William L. Healy

Orthopaedic surgeon workforce and volume assessment for total hip and knee replacement in the United States: Preparing for an epidemic

The demand for health-care services in general, and musculoskeletal care in particular, is expected to increase substantially in the United States because of the growth of the population, aging of the population, public expectations, economic growth, investment in health-care interventions, and improved diagnosis and treatment. The impact of an aging population is demonstrated by the fact that, in 2000, the eleven most costly medical conditions in the United States were far more prevalent among the elderly, and the population of elderly Americans is increasing. It is not clear that the future supply of physicians will be sufficient to meet the increasing demand for health care. The supply of American physicians is limited by the aging and retirement of current physicians, medical school graduation class size of allopathic medical doctors and osteopathic physicians, and United States immigration policies, which limit the number of physicians entering the country. Furthermore, among active physicians, the “effective physician supply” is limited by gender and generational differences, lifestyle choices, changing practice patterns, and variability in physician productivity. At current physician production levels, the ratio of physicians to population will peak between 2015 and 20201. Between 2000 and 2020, the demand for orthopaedic services in this country will increase by 23% while the supply of orthopaedic surgeons will increase by only 2% during the same interval2. During the next few decades, the demand for total joint arthroplasties in the United States may not be met because of an inadequate supply of total joint arthroplasty surgeons. This hypothesis or concern is based on data and trends associated with the prevalence of total joint arthroplasty, projected volumes of total joint arthroplasty, workforce trends in total joint arthroplasty, and reimbursement for total joint arthroplasty. The purposes of this paper are to evaluate the validity of this …

Tibial plateau fractures.

A retrospective study of 128 patients with fractures of the tibial plateau treated at the Johns Hopkins Medical Institutions over a 20-year period was undertaken to compare the results of operative treatment with the results of the nonoperative treatment. Outcome was evaluated with respect to healing, length of hospital stay, time to weight bearing and full activity, and functional result. The fractures were grouped into the four types of the Association for the Study of the Problems of Internal Fixation (AO/ASIF) system, with nondisplaced fractures considered separately. Overall, patients with displaced fractures treated operatively had a shorter average hospital stay (22 days vs 26 days), a higher percentage of satisfactory functional results (78% vs 63%), and a shorter period of immobilization (5 weeks vs 10 weeks), but took longer to return to prefracture activity level (23 weeks vs 18 weeks). The patients treated operatively had more complications with regard to infections (9 vs 2), fewer complications with regard to thromboembolism (2 vs 13), and approximately equal numbers of nonunion or malunion. Our study supports operative therapy for patients with displaced Type III or Type IV fractures and closed treatment for patients with Type I, Type II, and nondisplaced fractures.

Patellofemoral complications following total knee arthroplasty: Correlation with implant design and patient risk factors

Results of 211 total knee arthroplasty operations were retrospectively evaluated to identify patients with knees at greatest risk for the development of patellofemoral complications and to determine the incidence and type of patellofemoral complications associated with different patellar implants. Patellofemoral complications occurred in 27 knees (12.8%). Osteoarthritis and obesity were associated with an increased incidence of patellofemoral problems. Significantly higher rates of patellofemoral complications were noted with metal-backed patellar implants and with patellar components implanted without cement. The loosening rate with cementless fixation was 13.5%. The lowest rate of patellofemoral complications following total knee arthroplasty was obtained with all-polyethylene domed patellar components implanted with cement.

Athletic Activity after Joint Replacement

The first decade of the 21st century has been declared the “Bone and Joint Decade” by 35 nations and 44 states in the United States as of March 2001. It is not surprising that Americans are interested in musculoskeletal disease and the treatment of bone and joint disorders because our population is aging, the prevalence of arthritic joints is increasing, and senior Americans are demonstrating a strong desire to stay active in activities of daily living and athletics. One of the most successful treatments for painful arthritic joints, which limit activity, is total joint replacement, which predictably relieves pain and improves function. Much has been written about the technical aspects of total joint arthroplasty. Less has been written about safe and appropriate activities for patients who have had joint replacement operations. This article evaluates athletic activity after joint replacement by reviewing the orthopaedic literature and surveying members of The Hip Society, The Knee Society, and The American Shoulder and Elbow Surgeons Society. The authors have developed consensus recommendations for appropriate athletic activity for patients who have had joint replacement operations. This article is intended to serve as a guide for orthopaedic surgeons and primary care physicians who give patients recommendations for athletic activity after joint replacement. This article is also intended to stimulate further research in the area of athletic activity after total joint arthroplasty.

Operative treatment of distal femoral fractures proximal to total knee replacements

Twenty fractures of the distal part of the femur proximal to a total knee replacement were treated operatively by members of the New England Trauma Study Group. Notching of the anterior aspect of the femoral cortex was associated with only two of these fractures, and none of the knee prostheses was loose at the time of the fracture. All twenty fractures were treated with open reduction and stable internal fixation, and the operation on fifteen fractures was supplemented with bone grafts. Every fracture healed, and eighteen healed after a mean of sixteen weeks (range, six to forty weeks). Union of the other two fractures was delayed, but repeat open reduction and internal fixation combined with autogenous bone-grafting resulted in union. After operative treatment, the patients returned to the level of activity that they had had before the fracture. The pre-existing tibiofemoral alignment and range of motion of the knee were also restored. At the time of follow-up, the average clinical rating of the Knee Society for all twenty knees had not decreased compared with the score before the fracture.

Complications of Femoral Nerve Block for Total Knee Arthroplasty

AbstractPreemptive and multimodal pain control protocols have been introduced to enhance rehabilitation after total knee arthroplasty (TKA). We determined the complication rate associated with preoperative femoral nerve block (FNB) for TKA. Among 1018 TKA operations, we performed 709 FNBs using a single-injection technique into the femoral nerve sheath and confirming position with nerve stimulation before induction. After TKA, weightbearing as tolerated was initiated using a walker or crutches on postoperative Day 1. Twelve patients (1.6%) treated with FNB sustained falls, three (0.4%) of whom underwent reoperations. Five patients had postoperative femoral neuritis, which may have been secondary to the block. One patient had new onset of atrial fibrillation after FNB, and the TKA was postponed. Femoral nerve block before TKA is not a harmless intervention. We recommend postoperative protocols be modified for patients who have FNB to account for decreased quadriceps function in the early postoperative period, which can lead to falls. Level of Evidence: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Impact of Cost Reduction Programs on Short-Term Patient Outcome and Hospital Cost of Total Knee Arthroplasty

Background: During the 1990s, cost reduction programs were developed to decrease the hospital cost of total knee arthroplasty. The purpose of this study was to evaluate the impact of hospital cost reduction programs for total knee arthroplasty on patient outcome at our hospital.Methods: We evaluated 159 patients who had undergone unilateral primary total knee arthroplasty for the treatment of osteoarthritis at the Lahey Clinic. The results of fifty-six knee replacements performed in 1992 without a clinical pathway or a knee-implant standardization program (the control group) were compared with the results of 103 knee replacements performed in 1995 with a clinical pathway and a knee-implant standardization program (the study group). Before the operation, the two patient populations were similar in terms of age, pain score on a visual analog scale, and clinical knee scores; the groups were also similar with regard to the surgical approach and the time in the operating room. The minimum duration of follow-up was eight years for the control group and five years for the study group.Results: All patients in both groups had excellent relief of pain and improvement in function. There were no differences in clinical outcome between the patient groups. The rate of patient satisfaction was 98% in the control group and 99% in the study group. Implementation of the clinical pathway was associated with a reduction in the average length of the stay in the hospital from 6.79 days in 1992 to 4.16 days in 1995. Implementation of the knee-implant standardization program was associated with increased use of all-polyethylene tibial components in 1995. Hospital cost adjusted for medical inflation was reduced 19% with the implementation of the clinical pathway and the knee-implant standardization program.Conclusions: The clinical pathway and the knee-implant standardization program reduced resource utilization and hospital cost for total knee arthroplasty without affecting short-term patient outcome in our hospital. Orthopaedic surgeons should carefully evaluate cost reduction programs, which may affect their patients, in order to maintain high-quality orthopaedic care and consistently successful patient outcomes.

Rate Of And Risk Factors For Acute Inpatient Mortality After Orthopaedic Surgery

Background: Orthopaedic surgeons operate on a diverse group of patients, and many of these patients have concomitant medical problems. The purpose of this study was to identify the rate of mortality and to evaluate the risk factors associated with mortality after orthopaedic surgery. Methods: Data from the National Hospital Discharge Survey, a nationwide sample of hospital admissions, were obtained for the years 1995 through 1997. The study was limited to hospital admissions. Univariate and multivariate analyses were performed. Results: The 43,215 inpatient orthopaedic operations that we evaluated were associated with a mortality rate of 0.92%. Seventy-seven percent of all deaths occurred after procedures performed for patients who were more than seventy years old, and 50% of all deaths occurred after operations performed for the treatment of hip fractures. The independent preoperative medical risk factors for death included chronic renal failure, congestive heart failure, metastasis to bone, atrial fibrillation, chronic obstructive pulmonary disease, and osteomyelitis. The risk factors of diabetes, coronary artery disease, peripheral vascular disease, septic arthritis, and rheumatoid arthritis did not achieve significance. Among orthopaedic subspecialty categories, operations for tumors, trauma, and infection were associated with elevated mortality rates. In a predictive model, five critical risk factors were identified as most helpful in identifying patients at risk for death: chronic renal failure, congestive heart failure, chronic obstructive pulmonary disease, hip fracture, and an age of greater than seventy years. The mortality rate was 0.25% for patients with no critical risk factors. A linear increase in mortality was seen with increasing numbers of critical risk factors (p < 0.005). Conclusion: Death is rare after orthopaedic operations. In the United States, the rate of acute mortality after inpatient orthopaedic surgical procedures is approximately 1% for all patients, 3.1% for patients with a hip fracture, and 0.5% for patients without a hip fracture. These data will aid orthopaedic surgeons in predicting operative mortality for their patients.

Heterotopic Ossification After Hip and Knee Arthroplasty: Risk Factors, Prevention, and Treatment

&NA; Symptomatic heterotopic ossification (HO) after total hip arthroplasty (THA) and total knee arthroplasty (TKA) is relatively rare. Patients at high risk for developing HO after THA include men with bilateral hypertrophic osteoarthritis, patients with a history of HO in either hip, and patients with posttraumatic arthritis characterized by hypertrophic osteophytosis. Patients at moderate risk are those with ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis, Pagets disease, or unilateral hypertrophic osteoarthritis. Patients at high risk for developing HO after TKA include those with limited postoperative knee flexion, increased lumbar bone mineral density, hypertrophic arthrosis, excessive periosteal trauma and/or notching of the anterior femur, and those who require forced manipulation after TKA. Preoperative radiation is effective for preventing HO after THA, as are postoperative prophylactic drug regimens and single‐dose radiation treatments. Recurrence of HO after surgical excision should be expected unless prophylaxis is administered. Prophylactic measures against HO after THA and TKA should be administered before the fifth postoperative day, optimally within 24 to 48 hours.

Distal femoral varus osteotomy.

The results of twenty-three distal femoral varus osteotomies (in twenty-one patients) that were performed between 1977 and 1984 were evaluated. Fifteen osteotomies were done for osteoarthritis; three, for post-traumatic arthritis or deformity; three, for rheumatoid arthritis; and two, for renal osteodystrophy. The median age of the patients was fifty-six years (range, nineteen to seventy years). The length of follow-up averaged four years (range, two to nine years). The average tibiofemoral angle preoperatively was 18 degrees of valgus, which was corrected postoperatively to an average of 2 degrees of valgus. At follow-up, nineteen (83 per cent) of the twenty-three knees were rated as good or excellent according to The Hospital for Special Surgery knee score, which had improved from an average of 65 points preoperatively to 86 points post-operatively. Of the fifteen patients who had osteoarthritis (93 per cent), all but one had a good or excellent result. Most patients had no substantial improvement in the range of motion of the knee as a result of the operation. Eighty-six per cent of the patients expressed satisfaction with the outcome. We concluded that varus osteotomy of the distal part of the femur is a reliable and effective surgical procedure for the treatment of gonarthrosis associated with valgus deformity due to osteoarthritis or trauma. We do not recommend its use in patients who have rheumatoid arthritis or in those who have inadequate motion of the knee before the operation.