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BACKGROUND: Patients with limited health literacy have difficulty understanding their injuries and postoperative treatment, which can negatively affect their outcomes. MATERIALS AND METHODS: This cross-sectional questionnaire-based study of 103 adult patients sought to quantify patients' health literacy at a single county hospital's orthopedic trauma clinic and to examine their ability to understand injuries and treatment plans. Demographics, Newest Vital Sign (NVS) health literacy assessment, and knowledge scores were used to assess patients' comprehension of their injuries and treatment plan. Patients were grouped by NVS score (NVS <4: limited health literacy). Fisher's exact tests and t tests were used to compare demographic and comprehension scores. Multivariate logistic regression analysis was used to examine the association among low health literacy, sociodemographic variables, and knowledge scores. RESULTS: Of the 103 patients, 75% were determined to have limited health literacy. Patients younger than 30 years were more likely to have adequate literacy (50% vs 23%, P=.01). Patients who spoke Spanish as their primary language were 8.77 times more likely to have limited health literacy with respect to sociodemographic factors (odds ratio, 8.77; 95% CI, 1.03-76.92; P=.04). Low health literacy was 3.52 and 4.14 times more likely to predict discordance in answers to specific bone fractures and the narcotics prescribed (P=.04 and P=.02, respectively). CONCLUSION: Spanish-speaking patients have demonstrated limited health literacy and difficulty understanding their injuries and postoperative treatment plans compared with English-speaking patients. Patients with low health literacy are more likely to be unsure regarding which bone they fractured or their prescribed opiates. [Orthopedics. 2024;47(4):249-255.].

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INTRODUCTION: Rapid recovery protocols (RRPs) for total joint arthroplasty (TJA) can reduce hospital length of stay (LOS) and improve patient care in select cohorts; however, there is limited literature regarding their utility in marginalized patient populations. This report aimed to evaluate the outcomes of an institutional RRP for TJA at a safety net hospital. METHODS: A retrospective review of 573 primary TJA patients was done, comparing the standard recovery protocol (n = 294) and RRP cohorts (n = 279). Measured outcomes included LOS, 90-day complications, revision surgeries, readmissions, and emergency department visits. RESULTS: The mean LOS reduced from 3.0 ± 3.1 days in the standard recovery protocol cohort to 1.6 ± 0.9 days in the RRP cohort (P < 0.001). The RRP cohort had significantly fewer 90-day complications (11.1% versus 21.4%, P = 0.005), readmissions (1.4% versus 5.8%, P = 0.007), and revision surgeries (1.4% versus 4.4%, P = 0.047). CONCLUSION: A RRP for primary TJA can be successfully implemented at a safety net hospital with a shorter LOS and fewer acute adverse events. Such protocols require a coordinated, multidisciplinary effort with strict adherence to evidence-based practices to provide high-quality, value-based surgical health care to an underserved cohort.

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CASE: A 26-year-old man presented after an automobile versus pedestrian accident with a Type IIIA open femur fracture complicated by a necrotizing soft-tissue infection (NSTI) with significant bone loss. Multiple limb-preserving operations failed, including the placement of a plate-assisted, motorized lengthening intramedullary nail with a chimeric free flap. We describe the patient's successful definitive treatment with a Van Nes rotationplasty (VNR). The patient currently ambulates independently with a prosthesis and is without recurrent infection after 3 years of follow-up. CONCLUSION: VNR is a potential strategy to avoid transfemoral amputation or hip disarticulation in open femur fractures complicated by NSTI.

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BACKGROUND: Selective dental clearance before total joint arthroplasty (TJA) has been proposed; however, effective strategies of carrying out this practice are lacking. This study aims to determine the positive predictive value (PPV) of a novel oral examination performed by an orthopedic surgeon to better direct limited resources for marginalized patients in a safety net hospital system. METHODS: A retrospective review was conducted on 105 consecutive patients who had an oral examination performed by a single surgeon before elective TJA. Patients who screened negative proceeded to surgery without further formal dental clearance. Patients who screened positive underwent formal examination/intervention by a dentist before surgery. The rate of correct referral that resulted in patients undergoing an oral surgical intervention was determined. Complications during a minimum 90-day postoperative follow-up period were collected and compared. RESULTS: Thirty patients (28.6%) screened positive while 75 patients (71.4%) screened negative and proceeded to surgery without referral. The PPV of the screening test was high, with 73.3% of patients receiving a major surgical oral intervention before TJA. Patients sent for formal referral required 89.1 more days to receive their surgery than those that screened negative (54.9 days ± 4.24 vs 144.0 days ± 82.4, P < .001). CONCLUSION: An orthopedic surgeon's oral examination demonstrates a high PPV to identify high-risk patients in need of an oral surgical intervention before TJA. This provides a unique solution regarding over-referral for preoperative dental clearance and avoids delays for marginalized patients considering elective TJA in a safety net hospital system.

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AIMS: This study aimed to evaluate whether an enhanced recovery protocol (ERP) for arthroplasty established during the COVID-19 pandemic at a safety net hospital can be associated with a decrease in hospital length of stay (LOS) and an increase in same-day discharges (SDDs) without increasing acute adverse events. METHODS: A retrospective review of 124 consecutive primary arthroplasty procedures performed after resuming elective procedures on 11 May 2020 were compared to the previous 124 consecutive patients treated prior to 17 March 2020, at a single urban safety net hospital. Revision arthroplasty and patients with < 90-day follow-up were excluded. The primary outcome measures were hospital LOS and the number of SDDs. Secondary outcome measures included 90-day complications, 90-day readmissions, and 30day emergency department (ED) visits. RESULTS: The mean LOS was significantly reduced from 2.02 days (SD 0.80) in the pre-COVID cohort to 1.03 days (SD 0.65) in the post-COVID cohort (p < 0.001). No patients in the pre-COVID group were discharged on the day of surgery compared to 60 patients (48.4%) in the post-COVID group (p < 0.001). There were no significant differences in 90-day complications (13.7% (n = 17) vs 9.7% (n = 12); p = 0.429), 30-day ED visits (1.6% (n = 2) vs 3.2% (n = 4); p = 0.683), or 90-day readmissions (2.4% (n = 3) vs 1.6% (n = 2); p = 1.000) between the pre-COVID and post-COVID groups, respectively. CONCLUSION: Through use of an ERP, arthroplasty procedures were successfully resumed at a safety net hospital with a shorter LOS and increased SDDs without a difference in acute adverse events. The resulting increase in healthcare value therefore may be considered a 'silver lining' to the moratorium on elective arthroplasty during the COVID-19 pandemic. These improved efficiencies are expected to continue in post-pandemic era. Cite this article: Bone Jt Open 2021;2(10):871-878.

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INTRODUCTION: High-percentage outpatient total joint arthroplasty (TJA) performed in a safety net hospital system has not been described. A rapid recovery protocol (RRP) was instituted at our safety net hospital that allowed eventual transition to outpatient TJA. METHODS: Retrospective review of all primary total knee and hip arthroplasty performed by a single surgeon (RR) using an RRP was performed. The initial cohort of patients was monitored overnight with the goal of next-day discharge (n = 57), and as the RRP evolved, the subsequent cohort of patients had the possibility of same-day discharge (PSDD, n = 61). Outcome measures included the rate of same-day discharge in the PSDD cohort and short-term adverse event rates. RESULTS: In the PSDD cohort, 86.9% (n = 53) of patients were successfully discharged on the day of surgery, and hospital length of stay was decreased by 17.7 hours (13.5 versus 31.2 hours, P < 0.0001). Comparing the next-day discharge and PSDD groups, no significant differences were found in 30-day emergency department visits (5.3% versus 3.3%, P = 0.67), 90-day complications (15.8% versus 13.1%, P = 0.79), 90-day readmissions (0% versus 3.3%, P = 0.50), or 90-day revision surgeries (0% versus 3.3%, P = 0.50). CONCLUSIONS: This study demonstrates that the transition to outpatient TJA can be successfully performed in a safety net hospital system without increasing short-term adverse events.

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STUDY DESIGN: Level-1 diagnostic study. OBJECTIVE: The purpose of this study was to evaluate the sensitivity and specificity of combined motor and sensory intraoperative neuromonitoring (IONM) for cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA: Intraoperative neuromonitoring during spine surgery began with sensory modalities with the goal of reducing neurological complications. Motor monitoring was later added and purported to further increase sensitivity and specificity when used in concert with sensory monitoring. Debate continues, however, as to whether neuromonitoring reliably detects reversible neurologic changes during surgery or simply adds set-up time, cost, or mere medicolegal reassurance. METHODS: Neuromonitoring data using combined motor and sensory evoked potentials for 540 patients with CSM undergoing anterior or posterior decompressive surgery were collected prospectively. Patients were examined postoperatively to determine the clinical occurrence of new neurologic deficit which correlated with monitoring alerts recorded per established standard criteria. RESULTS: The overall incidence of positive IONM alerts was 1.3% (N = 7) all of which were motor alerts. All were false positives as no patient had clinical neurological deterioration post-operatively. The false-positive rate was 1.4% (N = 146) for anterior surgeries and 1.3% (N = 394) for posteriors with no statistical difference between them (P = 1.0, Fisher exact test). There were no false-negative alerts, and all negatives were true negatives (N = 533). The overall sensitivity of detecting a new neurologic deficit was 0%, overall specificity 98.7%. CONCLUSION: Combined motor and sensory neuromonitoring for CSM patients created a confusing choice between the motor or sensory data when in disagreement in 1.3% of surgical patients. Criterion standard clinical examinations confirmed all motor alerts were false positives. Surgical plan was negatively altered by following false motor alerts early on, but disregarded in later cases in favor of sensory data. Neuromonitoring added set-up time and cost, but without clear benefit in this series.Level of Evidence: 4.

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PURPOSE: This study aimed to develop and examine the acceptability, feasibility, and usability of a text messaging, or Short Message Service (SMS), system for improving the receipt of survivorship care for adolescent and young adult (AYA) survivors of childhood cancer. METHODS: Researchers developed and refined the text messaging system based on qualitative data from AYA survivors in an iterative three-stage process. In stage 1, a focus group (n = 4) addressed acceptability; in stage 2, key informant interviews (n = 10) following a 6-week trial addressed feasibility; and in stage 3, key informant interviews (n = 23) following a 6-week trial addressed usability. Qualitative data were analyzed using a constant comparative analytic approach exploring in-depth themes. RESULTS: The final system includes programmed reminders to schedule and attend late effect screening appointments, tailored suggestions for community resources for cancer survivors, and messages prompting participant feedback regarding the appointments and resources. Participants found the text messaging system an acceptable form of communication, the screening reminders and feedback prompts feasible for improving the receipt of survivorship care, and the tailored suggestions for community resources usable for connecting survivors to relevant services. Participants suggested supplementing survivorship care visits and forming AYA survivor social networks as future implementations for the text messaging system. CONCLUSIONS: The text messaging system may assist AYA survivors by coordinating late effect screening appointments, facilitating a partnership with the survivorship care team, and connecting survivors with relevant community resources. IMPLICATIONS FOR CANCER SURVIVORS: The text messaging system has the potential to improve the receipt of survivorship care.

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