Ast, Michael P.

AbstractFor patients who qualify, simultaneous bilateral total knee arthroplasty (TKA) is a viable option for the treatment of bilateral symptoms. However, the incidence of chronic obstructive pulmonary disease (COPD) has been steadily rising over the past few decades and may impact those who qualify as candidates for bilateral TKA. As such, the aim of this study was to determine the impact of COPD on postoperative outcomes in patients who receive simultaneous bilateral TKA. A retrospective cohort study was conducted utilizing data provided through the American College of Surgeons National Surgical Quality Improvement Program. All patients who had undergone simultaneous bilateral TKA between 2007 and 2016 were identified and further stratified into groups based upon the COPD status. Incidence of adverse events after TKA in the acute postoperative period was evaluated with univariate and multivariate analyses. COPD was found to be an independent risk factor for the development of major (odds ratio [OR]: 2.5; p = 0.015), renal (OR: 5.1; p = 0.02), and thromboembolic complications (OR: 2.5; p = 0.027). In addition, patients with COPD were at increased risk for having an extended hospital length of stay (LOS; p < 0.001) and development of urinary tract infections (p < 0.001). Patients with COPD are at higher risk for development of overall major complications, as well as renal and thromboembolic complications after simultaneous bilateral TKA. Interestingly, patients were not at increased risk for the development of pulmonary or wound complications. When considering a staged versus simultaneous bilateral TKA, surgeons should be aware of the impact COPD status has on the postoperative complication rate.

Background Peer-to-peer advisory among colleagues in orthopedic surgery is commonplace in academic medical centers. In the private practice setting, however, it becomes more difficult for surgeons to discuss complex cases among peers. Purpose/Questions We sought to study the effect of peer-to-peer mentorship on surgeons’ decision-making and on patient care across academic and private adult joint reconstruction practices via the use of group secured messages. Methods From 2013 to 2016, we established a messaging system that was compliant with the Health Insurance Portability and Accountability Act (HIPAA) among five previous adult hip and knee reconstruction co-fellows in order to discuss complex cases. Data collected from each case included patient demographics (age and sex), history and physical examination, relevant imaging in orthogonal planes, and preliminary diagnosis and treatment plans. Data collected from group responses included nature of additional inquiries, literature citations, operative recommendations, and sample imaging of similar cases previously treated. Results The group consisted of two private practice surgeons and three academic surgeons. Data was collected on 283 cases discussed during the study period. None of the patients had any HIPAA violations. The mean number of reviewers who commented on a case was 2.4, with at least one response in 97% of cases. In 33% of the cases, the peers confirmed the initial treatment plan, and in 67% of the cases, an alternative treatment plan was recommended and executed. The case distribution was 94 primary and 189 revision procedures, including 173 hips, 103 knees, three ankles, two shoulders, and two pelvises. Conclusion In the majority of cases exchanged between young surgeons via a group messaging system, a significant impact on patient care was appreciated. In a technology-driven era, peer-to-peer advisory for difficult cases via a rapid feedback method may allow for substantial improvement in patient care, particularly for surgeons not practicing at a large academic medical center with access to several partners and multiple opinions.