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Large Joints Feature

Volunteer surgeons Lorenzo Gamez, MD (left) and Geoffrey M. Tymms, MBBS (right) examine a young patient at the Vinh Orthopedics Rehab Center in Vinh, Vietnam. / Courtesy of AOFAS

AOFAS Volunteers Give and Teach in Vietnam; New Score Trumps ASA and CCI Risk Stratification Systems; Grapefruit Arthroscopic Training!?

Elizabeth Hofheinz, M.P.H., M.Ed. • Wed, August 30th, 2017

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AOFAS Volunteers Give and Teach in Vietnam

Thanks to the dedication of volunteers from the American Orthopaedic Foot & Ankle Society (AOFAS), there are 240 treated patients in Vietnam.

AOFAS volunteers have just returned from the 2017 trip to Vietnam. This is the 16th consecutive year they have been able to provide corrective surgery for children and adults with lower extremity deformities and disabilities.

Of the 240 patients evaluated, 91 underwent surgery—all at no cost to the them. As AOFAS wrote in its August 10, 2017 news release, “Since the first AOFAS Overseas Outreach Project to Vietnam in 2002, almost 1,400 patients have benefited from surgery performed by AOFAS volunteers, and more than 3,200 patients have been seen in the clinics. Most patients are from impoverished areas and lack access to care. Others are unable to afford advanced medical services.”

“The AOFAS surgeons volunteered their time and paid for their own travel to Vietnam. In-country expenses were supported by the AOFAS Orthopaedic Foot & Ankle Foundation with charitable donations from individuals and industry. This was the 16th annual project sponsored by the AOFAS and its partner organization, Mobility Outreach International (MOI).”

“Education is an important part of the outreach project. The AOFAS volunteers presented with Vietnamese surgeons at the annual conference on Surgery of the Lower Extremity held on June 3 in Hanoi. Co-sponsored by the AOFAS, MOI, the Vietnam Ministry of Health, and Viet Duc University Hospital, the conference utilized simultaneous translation and was attended by 170 Vietnamese orthopaedic surgeons.”

Michael B. Strauss, M.D., FACS, of Long Beach, California, took part in the trip to Vietnam. Dr. Strauss commented to OTW, “I have done previous humanitarian work, including care of earthquake victims for both the 1999 and 2009 Haiti earthquakes, and as an AOFAS member have wanted to participate in the Overseas Outreach Project to Vietnam since its inception. This year the timing and circumstances fit into my schedule.”

I used innovative techniques to manage severely neglected, terribly deformed club feet; specifically, a one-step procedure that involved the temporary use of spanning external fixators. This technique, to the best of my knowledge—and my initial literature review—had not been used before. In order to get outcome information, I have communicated with my Vietnamese counterparts on an almost weekly basis since I left. Based on the 11-week post-op communication (and accompanying photos the surgeons sent), the patients have done remarkably well with plantigrade feet and feet aligned with the legs.”

“It was uplifting to observe the immediate improvements as a result of the innovative techniques I used with minimally invasive surgeries (primarily releases and wedge osteotomies) plus temporary external fixation to correct the severest possible neglected club feet. It also was uplifting to see the apparent ‘complete faith’ and trust that the parents and their children patients had in us as visiting orthopedic surgeons—and to see that we could really do something to help them with their severe orthopaedic problems.”

New Scoring System Trumps ASA and CCI Risk Stratification Systems

New research involving 1,120 primary total joint arthroplasty patients has found that a novel risk stratification method is an improvement over current methods.

The study, “Safe Selection of Outpatient Joint Arthroplasty Patients With Medical Risk Stratification: the “‘Outpatient Arthroplasty Risk Assessment Score,’” appears in the August 2017 edition of The Journal of Arthroplasty.

R. Michael Meneghini, M.D., co-author on the study and an orthopedic surgeon at Indiana University Health, told OTW, “Total hip and knee replacement has been performed sporadically over the past decade, but as pain protocols improved and surgical techniques and blood conservation measures improved, there was a natural evolution to increasing the number of patients performed in the outpatient setting including discharge to home the same day of surgery.”

“In addition, this naturally lead surgeons to consider performing these procedures in ambulatory surgery centers. However, many hip and knee replacement patients are not the typical younger, healthy patients who have procedures in the outpatient setting and therefore, as a profession we must be careful to not put patients at risk with this transformation from the inpatient to outpatient setting.”

“In particular, the medical conditions and comorbidities of the patients must be evaluated for the feasibility and safety of performing hip and knee replacement procedures in the outpatient setting, particularly in an ambulatory surgery center away from the safety net of a hospital. Unfortunately, the metrics to risk-stratify patient medical co-morbidities and safety for performing these invasive procedures as an outpatient were crude and not validated for total hip and knee arthroplasty.”

“Ultimately, having over a decade of experience with early discharge and outpatient total hip and knee arthroplasty procedures, my colleague Dr. Pete Caccavallo and I developed the OARA Score to medically risk-stratify patients for outpatient joint arthroplasty.”

“The unique and exceptional aspect of this score development is that Dr. Caccavallo is a peri-operative medical specialist whose entire practice is dedicated to the medical care of hip and knee arthroplasty patients and his experience totals over 15,000 of such patients over a 15 year period. This experience makes him uniquely qualified to develop such a medical risk-stratification score to help surgeons and patients safely make the transition into the outpatient setting when performing total hip and knee arthroplasty.”

“I would say that the uniqueness of this study, compared to other studies of medical risk stratification of outpatient hip and knee arthroplasty in the existing peer-reviewed literature, is that this clinical data actually is derived from an early discharge and outpatient arthroplasty program which makes the scientific rigor more robust and valid than studies that attempt to interpret early outcome risk from a group of patients who are entirely inpatient.”

“The most important finding was that the OARA Score was superior to established risk stratification systems, such as ASA [American Society of Anesthesiologists Physical Status Classification System] and CCI [Charlson comorbidity index], in predicting the ability for patients to safely discharge home the same day or the next morning within 23 hours in the outpatient setting. In defense of ASA and CCI, they were not developed for risk stratification for outpatient hip and knee arthroplasty, and therefore we believe should not be used for such application accordingly.”

“We feel strongly that medical risk stratification should be an important aspect of an outpatient hip and knee replacement program in order to provide safety and reassurance to the patient and surgeon alike, and the OARA score may be a helpful tool in that aspect of the program. Further, our data was validated in the context of a mature outpatient joint replacement program that employs multi-modal pain protocols as well as modern, consistent and efficient surgical techniques that involve blood-conserving modalities in the framework of collaboration and communication between all stakeholders and caregivers with experience caring for patients in this setting.”

“If surgeons are just starting or considering performing hip and knee replacement in the outpatient setting or in an ambulatory surgery setting, we would strongly recommend that the OARA score be used in the setting of a comprehensive outpatient setting with established techniques and pathways, rather than in isolation where it has not been validated.”

“We feel this work developing the OARA Score is particularly relevant and timely, given the announcement by CMS [Centers for Medicare and Medicaid Services] a few weeks ago that total knee arthroplasty will be removed from the ‘inpatient-only’ list in 2018, and that we expect the same to be recommended 12 months later for total hip arthroplasty. Medicare beneficiaries tend to be older and with more medical issues. Therefore, appropriate medical risk stratification and assessment is critical to patient safety as we embark on expanding this patient group into the outpatient setting.”

Grapefruit Arthroscopic Training Model Proves Worthy

Is citrus an important part of your ortho training regimen? It might soon be!

A new study, “The Grapefruit: An Alternative Arthroscopic Tool Skill Platform,” just published in the August 2017 edition of Arthroscopy, shows why.

Martin Levy, M.D. director of the orthopedic residency program at The Albert Einstein College of Medicine in Bronx, New York and co-author on this work, told OTW, “For a long time, I have been interested in how we acquire skills. No matter the skill, whether it is baseball, cello or surgery, building a complex skill to fluency requires that we first build each of the component or foundation behaviors of that skill to fluency.”

“To achieve component behavior fluency, besides instruction, the learner needs repetition. The goal was to build a practice model that allows for emulation of the foundation behaviors, allows for high repetition and testing, and is not costly. Such a model gives a learner infinite access to practice, without the constraints of economy.”

The authors wrote, “For the grapefruit training model (GTM), an arthroscope and arthroscopic instruments were introduced through portals cut in the grapefruit skin of a whole prepared grapefruit. After institutional review board approval, participants performed a set of tasks inside the grapefruit. Performance for each component was assessed by recording errors, achievement of criteria, and time to completion. A total of 19 medical students, orthopaedic surgery residents, and fellowship-trained orthopaedic surgeons were included in the analysis and were divided into 3 groups based on arthroscopic experience.”

“It was most important to find that the model has construct validity. It is one thing to say we have a really neat model, you should try it. It is another to say we have a model that is valid. Developing economic and practical practice models that also respect limited resources is a function of our creativity. Focusing on foundation skills is essential if we are to expect that our learners will perform procedures fluently.”

“Learners can learn a foundation skill to fluency in a skills laboratory. Do not underestimate the time on a simulator. You cannot expect your learner to perform in an operating room if the foundation skills are not fluent. Luring a learner to success is not the same. Models like the grapefruit allow the learner to practice maneuvers to the point that they have the expectation of success.”

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