Quality in orthopaedic surgery--an international perspective: AOA critical issues

The benefits and limitations of establishing the PA profession globally: A systematic review and mixed-methods study

OBJECTIVE

Physician associates/assistants (PAs) and their equivalents offer a solution to the supply and demand crisis to alleviate global healthcare needs. This study investigated how PA and PA equivalents address global healthcare needs across different healthcare systems, revealing recommendations for their use. The study also sought to catalog the global healthcare needs that PAs and equivalents are successfully alleviating, the roles in which they function, and the barriers facing implementation.

METHODS

A systematic review was conducted from October 2021 to April 2022 and rerun in June 2023 following PRISMA 2020 guidelines; additionally, supporting interviews were conducted with PAs and global health experts. Primary outcomes were geographic region, economy, healthcare needs, and healthcare systems. Secondary outcomes were PA use, license recognition, and successes or barriers when implementing PAs.

RESULTS

The literature and interviews focused on the global use of PAs and PA equivalents in six geographic regions, 63 countries, and five US territories where PAs or PA equivalents are employed, have been employed, are volunteering, or are being considered to support global healthcare needs. Most countries have a developing economy and an out-of-pocket healthcare system. PAs and PA equivalents hold 35 different practice titles, and most work in primary care. PAs alleviate healthcare shortages and economic disparities, specifically related to inequitable healthcare access. Globally, the profession is limited by a lack of legislation, regulation, and support.

CONCLUSIONS

PAs and PA equivalents worldwide belong to an adaptable profession that has well-documented success in alleviating the global healthcare shortage and addressing healthcare needs. Countries desiring PAs or PA equivalents should identify their specific needs, train their existing workforce, employ pilot programs, and focus on seeking early legislation and regulation. Broad support for existing PA and PA equivalent international organizations is recommended for global collaboration. This study serves as a guide for those advocating for the continued or future implementation of PAs and PA equivalents in their own country and provides a comprehensive resource to aid in the globalization of this profession. We offer recommendations to address the dire healthcare needs and workforce shortage faced across the globe.

Cemented or uncemented fixation: Which allows a more acceptable prosthetic femoral version in total hip arthroplasty?

BACKGROUND

Three-dimensional computed-tomography (3D-CT) planning for primary Total Hip Arthroplasty (THA) typically uses the external femoral surface; as a result, it is difficult to predict the prosthetic femoral version (PFV) for uncemented femoral stems that press-fit to the internal surface of the bone. Cemented fixation allows the surgeon to adjust the version independent of the internal femoral anatomy. We aimed to better understand the effect of the fixation type on PFV.

METHODS

This was a case series study including a total of 95 consecutive patients (106 hips), who underwent uncemented (n = 81 hips) and cemented (n = 25 hips) primary THA using the posterior approach. The surgeon aimed for a PFV of 20°. Our primary objective was to compare PFV in both groups; our secondary objective was to evaluate the clinical outcomes.

RESULTS

The mean (± SD) PFV was 13° (± 9°) and 23° (± 8°) for the uncemented and cemented THA groups (P < 0.001), respectively. In the uncemented THA group, 36% of the patients had a PFV of < 10°. In the cemented THA group, this clinically important threshold dropped to 8%. Similarly, the Bland-Altman (BA) plots showed wider 95% limits of agreement for the uncemented group. Satisfactory clinical outcomes were recorded.

CONCLUSION

We found that the PFV was more clinically acceptable, for the posterior surgical approach, in the cemented group when compared to the uncemented group. Both THA groups reported high variability indicating the need to develop surgical tools to guide the PFV closer to the surgical target.

Assessment of 30 Years of Randomized Controlled Trials in The American Journal of Sports Medicine: 1990-2020

Background

Randomized controlled trials (RCTs) stand atop the evidence-based hierarchy of study designs for their ability to arrive at results with the lowest risk of bias. Even for RCTs, however, critical appraisal is essential before applying results to clinical practice.

Purpose

To analyze the quality of reporting of RCTs published in The American Journal of Sports Medicine (AJSM) from 1990 to 2020 and to identify trends over time and areas of improvement for future trials.

Study Design

Systematic review; Level of evidence, 1.

Methods

We queried the AJSM database for RCTs published between January 1990 and December 2020. Data pertaining to study characteristics were recorded. Quality assessments were conducted using the Detsky quality-of-reporting index and the modified Cochrane risk-of-bias (mROB) tool. Univariate and multivariable models were generated to establish factors with associations to study quality. The Fragility Index was calculated for eligible studies.

Results

A total of 277 RCTs were identified with a median sample size of 70 patients. A total of 19 RCTs were published between 1990 and 2000 (t₁); 82 RCTs between 2001 and 2010 (t₂); and 176 RCTs between 2011 and 2020 (t₃). From t₁ to t₃, significant increases were observed in the overall mean-transformed Detsky score (from 68.2% ± 9.8% to 87.4% ± 10.2%, respectively; P < .001) and mROB score (from 4.7 ± 1.6 to 6.9 ± 1.6, respectively; P < .001). Multivariable regression analysis revealed that trials with follow-up periods of <5 years clearly stated primary outcomes, and a focus on the elbow, shoulder, or knee were associated with higher mean-transformed Detsky and mROB scores. The median Fragility Index was 2 (interquartile range, 0-5) for trials with statistically significant. Studies with small sample sizes (<100 patients) were more likely to have low Fragility Index scores and less likely to have a statistically significant finding in any outcome.

Conclusion

The quantity and quality of published RCTs published in AJSM increased over the past 3 decades. However, single-center trials with small sample sizes were prone to fragile results.

Better Patient Care Through Physician Extenders and Advanced Practice Providers

Physician extenders and advanced practice providers (APPs) are now common in most adult and pediatric orthopaedic clinics and practices. Their utilization, with physician leadership, can improve patient care, patient satisfaction, and physician satisfaction and work/life balance in addition to having financial benefits. Physician extenders can include scribes, certified athletic trainers, and registered nurses, while APPs include nurse practitioners and physician assistants/associates. Different pediatric orthopaedic practices or divisions within a department might benefit from different physician extenders or APPs based on particular skill sets and licensed abilities. This article will review each of the physician extender and APP health care professionals regarding their training, salaries, background, specific skill sets, and scope of practice. While other physician extenders such as medical assistants, cast technicians, and orthotists/prosthetists have important roles in day-to-day clinical care, they will not be reviewed in this article. In addition, medical trainees, including medical students, residents, fellows, and APP students, have a unique position within some academic clinics but will also not be reviewed in this article. With the many different local, state, and national regulations, a careful understanding of the physician extender and APP roles will help clinicians optimize their ability to improve patient care.

Effects on health and process outcomes of physiotherapist-led orthopaedic triage for patients with musculoskeletal disorders: a systematic review of comparative studies

BACKGROUND

Physiotherapist-led (PT-led) orthopaedic triage is an evolving model of care for patients with musculoskeletal disorders. Objectives for this study were to establish the current evidence body on the impact of PT-led orthopaedic triage on health, quality, and service outcomes for patients referred for orthopaedic consultation, compared with standard (orthopaedic surgeon) care.

METHODS

Medline, EMBASE, Scopus and CINAHL were searched from inception until 7 May 2018; search updated 24 April 2020. Search terms (including derivatives) included physiotherapy, advanced/extended scope, musculoskeletal/orthopaedic, triage. The search was framed as Population = patients referred for orthopaedic consultation; Intervention = PT-led orthopaedic triage; Comparison = standard care; Outcomes = health, quality and process outcomes. Only randomised controlled trials (RCTs) and prospective comparative cohort studies were eligible for inclusion. Screening, study selection, data extraction, and assessment of methodological quality were performed independently by reviewer pairs. Quality was scored with the Downs and Black checklist. Certainty of evidence was determined using GRADE. PROSPERO registration number CRD42017070950.

RESULTS

We included two RCTs and eleven cohort studies (n = 1357 participants) of variable methodological quality (range 14-23 of possible 28). Certainty of evidence was low to moderate. There was no difference between PT-led orthopaedic triage and standard care for patient-reported outcomes (two RCTs). Perceived quality of care with PT-led orthopaedic triage was higher (two RCTs, four cohort studies) or equal (one cohort study) compared with standard care. PT-led orthopaedic triage had higher surgery conversion rates (one RCT, three cohort studies) (55-91% vs 22-38%), lower (two RCTs) or equal rate (two cohort studies) of referral for investigations, shorter waiting times (one RCT, one cohort study), and lower costs (one RCT). Furthermore, there was high agreement between physiotherapists' and orthopaedic surgeons' treatment approach (eight cohort studies), referral for investigation (five cohort studies), and diagnosis (nine cohort studies). Study limitations were the low number of RCTs, and variable methodological quality.

CONCLUSIONS

Evidence of low to moderate certainty suggests that PT-led orthopaedic triage leads to similar diagnostic decisions as standard care, has a higher conversion-to-surgery rate, reduces waiting times, is cost effective and valued by patients, and that health outcomes are equivalent.

Walk a Mile in the Leadership's Shoes: Why Focus on Quality Improvement?

Quality Improvement (QI) throughout health care in the United States continues to be of growing importance to both patients and providers. Leaders in health care including physicians, nurses, hospital administrators, and payors are all responsible for ensuring the continuation and growth of QI initiatives. This article will discuss various ways that healthcare leaders, with specific regard to orthopedic surgery, have utilized QI measures to provide better, more efficient, care to patients.

It Is All About Value Now: The Data You Need to Collect and How to Do It: AOA Critical Issues

Health care has entered an era where value and quality have become more important than just quantity. Patient-reported outcomes are a critical aspect of the value equation. Orthopaedic surgeons will need to demonstrate that their treatment regimens actually are enhancing their patients' quality of life. In order to do this, the collection of prospective patient-reported outcome data will be critical. For most patients, this will require the use of a general health survey and a disease-specific questionnaire. Currently, most orthopaedic surgeons are not collecting this type of data. The questions are: What types of patient-generated questionnaires can provide the information needed, and how can these data be collected in a cost-effective manner? We will discuss what value means to payers and what the outcome measures are that are selected by various orthopaedic subspecialty societies to evaluate patients who undergo total hip and knee arthroplasty as well as patients with shoulder and knee problems, and we will review potential strategies to collect prospective patient-outcome data in a cost-effective manner in the office.

Establishing Maximal Medical Improvement After Arthroscopic Rotator Cuff Repair

BACKGROUND

As health care transitions from a pay-for-service to a pay-for-performance infrastructure, the value of orthopaedic care must be defined accurately. Significant efforts have been made in defining quality and cost in arthroplasty; however, there remains a lag in ambulatory orthopaedic care.

PURPOSE

Two-year follow-up has been a general requirement for reporting outcomes after rotator cuff repair. However, this time requirement has not been established scientifically and is of increasing importance in the era of value-based health care. Given that arthroscopic rotator cuff repair is a common ambulatory orthopaedic procedure, the purpose of this study was to establish a time frame for maximal medical improvement (the state when improvement has stabilized) after arthroscopic rotator cuff repair.

STUDY DESIGN

Systematic review.

METHODS

A systematic review of the literature was conducted, identifying studies reporting sequential patient-reported outcomes up to a minimum of 2 years after arthroscopic rotator cuff repair. The primary clinical outcome was patient-reported outcomes at 3-month, 6-month, 1-year, and 2-year follow-up. Secondary clinical outcomes included range of motion, strength, retears, and complications. Clinically significant improvement was determined between various time intervals by use of the minimal clinically important difference.

RESULTS

The review included 19 studies including 1370 patients who underwent rotator cuff repair. Clinically significant improvement in patient-reported outcomes was seen up to 1 year after rotator cuff repair, but no clinical significance was noted from 1 year to 2 years. The majority of improvement in strength and range of motion was seen up to 6 months, but no clinically meaningful improvement was seen thereafter. All reported complications and the majority of retears occurred within 6 months after rotator cuff repair.

CONCLUSION

After rotator cuff repair, a clinically significant improvement in patient-reported outcomes, range of motion, and strength was seen up to 1 year after surgery, but not beyond this. This information is important not only to establish appropriate patient expectations but also to determine a time frame for outcome collection after surgery to better define value in orthopaedic care.

Big Data, Big Problems: Incorporating Mission, Values, and Culture in Provider Affiliations

This article explores how integration of data from clinical registries and electronic health records produces a quality impact within orthopedic practices. Data are differentiated from information, and several types of data that are collected and used in orthopedic outcome measurement are defined. Furthermore, the concept of comparative effectiveness and its impact on orthopedic clinical research are assessed. This article places emphasis on how the concept of big data produces health care challenges balanced with benefits that may be faced by patients and orthopedic surgeons. Finally, essential characteristics of an electronic health record that interlinks musculoskeletal care and big data initiatives are reviewed.

Large-diameter total hip arthroplasty modular heads require greater assembly forces for initial stability

Objectives

Modular junctions are ubiquitous in contemporary hip arthroplasty. The head-trunnion junction is implicated in the failure of large diameter metal-on-metal (MoM) hips which are the currently the topic of one the largest legal actions in the history of orthopaedics (estimated costs are stated to exceed $4 billion). Several factors are known to influence the strength of these press-fit modular connections. However, the influence of different head sizes has not previously been investigated. The aim of the study was to establish whether the choice of head size influences the initial strength of the trunnion-head connection.

Materials and Methods

Ti-6Al-4V trunnions (n = 60) and two different sizes of cobalt-chromium (Co-Cr) heads (28 mm and 36 mm; 30 of each size) were used in the study. Three different levels of assembly force were considered: 4 kN; 5 kN; and 6 kN (n = 10 each). The strength of the press-fit connection was subsequently evaluated by measuring the pull-off force required to break the connection. The statistical differences in pull-off force were examined using a Kruskal–Wallis test and two-sample Mann–Whitney U test. Finite element and analytical models were developed to understand the reasons for the experimentally observed differences.

Results

36 mm diameter heads had significantly lower pull-off forces than 28 mm heads when impacted at 4 kN and 5 kN (p < 0.001; p < 0.001), but not at 6 kN (p = 0.21). Mean pull-off forces at 4 kN and 5 kN impaction forces were approximately 20% larger for 28 mm heads compared with 36 mm heads. Finite element and analytical models demonstrate that the differences in pull-off strength can be explained by differences in structural rigidity and the resulting interface pressures.

Conclusion

This is the first study to show that 36 mm Co-Cr heads have up to 20% lower pull-off connection strength compared with 28 mm heads for equivalent assembly forces. This effect is likely to play a role in the high failure rates of large diameter MoM hips.

Cite this article: A. R. MacLeod, N. P. T. Sullivan, M. R. Whitehouse, H. S. Gill. Large-diameter total hip arthroplasty modular heads require greater assembly forces for initial stability. Bone Joint Res 2016;5:338–346. DOI: 10.1302/2046-3758.58.BJR-2016-0044.R1.

What Quality Metrics Is My Hospital Being Evaluated on and What Are the Consequences?

Quality, experience, and cost are important indicators of value to patients. However, stakeholders have yet to reach agreement on how to define quality and which measures should be used to assess quality. Measures that have been used to assess quality in health care include structural, process, patient experience, efficiency, and outcomes measures. Payers and other quality rating organizations use a combination of measures to rate or rank hospitals on the quality of care they provide. These ratings can be strictly informational or can be used to steer patients, for contracting between payers and providers, and more recently, for adjustments to reimbursements. Physicians and hospitals have a crucial role to play in the development of quality measures that are used to measure and improve value. Consensus on quality measures will facilitate meaningful comparisons across providers and insights that will enable improvements in the value of care we deliver to our patients.

Update on the Methodological Quality of Research Published in The American Journal of Sports Medicine: Comparing 2011-2013 to 10 and 20 Years Prior

BACKGROUND

In recent years, the number of articles in The American Journal of Sports Medicine (AJSM) has risen dramatically, with an increasing emphasis on evidence-based medicine in orthopaedics and sports medicine.

HYPOTHESIS

Despite the increase in the number of articles published in AJSM over the past decade, the methodological quality of articles in 2011-2013 has improved relative to those in 2001-2003 and 1991-1993.

STUDY DESIGN

Meta-analysis.

METHODS

All articles published in AJSM during 2011-2013 were reviewed and classified by study design. For each article, the use of pertinent methodologies, such as prospective data collection, randomization, control groups, and blinding, was recorded. The frequency of each article type and the use of evidence-based techniques were compared relative to 1991-1993 and 2001-2003 by use of Pearson χ(2) testing.

RESULTS

The number of research articles published in AJSM more than doubled from 402 in 1991-1993 and 423 in 2001-2003 to 953 in 2011-2013. Case reports decreased from 15.2% to 10.6% to 2.1% of articles published over the study period (P < .001). Cadaveric/human studies and meta-analysis/literature review studies increased from 5.7% to 7.1% to 12.4% (P < .001) and from 0.2% to 0.9% to 2.3% (P = .01), respectively. Randomized, prospective clinical trials increased from 2.7% to 5.9% to 7.4% (P = .007). Fewer studies used retrospective compared with prospective data collection (P < .001). More studies tested an explicit hypothesis (P < .001) and used controls (P < .001), randomization (P < .001), and blinding of those assessing outcomes (P < .001). Multi-investigator trials increased (P < .001), as did the proportion of articles citing a funding source (P < .001).

CONCLUSION

Despite a dramatic increase in the number of published articles, the research published in AJSM shifted toward more prospective, randomized, controlled, and blinded designs during 2011-2013 compared with 2001-2003 and 1991-1993, demonstrating a continued improvement in methodological quality.

Hospital Acquired Conditions Are the Strongest Predictor for Early Readmission: An Analysis of 26,710 Arthroplasties

Hospital readmission is a metric of hospital quality of care, yet little is known what factors predict hospital readmission following arthroplasty. Our aim was to identify variables associated with early readmission following knee and hip arthroplasty, with focus upon hospital acquired conditions (HACs). Retrospective cohort analysis using Surgical Care Improvement Project (SCIP) and Veteran's Affairs Surgical Quality Improvement Program (VASQIP) data was performed over a five-year period. Following 26,710 total and partial primary arthroplasties (16,808 knees and 9902 hips), the overall 30-day readmission was 7.3% (1940) with readmission rates of 6.6% for knee arthroplasty and 8.4% for hip arthroplasty. HACs accounted for 42% of all complications and were the strongest predictor of readmission. Efforts to reduce these events may improve cost and safety of arthroplasty.

Review of anterior cruciate ligament reconstruction cost variance within a regional health care system

BACKGROUND

Examination of value in health care has become a national priority in the United States. Regional variation in health care costs is an area of focus among national policy experts. Procedural cost data can be used to provide physicians with information to evaluate costs and value.

PURPOSE

To perform a cost review for anterior cruciate ligament (ACL) surgery to document the degree of variation in costs for ACL reconstruction.

STUDY DESIGN

Economic and decision analysis; Level of evidence, 4.

METHODS

A procedural cost review was performed for isolated ACL reconstructions within a 22-surgeon, 7-hospital system. Five consistent cost categories under the influence of the surgeon were identified and were analyzed for cost variation among surgeons: tibial fixation, femoral fixation, graft choice, sutures, and tools or disposable instruments.

RESULTS

For these 5 categories, the total costs to perform an ACL reconstruction (in 2013 US dollars) ranged from $392.80 to $4670.31, a difference of $4277.51 and a mean of $2039.09. Tibial fixation costs ranged from $95.00 to $760.00 (mean, $293.52). Femoral fixation ranged from $95.00 to $865.00 (mean, $367.14). The graft cost ranged from $1275.00 to $2545.75 (mean, $1976.43). Suture prices for each individual suture varied from $1.19 to $46.00 (mean, $18.26). Tools and disposable supplies ranged from $40.10 to $2136.00 (mean, $452.33).

CONCLUSION

There were substantial differences in ACL reconstruction costs in the implant and disposable instruments categories. As health systems and physicians collaborate to improve health care quality and value for patients, information on cost variation will be important. Rational variation in health care cost is appropriate, reflecting variation due to the unique requirements of procedures and patient-centered care. Irrational variations in procedural costs are those that do not add additional value.

Thumb basal joint: Utilizing new technology for the treatment of a common problem

New technology has the potential to greatly impact the medical field because it may lead to a greater quality of life, decreased pain, or increased function for our patients. This manuscript will discuss the introduction of one such advance in hand surgery and hand therapy. Utilizing the Mini-Tightrope™ (Arthrex, Naples, FL) for suspension of the thumb metacarpal following trapeziectomy is a new technique for treating thumb carpometacarpal (CMC) arthritis. This technique is described as an example of the advantages of considering new techniques and technologies when treating established problems. This article discusses the responsibility of health professionals in considering the adoption of new technologies over current ones in the context of describing a new type of CMC suspensionplasty procedure. Further, a description of the surgical technique, the hand therapy postoperatively, and a case study to demonstrate some of the features of the Tightrope suspensionplasty procedure is presented. In the author's experience, the reduced healing time, reduced weeks of immobility, and fewer therapy visits following the procedure suggest that the Tightrope procedure should be considered as an option for patients needing thumb CMC arthroplasty.

Raised levels of metal ions in the blood in patients who have undergone uncemented metal-on-polyethylene Trident-Accolade total hip replacement

The issues surrounding raised levels of metal ions in the blood following large head metal-on-metal total hip replacement (THR), such as cobalt and chromium, have been well documented. Despite the national popularity of uncemented metal-on-polyethylene (MoP) THR using a large-diameter femoral head, few papers have reported the levels of metal ions in the blood following this combination. Following an isolated failure of a 44 mm Trident-Accolade uncemented THR associated with severe wear between the femoral head and the trunnion in the presence of markedly elevated levels of cobalt ions in the blood, we investigated the relationship between modular femoral head diameter and the levels of cobalt and chromium ions in the blood following this THR. A total of 69 patients received an uncemented Trident-Accolade MoP THR in 2009. Of these, 43 patients (23 men and 20 women, mean age 67.0 years) were recruited and had levels of cobalt and chromium ions in the blood measured between May and June 2012. The patients were then divided into three groups according to the diameter of the femoral head used: 12 patients in the 28 mm group (controls), 18 patients in the 36 mm group and 13 patients in the 40 mm group. A total of four patients had identical bilateral prostheses in situ at phlebotomy: one each in the 28 mm and 36 mm groups and two in the 40 mm group. There was a significant increase in the mean levels of cobalt ions in the blood in those with a 36 mm diameter femoral head compared with those with a 28 mm diameter head (p = 0.013). The levels of cobalt ions in the blood were raised in those with a 40 mm diameter head but there was no statistically significant difference between this group and the control group (p = 0.152). The levels of chromium ions in the blood were normal in all patients. The clinical significance of this finding is unclear, but we have stopped using femoral heads with a diameter of ≤ 36 mm, and await further larger studies to clarify whether, for instance, this issue particularly affects this combination of components.

Cancer incidence and cause-specific mortality in patients with metal-on-metal hip replacements in Finland

BACKGROUND AND PURPOSE

Metal-on-metal hip implants have been widely used, especially in the USA, Australia, England and Wales, and Finland. We assessed risk of death and updated data on the risk of cancer related to metal-on-metal hip replacements.

PATIENTS AND METHODS

A cohort of 10,728 metal-on-metal hip replacement patients and a reference cohort of 18,235 conventional total hip replacement patients were extracted from the Finnish Arthroplasty Register for the years 2001-2010. Data on incident cancer cases and causes of death until 2011 were obtained from the Finnish Cancer Registry and Statistics Finland. The relative risk of cancer and death were expressed as standardized incidence ratio (SIR) and standardized mortality ratio (SMR). SIR/SIR ratios and SMR/SMR ratios, and Poisson regression were used to compare the cancer risk and the risk of death between cohorts.

RESULTS

The overall risk of cancer in the metal-on-metal cohort was not higher than that in the non-metal-on-metal cohort (RR = 0.91, 95% CI: 0.82-1.02). The risk of soft-tissue sarcoma and basalioma in the metal-on-metal cohort was higher than in the non-metal-on-metal cohort (SIR/SIR ratio = 2.6, CI: 1.02-6.4 for soft-tissue sarcoma; SIR/SIR ratio = 1.3, CI: 1.1-1.5 for basalioma). The overall risk of death in the metal-on-metal cohort was less than that in the non-metal-on-metal cohort (RR = 0.78, CI: 0.69-0.88).

INTERPRETATION

The overall risk of cancer or risk of death because of cancer is not increased after metal-on-metal hip replacement. The well-patient effect and selection bias contribute substantially to the findings concerning mortality. Arthrocobaltism does not increase mortality in patients with metal-on-metal hip implants in the short term. However, metal-on-metal hip implants should not be considered safe until data with longer follow-up time are available.