RA patients with patient outcomes revealed that osteoarthritic THA candidates had lower risk for cardiovascular complications, pulmonary complications, wound dehiscence, infections, and systemic complications, compared to rheumatoid patients. There was a significantly elevated risk of cerebrovascular complication in osteoarthritic THA compared to RA THA. OA patients undergoing TKA had significantly higher risk for cardiovascular and cerebrovascular complications. There were significant decreases in mechanical wounds, infection, and systemic complications in the OA TKA patients. RA patients are at higher risk for postoperative infection, wound dehiscence, and systemic complications after TKA and THA compared to OA patients. These findings highlight the importance of preoperative medical clearance and management to optimize RA patients and improve the postoperative outcomes.