Bryan D. Springer

Background: Accurate Evaluation and Management (E/M) coding depends on the precise documentation of medical decision making. Advances in artificial intelligence have introduced ambient listening technology as a novel documentation tool. Despite its rapid adoption, the effect of ambient listening technology on E/M code selection, coding accuracy, and downstream financial implications remains poorly defined. This study aimed to evaluate the effect of ambient listening technology on E/M code selection, coding concordance, and associated revenue implications within an orthopaedic surgery practice. Methods: A comparative cross-sectional analysis was done of all outpatient E/M services at a single academic medical center. Providers were required to have a minimum of 20 encounters documented using ambient listening technology and traditional dictation for the same encounter type. The final analytic cohort included 7,236 encounters. A randomized subset of 200 encounters (100 ambient listening and 100 traditional) underwent blinded, independent audit by an experienced orthopaedic coding auditor. Outcomes included concordance between provider-selected and auditor-determined E/M levels, weighted coding discrepancies, accuracy rates, and modeled revenue effect. Results: Encounters documented with ambient listening technology were associated with higher E/M levels than those documented with traditional dictation, as assessed by both auditors (3.24 vs 2.96) and providers (3.11 vs 2.82). Overall coding accuracy was 68% for ambient listening and 74% for dictation, while focused review of higher-level ambient listening encounters demonstrated 81.3% accuracy. Revenue modeling projected a potential annual increase of $232,313 if dictation-based encounters achieved E/M distributions observed with ambient listening. Conclusion: Ambient listening–generated documentation meaningfully influences E/M code determination in orthopaedic outpatient practice, supporting higher and more appropriate E/M level selection compared with dictation. Although distinct error patterns persist, ambient listening was associated with reduced undercoding and measurable financial impact. These findings position ambient listening technology as a clinically and financially consequential documentation modality, warranting thoughtful implementation and continued coding oversight.

Background/Objectives: Non-typhoidal Salmonella (NTS) species are well-recognized causes of invasive infection in patients with sickle cell disease (SCD), with a particular predilection for the musculoskeletal system. Although Salmonella osteomyelitis is well described in this population, septic arthritis is uncommon, especially involving the shoulder joint. We describe a case of NTS bacteremia complicated by native shoulder septic arthritis in a patient with SCD and review its clinical implications. Methods: We report the clinical course, diagnostic evaluation, microbiologic findings, imaging studies, and management of a 22-year-old man with homozygous SCD who presented with a vaso-occlusive pain crisis and subsequently developed severe sepsis with persistent Salmonella enterica bacteremia following ingestion of undercooked poultry. Persistent bacteremia prompted further evaluation for metastatic infection using advanced imaging and diagnostic arthrocentesis. Results: Whole-body imaging identified septic arthritis of the native right shoulder, which was confirmed by synovial fluid cultures growing Salmonella species. The patient underwent arthroscopic irrigation and debridement for source control. Antimicrobial therapy was narrowed to intravenous ceftriaxone based on susceptibility data and continued for six weeks. The patient demonstrated clinical improvement with resolution of bacteremia and was discharged to rehabilitation to complete therapy. Conclusions: This case highlights the importance of a careful exposure history, including foodborne sources, in patients with SCD presenting with invasive Salmonella infection. Persistent bacteremia should prompt early investigation for metastatic foci, and timely surgical source control combined with targeted antimicrobial therapy is essential for optimal outcomes in this population.

Background: A 2-stage approach is most commonly used to treat periprosthetic joint infection (PJI). Some successful studies of the 1-stage approach were underpowered, lacked a 2-stage comparative group, and excluded patients with draining sinuses, comorbidities, and/or antibiotic-resistant organisms. Given the morbidity and expense associated with 2-stage treatment, we conducted a prospective, multicenter, randomized trial to compare the results of 1- and 2-stage PJI treatment, specifically including patients with draining sinuses, comorbidities, and resistant organisms. Methods: Patients presenting for surgical treatment of a chronic PJI with a known organism following primary total hip or knee arthroplasty were included (with infection defined by Musculoskeletal Infection Society [MSIS] criteria). Patients with prior revision, culture-negative infection, or fungal infection, or who were immunosuppressed or had soft-tissue involvement precluding wound closure, were excluded. Patients were classified according to the McPherson host staging system. Clinical success was defined as (1) no clinical failure or reinfection with the same or new organism; (2) no reoperation for PJI; and (3) no PJI-related death. A double-instrument setup was used for all patients, as were similar irrigation and antibiotic protocols. A total of 323 patients (166 one-stage; 157 two-stage) were randomized. Groups were similar with respect to demographics and host classification. After excluding patients who died or were lost to follow-up, 258 of the 323 patients had 2-year follow-up (135 one-stage and 123 two-stage). The rate of patient loss to follow-up was similar between the treatment groups. Results: Sixteen patients in the 1-stage group and 9 patients in the 2-stage group died prior to 2-year follow-up. Overall, the 2-year success rate of 1-stage treatment was 97% (131 of 135), while the success of 2-stage treatment was 91% (112 of 123) (p = 0.04). Compared with the 2-stage group, the 1-stage group had 3-times the odds of overall success in a regression analysis (unadjusted odds ratio = 3.22 [95% confidence interval = 1.0 to 10.38]). After adjusting for specific variables (McPherson host grade, resistant organism, and draining sinuses), 1-stage treatment also had 3-times the odds of success. Conclusions: The results of this prospective randomized trial indicated that 1-stage treatment (97% success) was statistically noninferior to 2-stage treatment (91% success) when treating chronic PJI following primary total hip or knee arthroplasty, provided the protocols described here are explicitly followed. Extrapolation to other patient cohorts and clinical situations should be avoided. Level of Evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Background/Objectives: Streptococcus intermedius, a member of the Streptococcus anginosus group, is characterized by a marked propensity for abscess formation but only rarely causes native-joint septic arthritis. Involvement of the acromioclavicular (AC) joint is particularly uncommon. We describe a case of native AC joint septic arthritis due to S. intermedius in a patient with multiple predisposing factors and highlight diagnostic and management considerations. Methods: We report the clinical course of a 72-year-old man with poorly controlled type 2 diabetes mellitus who presented with progressive right shoulder pain, erythema, and swelling following recurrent minor skin abrasions from a newly adopted dog. Initial management for presumed inflammatory shoulder pathology included brief systemic corticosteroids and an ultrasound-guided intra-articular ketorolac injection. Magnetic resonance imaging (MRI) was performed after symptom progression. The patient underwent operative irrigation and debridement with collection of synovial fluid and deep tissue cultures. Blood cultures and transthoracic echocardiography were obtained to evaluate for systemic involvement. Results: MRI demonstrated multiloculated periarticular abscesses and osteolysis centered on the AC joint. Operative cultures yielded high colony counts of S. intermedius from synovial fluid and deep tissues. Blood cultures and echocardiography were negative. The patient required multiple operative debridements with irrigation, adjunctive local antibiotic therapy, and prolonged targeted β-lactam treatment. Clinical and radiographic improvement was achieved following surgical source control and antimicrobial therapy. Conclusions: Native AC joint septic arthritis due to S. intermedius is rare. Older age, uncontrolled diabetes, recent intra-articular intervention, and possible zoonotic inoculation from canine wound licking may represent contributory risk factors. Early imaging, prompt surgical source control, and guideline-concordant antimicrobial therapy are essential when bone and soft tissue involvement is present.

Background: Orthopaedic surgeons routinely delay surgical management of femoral neck fractures in patients taking direct oral anticoagulants (DOACs) to decrease perioperative bleeding and associated complications. However, this practice contradicts the principles of hip fracture management, as early surgery is associated with morbidity and mortality benefits. The purpose of this study was to quantify the association of DOAC use and perioperative outcomes in patients who underwent hemiarthroplasty (HA) or total hip arthroplasty (THA) for femoral neck fractures. We hypothesized that early surgical intervention on a patient taking a DOAC medication would not lead to worse perioperative outcomes. Methods: A retrospective cohort study was conducted on 2,833 patients who underwent primary THA or HA for femoral neck fractures between December 31, 2017, and January 29, 2024, across our hospital system. The patients taking a DOAC were divided into 3 groups based on the time since the last DOAC intake: 1 day, 2 days, and ≥3 days. Propensity matching was performed 1:1, accounting for age, sex, Elixhauser Comorbidity Index, preoperative chronic kidney disease stage, preoperative hemoglobin, body mass index, and hospital type. Subanalyses utilizing linear and conditional logistic regression models were performed to assess differences in outcomes between the groups that had a DOAC withheld and the control groups. Results: The mean age of all patients was 81 ± 10 years, 1,805 patients (64%) were women, and 207 patients (7%) were taking a DOAC prior to surgery. Despite comparable preoperative and postoperative hemoglobin levels between the groups that had a DOAC withheld and the control groups (all p > 0.05), the patients who had a DOAC withheld for 1 day were more likely to receive a postoperative blood transfusion (23.1% compared with 0%; p = 0.002). This difference in transfusion rate was not observed in other cohorts. There were no differences in medical complications, reoperation, discharge disposition, or mortality between the groups that had a DOAC withheld and the matched controls at any time point. Conclusions: Delaying surgical management due to DOAC medications may be unnecessary in patients undergoing arthroplasty for femoral neck fractures. Consideration should be given to adjusting transfusion triggers to reduce unwarranted blood transfusions in patients taking a DOAC. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Introduction: While two-stage exchange arthroplasty is the gold standard for treating periprosthetic joint infections (PJIs), it results in a prolonged treatment period with the potential for complications and non-planned additional procedures, limited joint function during the interstage period, and emotional stress for patients. The primary objective of this systematic literature review was to evaluate outcomes associated with two-stage exchange arthroplasty for treating total hip arthroplasty (THA) and total knee arthroplasty (TKA) PJIs. This literature review analyzed U.S. data on the timing and health consequences associated with the interstage period and outcomes following reimplantation in patients undergoing two-stage exchange arthroplasty. Materials and Methods: A search of U.S. studies published between January 2014 and January 2024 was conducted using PubMed and Embase databases. Results: Sixty-five studies reporting data on 26,354 patients undergoing two-stage exchange arthroplasty were included. There were 29.0% and 68.6% of patients who underwent THA and TKA respectively, with 2.4% patients not having the affecting joint identified. The mean interstage period was 141.4 ± 74.2 days with 16.9 ± 12.2% patients not re-implanted. The mean infection eradication was 74.2 ± 10.5% and the average reinfection rate was 15.7 ± 7.1%. Complications and additional procedures were common during the interstage and post-implant periods. Only four studies utilized Musculoskeletal Infection Society (MSIS) Outcomes Reporting Tool. Patients undergoing treatment for TKA PJIs had less successful MSIS outcomes compared to those being treated for THA PJIs. This includes a lower rate of infection control (46.0% vs. 65.5%), a higher rate of reoperation, revision, and/or spacer retention (40.6% vs. 25.2%) and a higher death rate (13.4% vs. 9.4%), respectively. Conclusion: Two-stage exchange arthroplasty treatment of PJIs is associated with major morbidity and often requires additional surgical procedures to address complications. The prolonged duration of the interstage period contributes to morbidity and negatively impacts patients’ quality of life and increases the risk of mortality.

Background: Periprosthetic tibial fractures around a total knee replacement (TKR) remain challenging to manage, with little published information for guidance. The purpose of this study was to review the types, management techniques, and outcomes of periprosthetic tibial fractures in the largest series to date. Methods: We identified 300 periprosthetic tibial fractures (285 patients) around a TKR (43% in primary TKRs and 57% in revision TKRs) sustained between 1996 and 2020. Fractures were classified according to Felix et al. as Type I (tibial plateau), Type II (adjacent to stem), Type III (distal to stem), or Type IV (tibial tubercle), with subtypes A (well-fixed component), B (loose component), and C (intraoperative fracture). Of the fractures in this study, 53% were Type I, 24% were Type II, 16% were Type III, and 8% were Type IV. A total of 46% of fractures occurred intraoperatively, and 54% of fractures occurred postoperatively (61% subtype A, 39% subtype B). The mean patient age at fracture was 67 years, and 64% of patients were female. The mean follow-up was 6 years. Results: The intraoperative fracture incidence was 1.40% in revision TKRs and 0.10% in primary TKRs. Among intraoperative fractures, the 2-year survivorship free from tibial component revision was highest in Type I (100%) and lowest in Type IV (67%) (p < 0.001). For postoperative fractures, the 2-year survivorship free from any reoperation was 29% and the 2-year survivorship free from tibial component revision was 51%. Type-I postoperative fractures had the lowest 2-year survivorship free from tibial component revision (10%), whereas Type-III fractures had the highest survivorship (88%) (p < 0.001). Conclusions: Intraoperative periprosthetic fracture of the tibia was fourteenfold more likely in revision TKRs compared with primary TKRs. Among all intraoperative fractures, Type-I fractures were well-tolerated, with 100% survivorship free from tibial component revision at 2 years. Conversely, Type-I postoperative fractures had only 10% survivorship at 2 years. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.